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.
47
48 Be It Enacted by the Legislature of the State of Florida:
49
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.—
174 (1) UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE
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:
182 627.64194 Coverage 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.
223
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.
239
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
288 BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED.
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
296 TO PAY MORE THAN THE COINSURANCE OR COPAYMENT AMOUNT.
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.