Florida Senate - 2016                             CS for SB 1442
       By the Committee on Health Policy; and Senator Garcia
       588-02881-16                                          20161442c1
    1                        A bill to be entitled                      
    2         An act relating to out-of-network health insurance
    3         coverage; amending s. 395.003, F.S.; requiring
    4         hospitals, ambulatory surgical centers, specialty
    5         hospitals, and urgent care centers to comply with
    6         certain provisions as a condition of licensure;
    7         amending s. 395.301, F.S.; requiring a hospital to
    8         post certain information on its website regarding its
    9         contracts with health insurers, health maintenance
   10         organizations, and health care practitioners and
   11         practice groups and a specified statement to patients
   12         and prospective patients; amending s. 456.072, F.S.;
   13         adding a ground for discipline of referring health
   14         care providers by the Department of Health; creating
   15         s. 627.64194, F.S.; defining terms; specifying
   16         requirements for coverage provided by an insurer for
   17         emergency services; providing that an insurer is
   18         solely liable for payment of certain fees to a
   19         provider; providing that an insured is not liable for
   20         payment of certain fees; providing limitations and
   21         requirements for reimbursements by an insurer to a
   22         nonparticipating provider; providing applicability;
   23         authorizing a nonparticipating provider or insurer to
   24         initiate action in a court of competent jurisdiction
   25         or through voluntary dispute resolution; amending s.
   26         627.6471, F.S.; requiring an insurer that issues a
   27         policy including coverage for the services of a
   28         preferred provider to post certain information about
   29         participating providers on its website; requiring a
   30         specified disclosure to be included in policies
   31         providing coverage for the services of a preferred
   32         provider; providing an effective date.
   34  Be It Enacted by the Legislature of the State of Florida:
   36         Section 1. Paragraph (d) is added to subsection (5) of
   37  section 395.003, Florida Statutes, to read:
   38         395.003 Licensure; denial, suspension, and revocation.—
   39         (5)
   40         (d) A hospital, ambulatory surgical center, specialty
   41  hospital, or urgent care center shall comply with the provisions
   42  of ss. 627.64194 and 641.513 as a condition of licensure.
   43         Section 2. Subsection (13) is added to section 395.301,
   44  Florida Statutes, to read:
   45         395.301 Itemized patient bill; form and content prescribed
   46  by the agency; patient admission status notification.—
   47         (13) A hospital shall post on its website:
   48         (a) The names and hyperlinks for direct access to the
   49  websites of all health insurers and health maintenance
   50  organizations for which the hospital contracts as a network
   51  provider or a participating provider.
   52         (b) A statement that:
   53         1. Services provided in the hospital by health care
   54  practitioners may not be included in the hospital’s charges;
   55         2. Health care practitioners who provide services in the
   56  hospital may or may not participate with the same health
   57  insurance plans as the hospital;
   58         3. Prospective patients should contact the health care
   59  practitioner arranging for the services to determine the health
   60  care plans in which the health care practitioner participates.
   61         (c) As applicable, the names, mailing addresses, and
   62  telephone numbers of the health care practitioners and practice
   63  groups that the hospital has contracted with to provide services
   64  in the hospital and instruction on how to contact these health
   65  care practitioners and practice groups to determine the health
   66  insurers and health maintenance organizations for which the
   67  hospital contracts as a network provider or a participating
   68  provider.
   69         Section 3. Paragraph (oo) is added to subsection (1) of
   70  section 456.072, Florida Statutes, to read:
   71         456.072 Grounds for discipline; penalties; enforcement.—
   72         (1) The following acts shall constitute grounds for which
   73  the disciplinary actions specified in subsection (2) may be
   74  taken:
   75         (oo) Failing to comply with the provisions of s. 627.64194
   76  or s. 641.513 with such frequency as to constitute a general
   77  business practice.
   78         Section 4. Section 627.64194, Florida Statutes, is created
   79  to read:
   80         627.64194 Coverage requirements for services provided by
   81  nonparticipating providers.—
   82         (1) As used in this section, the term:
   83         (a) “Emergency services” means the services and care to
   84  treat an emergency medical condition, as defined in s. 641.47.
   85  For purposes of this section, the term includes emergency
   86  transportation and ambulance services, to the extent permitted
   87  by applicable state and federal law.
   88         (b) “Facility” means a licensed facility as defined in s.
   89  395.002(16) or an urgent care center as defined in s.
   90  395.002(30).
   91         (c) “Nonemergency services” means the services and care to
   92  treat a condition other than an emergency medical condition, as
   93  defined in s. 395.002(8).
   94         (d) “Nonparticipating provider” means a provider who is not
   95  a “preferred provider” as defined in s. 627.6471, an “exclusive
   96  provider” as defined in s. 627.6472, or a facility licensed
   97  under chapter 395. A provider that is employed by a facility
   98  licensed under chapter 395, and that is not a “preferred
   99  provider” as defined in s. 627.6471 or an “exclusive provider”
  100  as defined in s. 627.6472, is a nonparticipating provider.
  101         (e) “Participating provider” means a “preferred provider”
  102  as defined in s. 627.6471 or an “exclusive provider” as defined
  103  in s. 627.6472, but not a facility licensed under chapter 395.
  104         (f) “Insured” means a person who is covered under an
  105  individual or group health insurance policy delivered or issued
  106  for delivery in this state by an insurer authorized to transact
  107  business in the state.
  108         (2) An insurer is solely liable for payment of fees to a
  109  nonparticipating provider of emergency services provided to an
  110  insured in accordance with the terms of the health insurance
  111  policy. Such insured is not liable for payment of fees to a
  112  nonparticipating provider of emergency services other than
  113  applicable copayments and deductibles. An insurer must provide
  114  coverage for emergency services that:
  115         (a) May not require prior authorization.
  116         (b) Must be provided regardless of whether the service is
  117  furnished by a participating or nonparticipating provider.
  118         (c) May impose a coinsurance amount, copayment, or
  119  limitation of benefits requirement for a nonparticipating
  120  provider only if the same requirement applies to a participating
  121  provider.
  122         (3) An insurer is solely liable for payment of fees to a
  123  nonparticipating provider of nonemergency services provided to
  124  an insured in accordance with the terms of the health insurance
  125  policy. Such insured is not liable for payment of fees to a
  126  nonparticipating provider, other than applicable copayments and
  127  deductibles, for nonemergency services:
  128         (a) That are provided in a facility that has a contract for
  129  the nonemergency services with the insurer which the facility
  130  would be otherwise obligated to provide under contract with the
  131  insurer; and
  132         (b)Where the insured has no ability and opportunity to
  133  choose a participating provider at the facility.
  135  If the insured makes an informed affirmative decision to choose
  136  a nonparticipating provider instead of a participating provider
  137  who is available at the facility to treat the insured, the
  138  provisions of this subsection do not apply.
  139         (4) An insurer must reimburse a nonparticipating provider
  140  for services under subsections (2) and (3) as specified in s.
  141  641.513(5) within the applicable timeframe provided by s.
  142  627.6131.
  143         (5) A nonparticipating provider of emergency services as
  144  provided in subsection (2) or nonemergency services as provided
  145  in subsection (3) may not be reimbursed an amount greater than
  146  the amount provided in subsection (4) and may not collect or
  147  attempt to collect from the patient, directly or indirectly, any
  148  excess amount except for copays and deductibles.
  149         (6) A dispute with regard to the amount of reimbursement
  150  owed to the nonparticipating provider of emergency or
  151  nonemergency services as provided in subsection (4) must be
  152  resolved in a court of competent jurisdiction or by the
  153  voluntary dispute resolution process in s. 408.7057.
  154         Section 5. Subsection (2) of section 627.6471, Florida
  155  Statutes, is amended, and a new subsection (7) is added to that
  156  section, to read:
  157         627.6471 Contracts for reduced rates of payment;
  158  limitations; coinsurance and deductibles.—
  159         (2) Any insurer issuing a policy of health insurance in
  160  this state, which insurance includes coverage for the services
  161  of a preferred provider, must provide each policyholder and
  162  certificateholder with a current list of preferred providers and
  163  must make the list available on its website. The list must
  164  include, where applicable and reported, a listing by specialty
  165  of the names, addresses, and telephone numbers of all
  166  participating providers, including facilities; and in the case
  167  of physicians, board certifications, languages spoken, and any
  168  affiliations with participating hospitals. Information posted to
  169  the insurer’s website must be updated on at least a calendar
  170  month basis with additions or terminations of providers from the
  171  insurer’s network or reported changes in physician’s hospital
  172  affiliations must make the list available for public inspection
  173  during regular business hours at the principal office of the
  174  insurer within the state.
  175         (7) Any policy issued after January 1, 2017 under this
  176  section must include the following disclosure: “WARNING: LIMITED
  178  You should be aware that when you elect to utilize the services
  179  of a nonparticipating provider for a covered nonemergency
  180  service, benefit payments to the provider are not based upon the
  181  amount the provider charges. The basis of the payment will be
  182  determined according to your policy’s out-of-network
  183  reimbursement benefit. Nonparticipating providers may bill
  184  insureds for any difference in the amount. YOU MAY BE REQUIRED
  186  providers have agreed to accept discounted payments for services
  187  with no additional billing to you other than coinsurance and
  188  deductible amounts. You may obtain further information about the
  189  providers who have contracted with your insurance plan by
  190  consulting your insurer’s website or contacting your insurer or
  191  agent directly.”
  192         Section 6. This act shall take effect October 1, 2016.