Florida Senate - 2016                      CS for CS for SB 1442
       By the Committees on Banking and Insurance; and Health Policy;
       and Senator Garcia
       597-03666-16                                          20161442c2
    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 on its website certain information regarding its
    9         contracts with health insurers, health maintenance
   10         organizations, and health care practitioners and
   11         practice groups and specified notice to patients and
   12         prospective patients; amending s. 408.7057, F.S.;
   13         providing requirements for settlement offers between
   14         certain providers and health plans in a specified
   15         dispute resolution program; requiring a final order to
   16         be subject to judicial review; amending ss. 456.072,
   17         458.331, and 459.015, F.S.; providing additional acts
   18         that constitute grounds for denial of a license or
   19         disciplinary action, to which penalties apply;
   20         amending s. 626.9541, F.S.; specifying an additional
   21         unfair method of competition and unfair or deceptive
   22         act or practice; creating s. 627.64194, F.S.; defining
   23         terms; providing that an insurer is solely liable for
   24         payment of certain fees to a nonparticipating
   25         provider; providing limitations and requirements for
   26         reimbursements by an insurer to a nonparticipating
   27         provider; providing that certain disputes relating to
   28         reimbursement of a nonparticipating provider shall be
   29         resolved in a court of competent jurisdiction or
   30         through a specified voluntary dispute resolution
   31         process; amending s. 627.6471, F.S.; requiring an
   32         insurer that issues a policy including coverage for
   33         the services of a preferred provider to post on its
   34         website certain information about participating
   35         providers and physicians; requiring that specified
   36         notice be included in policies issued after a
   37         specified date which provide coverage for the services
   38         of a preferred provider; amending s. 627.662, F.S.;
   39         providing applicability of provisions relating to
   40         coverage for services and payment collection
   41         limitations to group health insurance, blanket health
   42         insurance, and franchise health insurance; providing
   43         effective dates.
   45  Be It Enacted by the Legislature of the State of Florida:
   47         Section 1. Paragraph (d) is added to subsection (5) of
   48  section 395.003, Florida Statutes, to read:
   49         395.003 Licensure; denial, suspension, and revocation.—
   50         (5)
   51         (d)A hospital, an ambulatory surgical center, a specialty
   52  hospital, or an urgent care center shall comply with ss.
   53  627.64194 and 641.513 as a condition of licensure.
   54         Section 2. Subsection (13) is added to section 395.301,
   55  Florida Statutes, to read:
   56         395.301 Itemized patient bill; form and content prescribed
   57  by the agency; patient admission status notification.—
   58         (13)A hospital shall post on its website:
   59         (a)The names and hyperlinks for direct access to the
   60  websites of all health insurers and health maintenance
   61  organizations for which the hospital contracts as a network
   62  provider or participating provider.
   63         (b)A statement that:
   64         1.Services provided in the hospital by health care
   65  practitioners may not be included in the hospital’s charges;
   66         2.Health care practitioners who provide services in the
   67  hospital may or may not participate in the same health insurance
   68  plans as the hospital; and
   69         3.Prospective patients should contact the health care
   70  practitioner arranging for the services to determine the health
   71  care plans in which the health care practitioner participates.
   72         (c)As applicable, the names, mailing addresses, and
   73  telephone numbers of the health care practitioners and practice
   74  groups that the hospital has contracted with to provide services
   75  in the hospital and instructions on how to contact these health
   76  care practitioners and practice groups to determine the health
   77  insurers and health maintenance organizations for which the
   78  hospital contracts as a network provider or participating
   79  provider.
   80         Section 3. Paragraph (h) is added to subsection (2) of
   81  section 408.7057, Florida Statutes, and subsection (4) of that
   82  section is amended, to read:
   83         408.7057 Statewide provider and health plan claim dispute
   84  resolution program.—
   85         (2)
   86         (h)Either the contracted or noncontracted provider or the
   87  health plan may make an offer to settle the claim dispute when
   88  it submits a request for a claim dispute and supporting
   89  documentation. The offer to settle the claim dispute must state
   90  its total amount, and the party to whom it is directed has 15
   91  days to accept the offer once it is received. If the party
   92  receiving the offer does not accept the offer and the final
   93  order amount is more than 90 percent or less than 110 percent of
   94  the offer amount, the party receiving the offer must pay the
   95  final order amount to the offering party and is deemed a
   96  nonprevailing party for purposes of this section. The amount of
   97  an offer made by a contracted or noncontracted provider to
   98  settle an alleged underpayment by the health plan must be
   99  greater than 110 percent of the reimbursement amount the
  100  provider received. The amount of an offer made by a health plan
  101  to settle an alleged overpayment to the provider must be less
  102  than 90 percent of the alleged overpayment amount by the health
  103  plan. Both parties may agree to settle the disputed claim at any
  104  time, for any amount, regardless of whether an offer to settle
  105  was made or rejected.
  106         (4) Within 30 days after receipt of the recommendation of
  107  the resolution organization, the agency shall adopt the
  108  recommendation as a final order. The final order is subject to
  109  judicial review pursuant to s. 120.68.
  110         Section 4. Paragraph (oo) is added to subsection (1) of
  111  section 456.072, Florida Statutes, to read:
  112         456.072 Grounds for discipline; penalties; enforcement.—
  113         (1) The following acts shall constitute grounds for which
  114  the disciplinary actions specified in subsection (2) may be
  115  taken:
  116         (oo)Willfully failing to comply with s. 627.64194 or s.
  117  641.513 with such frequency as to indicate a general business
  118  practice.
  119         Section 5. Paragraph (tt) is added to subsection (1) of
  120  section 458.331, Florida Statutes, to read:
  121         458.331 Grounds for disciplinary action; action by the
  122  board and department.—
  123         (1) The following acts constitute grounds for denial of a
  124  license or disciplinary action, as specified in s. 456.072(2):
  125         (tt)Willfully failing to comply with s. 627.64194 or s.
  126  641.513 with such frequency as to indicate a general business
  127  practice.
  128         Section 6. Paragraph (vv) is added to subsection (1) of
  129  section 459.015, Florida Statutes, to read:
  130         459.015 Grounds for disciplinary action; action by the
  131  board and department.—
  132         (1) The following acts constitute grounds for denial of a
  133  license or disciplinary action, as specified in s. 456.072(2):
  134         (vv)Willfully failing to comply with s. 627.64194 or s.
  135  641.513 with such frequency as to indicate a general business
  136  practice.
  137         Section 7. Paragraph (gg) is added to subsection (1) of
  138  section 626.9541, Florida Statutes, to read:
  139         626.9541 Unfair methods of competition and unfair or
  140  deceptive acts or practices defined.—
  142  ACTS.—The following are defined as unfair methods of competition
  143  and unfair or deceptive acts or practices:
  144         (gg)Out-of-network reimbursement.—Willfully failing to
  145  comply with s. 627.64194 with such frequency as to indicate a
  146  general business practice.
  147         Section 8. Section 627.64194, Florida Statutes, is created
  148  to read:
  149         627.64194Coverage requirements for services provided by
  150  nonparticipating providers; payment collection limitations.—
  151         (1)As used in this section, the term:
  152         (a)“Emergency services” means the services and care to
  153  treat an emergency medical condition as defined in s. 641.47(8).
  154         (b)“Facility” means a licensed facility as defined in s.
  155  395.002(16) and an urgent care center as defined in s.
  156  395.002(30).
  157         (c)“Insured” means a person who is covered under an
  158  individual or group health insurance policy delivered or issued
  159  for delivery in this state by an insurer authorized to transact
  160  business in this state.
  161         (d)“Nonemergency services” means the services and care to
  162  treat a condition other than an emergency medical condition.
  163         (e)“Nonparticipating provider” means a provider who is not
  164  a preferred provider as defined in s. 627.6471 or a provider who
  165  is not an exclusive provider as defined in s. 627.6472. For
  166  purposes of covered emergency services under this section, a
  167  facility licensed under chapter 395 or an urgent care center
  168  defined in s. 395.002(30) is a nonparticipating provider if the
  169  facility has not contracted with an insurer to provide emergency
  170  services to its insureds at a specified rate.
  171         (f)“Participating provider” means, for purposes of this
  172  section, a preferred provider as defined in s. 627.6471 or an
  173  exclusive provider as defined in s. 627.6472.
  174         (2)An insurer is solely liable for payment of fees to a
  175  nonparticipating provider of covered emergency services provided
  176  to an insured in accordance with the coverage terms of the
  177  health insurance policy, and such insured is not liable for
  178  payment of fees for covered services to a nonparticipating
  179  provider of emergency services, other than applicable
  180  copayments, coinsurance, and deductibles. An insurer must
  181  provide coverage for emergency services that:
  182         (a)May not require prior authorization.
  183         (b)Must be provided regardless of whether the services are
  184  furnished by a participating provider or a nonparticipating
  185  provider.
  186         (c)May impose a coinsurance amount, copayment, or
  187  limitation of benefits requirement for a nonparticipating
  188  provider only if the same requirement applies to a participating
  189  provider.
  191  The provisions of s. 627.638 apply to this subsection.
  192         (3)An insurer is solely liable for payment of fees to a
  193  nonparticipating provider of covered nonemergency services
  194  provided to an insured in accordance with the coverage terms of
  195  the health insurance policy, and such insured is not liable for
  196  payment of fees to a nonparticipating provider, other than
  197  applicable copayments, coinsurance, and deductibles, for covered
  198  nonemergency services that are:
  199         (a)Provided in a facility that has a contract for the
  200  nonemergency services with the insurer which the facility would
  201  be otherwise obligated to provide under contract with the
  202  insurer; and
  203         (b)Provided when the insured does not have the ability and
  204  opportunity to choose a participating provider at the facility
  205  who is available to treat the insured.
  207  The provisions of s. 627.638 apply to this subsection.
  208         (4)An insurer must reimburse a nonparticipating provider
  209  of services under subsections (2) and (3) as specified in s.
  210  641.513(5), reduced only by insured cost share responsibilities
  211  as specified in the health insurance policy, within the
  212  applicable timeframe provided in s. 627.6131.
  213         (5)A nonparticipating provider of emergency services as
  214  provided in subsection (2) or a nonparticipating provider of
  215  nonemergency services as provided in subsection (3) may not be
  216  reimbursed an amount greater than the amount provided in
  217  subsection (4) and may not collect or attempt to collect from
  218  the insured, directly or indirectly, any excess amount, other
  219  than copayments, coinsurance, and deductibles. This section does
  220  not prohibit a nonparticipating provider from collecting or
  221  attempting to collect from the insured an amount due for the
  222  provision of noncovered services.
  223         (6)Any dispute with regard to the reimbursement to the
  224  nonparticipating provider of emergency or nonemergency services
  225  as provided in subsection (4) shall be resolved in a court of
  226  competent jurisdiction or through the voluntary dispute
  227  resolution process in s. 408.7057.
  228         Section 9. Subsection (2) of section 627.6471, Florida
  229  Statutes, is amended to read:
  230         627.6471 Contracts for reduced rates of payment;
  231  limitations; coinsurance and deductibles.—
  232         (2) Any insurer issuing a policy of health insurance in
  233  this state, which insurance includes coverage for the services
  234  of a preferred provider, must provide each policyholder and
  235  certificateholder with a current list of preferred providers and
  236  must make the list available on its website. The list must
  237  include, when applicable and reported, a listing by specialty of
  238  the names, addresses, and telephone numbers of all participating
  239  providers, including facilities, and, in the case of physicians,
  240  must also include board certifications, languages spoken, and
  241  any affiliations with participating hospitals. Information
  242  posted on the insurer’s website must be updated on at least a
  243  calendar-month basis with additions or terminations of providers
  244  from the insurer’s network or reported changes in physicians’
  245  hospital affiliations for public inspection during regular
  246  business hours at the principal office of the insurer within the
  247  state.
  248         Section 10. Effective upon this act becoming a law,
  249  subsection (7) is added to section 627.6471, Florida Statutes,
  250  to read:
  251         627.6471 Contracts for reduced rates of payment;
  252  limitations; coinsurance and deductibles.—
  253         (7)Any policy issued under this section after January 1,
  254  2017, must include the following disclosure: “WARNING: LIMITED
  256  You should be aware that when you elect to utilize the services
  257  of a nonparticipating provider for a covered nonemergency
  258  service, benefit payments to the provider are not based upon the
  259  amount the provider charges. The basis of the payment will be
  260  determined according to your policy’s out-of-network
  261  reimbursement benefit. Nonparticipating providers may bill
  262  insureds for any difference in the amount. YOU MAY BE REQUIRED
  264  Participating providers have agreed to accept discounted
  265  payments for services with no additional billing to you other
  266  than coinsurance, copayment, and deductible amounts. You may
  267  obtain further information about the providers who have
  268  contracted with your insurance plan by consulting your insurer’s
  269  website or contacting your insurer or agent directly.”
  270         Section 11. Subsection (15) is added to section 627.662,
  271  Florida Statutes, to read:
  272         627.662 Other provisions applicable.—The following
  273  provisions apply to group health insurance, blanket health
  274  insurance, and franchise health insurance:
  275         (15)Section 627.64194, relating to coverage requirements
  276  for services provided by nonparticipating providers and payment
  277  collection limitations.
  278         Section 12. Except as otherwise expressly provided in this
  279  act and except for this section, which shall take effect upon
  280  this act becoming a law, this act shall take effect October 1,
  281  2016.