Florida Senate - 2016               CS for CS for CS for SB 1442
       By the Committees on Appropriations; Banking and Insurance; and
       Health Policy; and Senator Garcia
       576-04210-16                                          20161442c3
    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
    9         health insurers, health maintenance organizations,
   10         health care practitioners, and practice groups that it
   11         contracts with, and a specified disclosure statement;
   12         amending s. 408.7057, F.S.; providing requirements for
   13         settlement offers between certain providers and health
   14         plans in a specified dispute resolution program;
   15         requiring the Agency for Health Care Administration to
   16         include in its rules additional requirements relating
   17         to a resolution organization’s process in considering
   18         certain claim disputes; requiring a final order to be
   19         subject to judicial review; amending ss. 456.072,
   20         458.331, and 459.015, F.S.; providing additional acts
   21         that constitute grounds for denial of a license or
   22         disciplinary action to which penalties apply; amending
   23         s. 626.9541, F.S.; specifying an additional unfair
   24         method of competition and unfair or deceptive act or
   25         practice; creating s. 627.64194, F.S.; defining terms;
   26         providing that an insurer is solely liable for payment
   27         of certain fees to a nonparticipating provider;
   28         providing limitations and requirements for
   29         reimbursements by an insurer to a nonparticipating
   30         provider; providing that certain disputes relating to
   31         reimbursement of a nonparticipating provider shall be
   32         resolved in a court of competent jurisdiction or
   33         through a specified voluntary dispute resolution
   34         process; amending s. 627.6471, F.S.; requiring an
   35         insurer that issues a policy including coverage for
   36         the services of a preferred provider to post on its
   37         website certain information about participating
   38         providers and physicians; requiring that specified
   39         notice be included in policies issued after a
   40         specified date which provide coverage for the services
   41         of a preferred provider; amending s. 627.662, F.S.;
   42         providing applicability of provisions relating to
   43         coverage for services and payment collection
   44         limitations to group health insurance, blanket health
   45         insurance, and franchise health insurance; providing
   46         effective dates.
   48  Be It Enacted by the Legislature of the State of Florida:
   50         Section 1. Paragraph (d) is added to subsection (5) of
   51  section 395.003, Florida Statutes, to read:
   52         395.003 Licensure; denial, suspension, and revocation.—
   53         (5)
   54         (d)A hospital, an ambulatory surgical center, a specialty
   55  hospital, or an urgent care center shall comply with ss.
   56  627.64194 and 641.513 as a condition of licensure.
   57         Section 2. Subsection (13) is added to section 395.301,
   58  Florida Statutes, to read:
   59         395.301 Itemized patient bill; form and content prescribed
   60  by the agency; patient admission status notification.—
   61         (13)A hospital shall post on its website:
   62         (a)The names and hyperlinks for direct access to the
   63  websites of all health insurers and health maintenance
   64  organizations for which the hospital contracts as a network
   65  provider or participating provider.
   66         (b)A statement that:
   67         1. Services may be provided in the hospital by the facility
   68  as well as by other health care practitioners who may separately
   69  bill the patient;
   70         2. Health care practitioners who provide services in the
   71  hospital may or may not participate with the same health
   72  insurers or health maintenance organizations as the hospital;
   73  and
   74         3. Prospective patients should contact the health care
   75  practitioner who will provide services in the hospital to
   76  determine which health insurers and health maintenance
   77  organizations the practitioner participates in as a network
   78  provider or preferred provider.
   79         (c) As applicable, the names, mailing addresses, and
   80  telephone numbers of the health care practitioners and medical
   81  practice groups with which it contracts to provide services in
   82  the hospital, and instructions on how to contact the
   83  practitioners and groups to determine which health insurers and
   84  health maintenance organizations they participate in as network
   85  providers or preferred providers.
   86         Section 3. Paragraph (h) is added to subsection (2) of
   87  section 408.7057, Florida Statutes, and subsections (3) and (4)
   88  of that section are amended, to read:
   89         408.7057 Statewide provider and health plan claim dispute
   90  resolution program.—
   91         (2)
   92         (h)Either the contracted or noncontracted provider or the
   93  health plan may make an offer to settle the claim dispute when
   94  it submits a request for a claim dispute and supporting
   95  documentation. The offer to settle the claim dispute must state
   96  its total amount, and the party to whom it is directed has 15
   97  days to accept the offer once it is received. If the party
   98  receiving the offer does not accept the offer and the final
   99  order amount is more than 90 percent or less than 110 percent of
  100  the offer amount, the party receiving the offer must pay the
  101  final order amount to the offering party and is deemed a
  102  nonprevailing party for purposes of this section. The amount of
  103  an offer made by a contracted or noncontracted provider to
  104  settle an alleged underpayment by the health plan must be
  105  greater than 110 percent of the reimbursement amount the
  106  provider received. The amount of an offer made by a health plan
  107  to settle an alleged overpayment to the provider must be less
  108  than 90 percent of the alleged overpayment amount by the health
  109  plan. Both parties may agree to settle the disputed claim at any
  110  time, for any amount, regardless of whether an offer to settle
  111  was made or rejected.
  112         (3) The agency shall adopt rules to establish a process to
  113  be used by the resolution organization in considering claim
  114  disputes submitted by a provider or health plan which must
  115  include:
  116         (a) That the resolution organization review and consider
  117  all documentation submitted by both the health plan and the
  118  provider;
  119         (b) That the resolution organization’s recommendation make
  120  findings of fact;
  121         (c) That either party may request that the resolution
  122  organization conduct an evidentiary hearing in which both sides
  123  can present evidence and examine witnesses, and for which the
  124  cost of the hearing is equally shared by the parties;
  125         (d) That the resolution organization may not communicate ex
  126  parte with either the health plan or the provider during the
  127  dispute resolution;
  128         (e) That the resolution organization’s written
  129  recommendation, including findings of fact relating to the
  130  calculation under s. 641.513(5) for the recommended amount due
  131  for the disputed claim, include any evidence relied upon; and
  132         (f)That the issuance by the resolution organization issue
  133  of a written recommendation, supported by findings of fact, to
  134  the agency within 60 days after the requested information is
  135  received by the resolution organization within the timeframes
  136  specified by the resolution organization. In no event shall the
  137  review time exceed 90 days following receipt of the initial
  138  claim dispute submission by the resolution organization.
  139         (4) Within 30 days after receipt of the recommendation of
  140  the resolution organization, the agency shall adopt the
  141  recommendation as a final order. The final order is subject to
  142  judicial review pursuant to s. 120.68.
  143         Section 4. Paragraph (oo) is added to subsection (1) of
  144  section 456.072, Florida Statutes, to read:
  145         456.072 Grounds for discipline; penalties; enforcement.—
  146         (1) The following acts shall constitute grounds for which
  147  the disciplinary actions specified in subsection (2) may be
  148  taken:
  149         (oo)Willfully failing to comply with s. 627.64194 or s.
  150  641.513 with such frequency as to indicate a general business
  151  practice.
  152         Section 5. Paragraph (tt) is added to subsection (1) of
  153  section 458.331, Florida Statutes, to read:
  154         458.331 Grounds for disciplinary action; action by the
  155  board and department.—
  156         (1) The following acts constitute grounds for denial of a
  157  license or disciplinary action, as specified in s. 456.072(2):
  158         (tt)Willfully failing to comply with s. 627.64194 or s.
  159  641.513 with such frequency as to indicate a general business
  160  practice.
  161         Section 6. Paragraph (vv) is added to subsection (1) of
  162  section 459.015, Florida Statutes, to read:
  163         459.015 Grounds for disciplinary action; action by the
  164  board and department.—
  165         (1) The following acts constitute grounds for denial of a
  166  license or disciplinary action, as specified in s. 456.072(2):
  167         (vv)Willfully failing to comply with s. 627.64194 or s.
  168  641.513 with such frequency as to indicate a general business
  169  practice.
  170         Section 7. Paragraph (gg) is added to subsection (1) of
  171  section 626.9541, Florida Statutes, to read:
  172         626.9541 Unfair methods of competition and unfair or
  173  deceptive acts or practices defined.—
  175  ACTS.—The following are defined as unfair methods of competition
  176  and unfair or deceptive acts or practices:
  177         (gg)Out-of-network reimbursement.—Willfully failing to
  178  comply with s. 627.64194 with such frequency as to indicate a
  179  general business practice.
  180         Section 8. Section 627.64194, Florida Statutes, is created
  181  to read:
  182         627.64194Coverage requirements for services provided by
  183  nonparticipating providers; payment collection limitations.—
  184         (1)As used in this section, the term:
  185         (a) “Emergency services” means emergency services and care,
  186  as defined in s. 641.47(8), which are provided in a facility.
  187         (b)“Facility” means a licensed facility as defined in s.
  188  395.002(16) and an urgent care center as defined in s.
  189  395.002(30).
  190         (c)“Insured” means a person who is covered under an
  191  individual or group health insurance policy delivered or issued
  192  for delivery in this state by an insurer authorized to transact
  193  business in this state.
  194         (d) “Nonemergency services” means the services and care
  195  that are not emergency services.
  196         (e)“Nonparticipating provider” means a provider who is not
  197  a preferred provider as defined in s. 627.6471 or a provider who
  198  is not an exclusive provider as defined in s. 627.6472. For
  199  purposes of covered emergency services under this section, a
  200  facility licensed under chapter 395 or an urgent care center
  201  defined in s. 395.002(30) is a nonparticipating provider if the
  202  facility has not contracted with an insurer to provide emergency
  203  services to its insureds at a specified rate.
  204         (f)“Participating provider” means, for purposes of this
  205  section, a preferred provider as defined in s. 627.6471 or an
  206  exclusive provider as defined in s. 627.6472.
  207         (2)An insurer is solely liable for payment of fees to a
  208  nonparticipating provider of covered emergency services provided
  209  to an insured in accordance with the coverage terms of the
  210  health insurance policy, and such insured is not liable for
  211  payment of fees for covered services to a nonparticipating
  212  provider of emergency services, other than applicable
  213  copayments, coinsurance, and deductibles. An insurer must
  214  provide coverage for emergency services that:
  215         (a)May not require prior authorization.
  216         (b)Must be provided regardless of whether the services are
  217  furnished by a participating provider or a nonparticipating
  218  provider.
  219         (c)May impose a coinsurance amount, copayment, or
  220  limitation of benefits requirement for a nonparticipating
  221  provider only if the same requirement applies to a participating
  222  provider.
  224  The provisions of s. 627.638 apply to this subsection.
  225         (3)An insurer is solely liable for payment of fees to a
  226  nonparticipating provider of covered nonemergency services
  227  provided to an insured in accordance with the coverage terms of
  228  the health insurance policy, and such insured is not liable for
  229  payment of fees to a nonparticipating provider, other than
  230  applicable copayments, coinsurance, and deductibles, for covered
  231  nonemergency services that are:
  232         (a)Provided in a facility that has a contract for the
  233  nonemergency services with the insurer which the facility would
  234  be otherwise obligated to provide under contract with the
  235  insurer; and
  236         (b)Provided when the insured does not have the ability and
  237  opportunity to choose a participating provider at the facility
  238  who is available to treat the insured.
  240  The provisions of s. 627.638 apply to this subsection.
  241         (4)An insurer must reimburse a nonparticipating provider
  242  of services under subsections (2) and (3) as specified in s.
  243  641.513(5), reduced only by insured cost share responsibilities
  244  as specified in the health insurance policy, within the
  245  applicable timeframe provided in s. 627.6131.
  246         (5)A nonparticipating provider of emergency services as
  247  provided in subsection (2) or a nonparticipating provider of
  248  nonemergency services as provided in subsection (3) may not be
  249  reimbursed an amount greater than the amount provided in
  250  subsection (4) and may not collect or attempt to collect from
  251  the insured, directly or indirectly, any excess amount, other
  252  than copayments, coinsurance, and deductibles. This section does
  253  not prohibit a nonparticipating provider from collecting or
  254  attempting to collect from the insured an amount due for the
  255  provision of noncovered services.
  256         (6)Any dispute with regard to the reimbursement to the
  257  nonparticipating provider of emergency or nonemergency services
  258  as provided in subsection (4) shall be resolved in a court of
  259  competent jurisdiction or through the voluntary dispute
  260  resolution process in s. 408.7057.
  261         Section 9. Subsection (2) of section 627.6471, Florida
  262  Statutes, is amended to read:
  263         627.6471 Contracts for reduced rates of payment;
  264  limitations; coinsurance and deductibles.—
  265         (2) Any insurer issuing a policy of health insurance in
  266  this state, which insurance includes coverage for the services
  267  of a preferred provider, must provide each policyholder and
  268  certificateholder with a current list of preferred providers and
  269  must make the list available on its website. The list must
  270  include, when applicable and reported, a listing by specialty of
  271  the names, addresses, and telephone numbers of all participating
  272  providers, including facilities, and, in the case of physicians,
  273  must also include board certifications, languages spoken, and
  274  any affiliations with participating hospitals. Information
  275  posted on the insurer’s website must be updated on at least a
  276  calendar-month basis with additions or terminations of providers
  277  from the insurer’s network or reported changes in physicians’
  278  hospital affiliations for public inspection during regular
  279  business hours at the principal office of the insurer within the
  280  state.
  281         Section 10. Effective upon this act becoming a law,
  282  subsection (7) is added to section 627.6471, Florida Statutes,
  283  to read:
  284         627.6471 Contracts for reduced rates of payment;
  285  limitations; coinsurance and deductibles.—
  286         (7)Any policy issued under this section after January 1,
  287  2017, must include the following disclosure: “WARNING: LIMITED
  289  You should be aware that when you elect to utilize the services
  290  of a nonparticipating provider for a covered nonemergency
  291  service, benefit payments to the provider are not based upon the
  292  amount the provider charges. The basis of the payment will be
  293  determined according to your policy’s out-of-network
  294  reimbursement benefit. Nonparticipating providers may bill
  295  insureds for any difference in the amount. YOU MAY BE REQUIRED
  297  Participating providers have agreed to accept discounted
  298  payments for services with no additional billing to you other
  299  than coinsurance, copayment, and deductible amounts. You may
  300  obtain further information about the providers who have
  301  contracted with your insurance plan by consulting your insurer’s
  302  website or contacting your insurer or agent directly.”
  303         Section 11. Subsection (15) is added to section 627.662,
  304  Florida Statutes, to read:
  305         627.662 Other provisions applicable.—The following
  306  provisions apply to group health insurance, blanket health
  307  insurance, and franchise health insurance:
  308         (15)Section 627.64194, relating to coverage requirements
  309  for services provided by nonparticipating providers and payment
  310  collection limitations.
  311         Section 12. Except as otherwise expressly provided in this
  312  act and except for this section, which shall take effect upon
  313  this act becoming a law, this act shall take effect October 1,
  314  2016.