Florida Senate - 2016 SENATOR AMENDMENT
Bill No. CS/CS/CS/HB 221, 1st Eng.
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LEGISLATIVE ACTION
Senate . House
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Floor: 1/AD/RM . Floor: SENAT/CA
03/11/2016 05:25 PM . 03/11/2016 05:48 PM
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Senator Garcia moved the following:
1 Senate Amendment (with title amendment)
2
3 Delete everything after the enacting clause
4 and insert:
5 Section 1. Paragraph (b) of subsection (3) of section
6 627.6686, Florida Statutes, is amended to read:
7 627.6686 Coverage for individuals with autism spectrum
8 disorder required; exception.—
9 (3) A health insurance plan issued or renewed on or after
10 April 1, 2009, shall provide coverage to an eligible individual
11 for:
12 (b) Treatment of autism spectrum disorder and developmental
13 disability as defined in s. 393.063(9) through speech therapy,
14 occupational therapy, physical therapy, and applied behavior
15 analysis. Applied behavior analysis services shall be provided
16 by an individual certified pursuant to s. 393.17 or an
17 individual licensed under chapter 490 or chapter 491.
18 Section 2. Paragraph (b) of subsection (3) of section
19 641.31098, Florida Statutes, is amended to read:
20 641.31098 Coverage for individuals with developmental
21 disabilities.—
22 (3) A health maintenance contract issued or renewed on or
23 after April 1, 2009, shall provide coverage to an eligible
24 individual for:
25 (b) Treatment of autism spectrum disorder and developmental
26 disability, as defined in s. 393.063(9), through speech therapy,
27 occupational therapy, physical therapy, and applied behavior
28 analysis services. Applied behavior analysis services shall be
29 provided by an individual certified pursuant to s. 393.17 or an
30 individual licensed under chapter 490 or chapter 491.
31 Section 3. Subsection (11) of section 627.6131, Florida
32 Statutes, is amended to read:
33 627.6131 Payment of claims.—
34 (11) A health insurer may not retroactively deny a claim
35 because of insured ineligibility:
36 (a) At any time, if the health insurer verified the
37 eligibility of an insured who is not a recipient of advance
38 payments of the federal premium tax credit and the insurer
39 issued an authorization for payment to a provider.
40 (b) For services authorized by the insurer and rendered
41 during the first 30 days of a federally required grace period
42 when an insured is a recipient of advance payments of the
43 federal premium tax credit.
44 (c) More than 1 year after the date of payment of the
45 claim.
46 Section 4. Subsection (10) of section 641.3155, Florida
47 Statutes, is amended to read:
48 641.3155 Prompt payment of claims.—
49 (10) A health maintenance organization may not
50 retroactively deny a claim because of subscriber ineligibility:
51 (a) At any time, if the health maintenance organization
52 verified the eligibility of a subscriber who is not a recipient
53 of advance payments of the federal premium tax credit and the
54 health maintenance organization issued an authorization for
55 payment to a provider.
56 (b) For services authorized by the health maintenance
57 organization and rendered during the first 30 days of a
58 federally required grace period when a subscriber is a recipient
59 of advance payments of the federal premium tax credit.
60 (c) More than 1 year after the date of payment of the
61 claim.
62 Section 5. Paragraph (d) is added to subsection (5) of
63 section 395.003, Florida Statutes, to read:
64 395.003 Licensure; denial, suspension, and revocation.—
65 (5)
66 (d) A hospital, an ambulatory surgical center, a specialty
67 hospital, or an urgent care center shall comply with ss.
68 627.64194 and 641.513 as a condition of licensure.
69 Section 6. Subsection (13) is added to section 395.301,
70 Florida Statutes, to read:
71 395.301 Itemized patient bill; form and content prescribed
72 by the agency; patient admission status notification.—
73 (13) A hospital shall post on its website:
74 (a) The names and hyperlinks for direct access to the
75 websites of all health insurers and health maintenance
76 organizations for which the hospital contracts as a network
77 provider or participating provider.
78 (b) A statement that:
79 1. Services may be provided in the hospital by the facility
80 as well as by other health care practitioners who may separately
81 bill the patient;
82 2. Health care practitioners who provide services in the
83 hospital may or may not participate with the same health
84 insurers or health maintenance organizations as the hospital;
85 and
86 3. Prospective patients should contact the health care
87 practitioner who will provide services in the hospital to
88 determine which health insurers and health maintenance
89 organizations the practitioner participates in as a network
90 provider or preferred provider.
91 (c) As applicable, the names, mailing addresses, and
92 telephone numbers of the health care practitioners and medical
93 practice groups with which it contracts to provide services in
94 the hospital, and instructions on how to contact the
95 practitioners and groups to determine which health insurers and
96 health maintenance organizations they participate in as network
97 providers or preferred providers.
98 Section 7. Paragraph (h) is added to subsection (2) of
99 section 408.7057, Florida Statutes, and subsections (3) and (4)
100 of that section are amended, to read:
101 408.7057 Statewide provider and health plan claim dispute
102 resolution program.—
103 (2)
104 (h) Either the contracted or noncontracted provider or the
105 health plan may make an offer to settle the claim dispute when
106 it submits a request for a claim dispute and supporting
107 documentation. The offer to settle the claim dispute must state
108 its total amount, and the party to whom it is directed has 15
109 days to accept the offer once it is received. If the party
110 receiving the offer does not accept the offer and the final
111 order amount is more than 90 percent or less than 110 percent of
112 the offer amount, the party receiving the offer must pay the
113 final order amount to the offering party and is deemed a
114 nonprevailing party for purposes of this section. The amount of
115 an offer made by a contracted or noncontracted provider to
116 settle an alleged underpayment by the health plan must be
117 greater than 110 percent of the reimbursement amount the
118 provider received. The amount of an offer made by a health plan
119 to settle an alleged overpayment to the provider must be less
120 than 90 percent of the alleged overpayment amount by the health
121 plan. Both parties may agree to settle the disputed claim at any
122 time, for any amount, regardless of whether an offer to settle
123 was made or rejected.
124 (3) The agency shall adopt rules to establish a process to
125 be used by the resolution organization in considering claim
126 disputes submitted by a provider or health plan which must
127 include:
128 (a) That the resolution organization review and consider
129 all documentation submitted by both the health plan and the
130 provider;
131 (b) That the resolution organization’s recommendation make
132 findings of fact;
133 (c) That either party may request that the resolution
134 organization conduct an evidentiary hearing in which both sides
135 can present evidence and examine witnesses, and for which the
136 cost of the hearing is equally shared by the parties;
137 (d) That the resolution organization may not communicate ex
138 parte with either the health plan or the provider during the
139 dispute resolution;
140 (e) That the resolution organization’s written
141 recommendation, including findings of fact relating to the
142 calculation under s. 641.513(5) for the recommended amount due
143 for the disputed claim, include any evidence relied upon; and
144 (f) That the issuance by the resolution organization issue
145 of a written recommendation, supported by findings of fact, to
146 the agency within 60 days after the requested information is
147 received by the resolution organization within the timeframes
148 specified by the resolution organization. In no event shall the
149 review time exceed 90 days following receipt of the initial
150 claim dispute submission by the resolution organization.
151 (4) Within 30 days after receipt of the recommendation of
152 the resolution organization, the agency shall adopt the
153 recommendation as a final order. The final order is subject to
154 judicial review pursuant to s. 120.68.
155 Section 8. Paragraph (oo) is added to subsection (1) of
156 section 456.072, Florida Statutes, to read:
157 456.072 Grounds for discipline; penalties; enforcement.—
158 (1) The following acts shall constitute grounds for which
159 the disciplinary actions specified in subsection (2) may be
160 taken:
161 (oo) Willfully failing to comply with s. 627.64194 or s.
162 641.513 with such frequency as to indicate a general business
163 practice.
164 Section 9. Paragraph (tt) is added to subsection (1) of
165 section 458.331, Florida Statutes, to read:
166 458.331 Grounds for disciplinary action; action by the
167 board and department.—
168 (1) The following acts constitute grounds for denial of a
169 license or disciplinary action, as specified in s. 456.072(2):
170 (tt) Willfully failing to comply with s. 627.64194 or s.
171 641.513 with such frequency as to indicate a general business
172 practice.
173 Section 10. Paragraph (vv) is added to subsection (1) of
174 section 459.015, Florida Statutes, to read:
175 459.015 Grounds for disciplinary action; action by the
176 board and department.—
177 (1) The following acts constitute grounds for denial of a
178 license or disciplinary action, as specified in s. 456.072(2):
179 (vv) Willfully failing to comply with s. 627.64194 or s.
180 641.513 with such frequency as to indicate a general business
181 practice.
182 Section 11. Paragraph (gg) is added to subsection (1) of
183 section 626.9541, Florida Statutes, to read:
184 626.9541 Unfair methods of competition and unfair or
185 deceptive acts or practices defined.—
186 (1) UNFAIR METHODS OF COMPETITION AND UNFAIR OR DECEPTIVE
187 ACTS.—The following are defined as unfair methods of competition
188 and unfair or deceptive acts or practices:
189 (gg) Out-of-network reimbursement.—Willfully failing to
190 comply with s. 627.64194 with such frequency as to indicate a
191 general business practice.
192 Section 12. Section 627.64194, Florida Statutes, is created
193 to read:
194 627.64194 Coverage requirements for services provided by
195 nonparticipating providers; payment collection limitations.—
196 (1) As used in this section, the term:
197 (a) “Emergency services” means emergency services and care,
198 as defined in s. 641.47(8), which are provided in a facility.
199 (b) “Facility” means a licensed facility as defined in s.
200 395.002(16) and an urgent care center as defined in s.
201 395.002(30).
202 (c) “Insured” means a person who is covered under an
203 individual or group health insurance policy delivered or issued
204 for delivery in this state by an insurer authorized to transact
205 business in this state.
206 (d) “Nonemergency services” means the services and care
207 that are not emergency services.
208 (e) “Nonparticipating provider” means a provider who is not
209 a preferred provider as defined in s. 627.6471 or a provider who
210 is not an exclusive provider as defined in s. 627.6472. For
211 purposes of covered emergency services under this section, a
212 facility licensed under chapter 395 or an urgent care center
213 defined in s. 395.002(30) is a nonparticipating provider if the
214 facility has not contracted with an insurer to provide emergency
215 services to its insureds at a specified rate.
216 (f) “Participating provider” means, for purposes of this
217 section, a preferred provider as defined in s. 627.6471 or an
218 exclusive provider as defined in s. 627.6472.
219 (2) An insurer is solely liable for payment of fees to a
220 nonparticipating provider of covered emergency services provided
221 to an insured in accordance with the coverage terms of the
222 health insurance policy, and such insured is not liable for
223 payment of fees for covered services to a nonparticipating
224 provider of emergency services, other than applicable
225 copayments, coinsurance, and deductibles. An insurer must
226 provide coverage for emergency services that:
227 (a) May not require prior authorization.
228 (b) Must be provided regardless of whether the services are
229 furnished by a participating provider or a nonparticipating
230 provider.
231 (c) May impose a coinsurance amount, copayment, or
232 limitation of benefits requirement for a nonparticipating
233 provider only if the same requirement applies to a participating
234 provider.
235
236 The provisions of s. 627.638 apply to this subsection.
237 (3) An insurer is solely liable for payment of fees to a
238 nonparticipating provider of covered nonemergency services
239 provided to an insured in accordance with the coverage terms of
240 the health insurance policy, and such insured is not liable for
241 payment of fees to a nonparticipating provider, other than
242 applicable copayments, coinsurance, and deductibles, for covered
243 nonemergency services that are:
244 (a) Provided in a facility that has a contract for the
245 nonemergency services with the insurer which the facility would
246 be otherwise obligated to provide under contract with the
247 insurer; and
248 (b) Provided when the insured does not have the ability and
249 opportunity to choose a participating provider at the facility
250 who is available to treat the insured.
251
252 The provisions of s. 627.638 apply to this subsection.
253 (4) An insurer must reimburse a nonparticipating provider
254 of services under subsections (2) and (3) as specified in s.
255 641.513(5), reduced only by insured cost share responsibilities
256 as specified in the health insurance policy, within the
257 applicable timeframe provided in s. 627.6131.
258 (5) A nonparticipating provider of emergency services as
259 provided in subsection (2) or a nonparticipating provider of
260 nonemergency services as provided in subsection (3) may not be
261 reimbursed an amount greater than the amount provided in
262 subsection (4) and may not collect or attempt to collect from
263 the insured, directly or indirectly, any excess amount, other
264 than copayments, coinsurance, and deductibles. This section does
265 not prohibit a nonparticipating provider from collecting or
266 attempting to collect from the insured an amount due for the
267 provision of noncovered services.
268 (6) Any dispute with regard to the reimbursement to the
269 nonparticipating provider of emergency or nonemergency services
270 as provided in subsection (4) shall be resolved in a court of
271 competent jurisdiction or through the voluntary dispute
272 resolution process in s. 408.7057.
273 Section 13. Subsection (2) of section 627.6471, Florida
274 Statutes, is amended to read:
275 627.6471 Contracts for reduced rates of payment;
276 limitations; coinsurance and deductibles.—
277 (2) Any insurer issuing a policy of health insurance in
278 this state, which insurance includes coverage for the services
279 of a preferred provider, must provide each policyholder and
280 certificateholder with a current list of preferred providers and
281 must make the list available on its website. The list must
282 include, when applicable and reported, a listing by specialty of
283 the names, addresses, and telephone numbers of all participating
284 providers, including facilities, and, in the case of physicians,
285 must also include board certifications, languages spoken, and
286 any affiliations with participating hospitals. Information
287 posted on the insurer’s website must be updated on at least a
288 calendar-month basis with additions or terminations of providers
289 from the insurer’s network or reported changes in physicians’
290 hospital affiliations for public inspection during regular
291 business hours at the principal office of the insurer within the
292 state.
293 Section 14. Effective upon this act becoming a law,
294 subsection (7) is added to section 627.6471, Florida Statutes,
295 to read:
296 627.6471 Contracts for reduced rates of payment;
297 limitations; coinsurance and deductibles.—
298 (7) Any policy issued under this section after January 1,
299 2017, must include the following disclosure: “WARNING: LIMITED
300 BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED.
301 You should be aware that when you elect to utilize the services
302 of a nonparticipating provider for a covered nonemergency
303 service, benefit payments to the provider are not based upon the
304 amount the provider charges. The basis of the payment will be
305 determined according to your policy’s out-of-network
306 reimbursement benefit. Nonparticipating providers may bill
307 insureds for any difference in the amount. YOU MAY BE REQUIRED
308 TO PAY MORE THAN THE COINSURANCE OR COPAYMENT AMOUNT.
309 Participating providers have agreed to accept discounted
310 payments for services with no additional billing to you other
311 than coinsurance, copayment, and deductible amounts. You may
312 obtain further information about the providers who have
313 contracted with your insurance plan by consulting your insurer’s
314 website or contacting your insurer or agent directly.”
315 Section 15. Subsection (15) is added to section 627.662,
316 Florida Statutes, to read:
317 627.662 Other provisions applicable.—The following
318 provisions apply to group health insurance, blanket health
319 insurance, and franchise health insurance:
320 (15) Section 627.64194, relating to coverage requirements
321 for services provided by nonparticipating providers and payment
322 collection limitations.
323 Section 16. Except as otherwise expressly provided in this
324 act and except for this section, which shall take effect upon
325 this act becoming a law, this act shall take effect July 1,
326 2016.
327
328 ================= T I T L E A M E N D M E N T ================
329 And the title is amended as follows:
330 Delete everything before the enacting clause
331 and insert:
332 A bill to be entitled
333 An act relating to health care services; amending s.
334 627.6686, F.S.; requiring a specified health insurance
335 plan to provide specified coverage for treatment of a
336 developmental disability; amending s. 641.31098, F.S.;
337 requiring a specified health maintenance contract to
338 provide specified coverage for treatment of a
339 developmental disability; amending s. 627.6131, F.S.;
340 prohibiting a health insurer from retroactively
341 denying a claim under specified circumstances;
342 amending s. 641.3155, F.S.; prohibiting a health
343 maintenance organization from retroactively denying a
344 claim under specified circumstances; amending s.
345 395.003, F.S.; requiring hospitals, ambulatory
346 surgical centers, specialty hospitals, and urgent care
347 centers to comply with certain provisions as a
348 condition of licensure; amending s. 395.301, F.S.;
349 requiring a hospital to post on its website certain
350 information regarding health insurers, health
351 maintenance organizations, health care practitioners,
352 and practice groups that it contracts with, and a
353 specified disclosure statement; amending s. 408.7057,
354 F.S.; providing requirements for settlement offers
355 between certain providers and health plans in a
356 specified dispute resolution program; requiring the
357 Agency for Health Care Administration to include in
358 its rules additional requirements relating to a
359 resolution organization’s process in considering
360 certain claim disputes; requiring a final order to be
361 subject to judicial review; amending ss. 456.072,
362 458.331, and 459.015, F.S.; providing additional acts
363 that constitute grounds for denial of a license or
364 disciplinary action to which penalties apply; amending
365 s. 626.9541, F.S.; specifying an additional unfair
366 method of competition and unfair or deceptive act or
367 practice; creating s. 627.64194, F.S.; defining terms;
368 providing that an insurer is solely liable for payment
369 of certain fees to a nonparticipating provider;
370 providing limitations and requirements for
371 reimbursements by an insurer to a nonparticipating
372 provider; providing that certain disputes relating to
373 reimbursement of a nonparticipating provider shall be
374 resolved in a court of competent jurisdiction or
375 through a specified voluntary dispute resolution
376 process; amending s. 627.6471, F.S.; requiring an
377 insurer that issues a policy including coverage for
378 the services of a preferred provider to post on its
379 website certain information about participating
380 providers and physicians; requiring that specified
381 notice be included in policies issued after a
382 specified date which provide coverage for the services
383 of a preferred provider; amending s. 627.662, F.S.;
384 providing applicability of provisions relating to
385 coverage for services and payment collection
386 limitations to group health insurance, blanket health
387 insurance, and franchise health insurance; providing
388 effective dates.