Florida Senate - 2018 COMMITTEE AMENDMENT
Bill No. SB 1422
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LEGISLATIVE ACTION
Senate . House
Comm: RCS .
02/06/2018 .
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The Committee on Banking and Insurance (Rouson) recommended the
following:
1 Senate Amendment (with title amendment)
2
3 Delete lines 96 - 304
4 and insert:
5 2008 (MHPAEA), and any federal guidance or regulations relating
6 to MHPAEA, including, but not limited to, 45 C.F.R. s. 146.136,
7 45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3).
8 Section 2. Paragraph (b) of subsection (8) of section
9 627.6675, Florida Statutes, is amended to read:
10 627.6675 Conversion on termination of eligibility.—Subject
11 to all of the provisions of this section, a group policy
12 delivered or issued for delivery in this state by an insurer or
13 nonprofit health care services plan that provides, on an
14 expense-incurred basis, hospital, surgical, or major medical
15 expense insurance, or any combination of these coverages, shall
16 provide that an employee or member whose insurance under the
17 group policy has been terminated for any reason, including
18 discontinuance of the group policy in its entirety or with
19 respect to an insured class, and who has been continuously
20 insured under the group policy, and under any group policy
21 providing similar benefits that the terminated group policy
22 replaced, for at least 3 months immediately prior to
23 termination, shall be entitled to have issued to him or her by
24 the insurer a policy or certificate of health insurance,
25 referred to in this section as a “converted policy.” A group
26 insurer may meet the requirements of this section by contracting
27 with another insurer, authorized in this state, to issue an
28 individual converted policy, which policy has been approved by
29 the office under s. 627.410. An employee or member shall not be
30 entitled to a converted policy if termination of his or her
31 insurance under the group policy occurred because he or she
32 failed to pay any required contribution, or because any
33 discontinued group coverage was replaced by similar group
34 coverage within 31 days after discontinuance.
35 (8) BENEFITS OFFERED.—
36 (b) An insurer shall offer the benefits specified in s.
37 627.4193 s. 627.668 and the benefits specified in s. 627.669 if
38 those benefits were provided in the group plan.
39 Section 3. Section 627.668, Florida Statutes, is
40 transferred, renumbered as section 627.4193, Florida Statutes,
41 and amended, to read:
42 627.4193 627.668 Requirements for mental health and
43 substance use disorder benefits; reporting requirements Optional
44 coverage for mental and nervous disorders required; exception.—
45 (1) Every insurer, health maintenance organization, and
46 nonprofit hospital and medical service plan corporation
47 transacting individual or group health insurance or providing
48 prepaid health care in this state must comply with the federal
49 Paul Wellstone and Pete Domenici Mental Health Parity and
50 Addiction Equity Act of 2008 (MHPAEA) and any regulations
51 relating to MHPAEA, including, but not limited to, 45 C.F.R. s.
52 146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3);
53 and must provide shall make available to the policyholder as
54 part of the application, for an appropriate additional premium
55 under a group hospital and medical expense-incurred insurance
56 policy, under a group prepaid health care contract, and under a
57 group hospital and medical service plan contract, the benefits
58 or level of benefits specified in subsection (2) for the
59 necessary care and treatment of mental and nervous disorders,
60 including substance use disorders, as defined in the Diagnostic
61 and Statistical Manual of Mental Disorders, Fifth Edition,
62 published by standard nomenclature of the American Psychiatric
63 Association, subject to the right of the applicant for a group
64 policy or contract to select any alternative benefits or level
65 of benefits as may be offered by the insurer, health maintenance
66 organization, or service plan corporation provided that, if
67 alternate inpatient, outpatient, or partial hospitalization
68 benefits are selected, such benefits shall not be less than the
69 level of benefits required under paragraph (2)(a), paragraph
70 (2)(b), or paragraph (2)(c), respectively.
71 (2) Under individual or group policies or contracts,
72 inpatient hospital benefits, partial hospitalization benefits,
73 and outpatient benefits consisting of durational limits, dollar
74 amounts, deductibles, and coinsurance factors may shall not be
75 less favorable than for physical illness, in accordance with 45
76 C.F.R. s. 146.136(c)(2) and (3) generally, except that:
77 (a) Inpatient benefits may be limited to not less than 30
78 days per benefit year as defined in the policy or contract. If
79 inpatient hospital benefits are provided beyond 30 days per
80 benefit year, the durational limits, dollar amounts, and
81 coinsurance factors thereto need not be the same as applicable
82 to physical illness generally.
83 (b) Outpatient benefits may be limited to $1,000 for
84 consultations with a licensed physician, a psychologist licensed
85 pursuant to chapter 490, a mental health counselor licensed
86 pursuant to chapter 491, a marriage and family therapist
87 licensed pursuant to chapter 491, and a clinical social worker
88 licensed pursuant to chapter 491. If benefits are provided
89 beyond the $1,000 per benefit year, the durational limits,
90 dollar amounts, and coinsurance factors thereof need not be the
91 same as applicable to physical illness generally.
92 (c) Partial hospitalization benefits shall be provided
93 under the direction of a licensed physician. For purposes of
94 this part, the term “partial hospitalization services” is
95 defined as those services offered by a program that is
96 accredited by an accrediting organization whose standards
97 incorporate comparable regulations required by this state.
98 Alcohol rehabilitation programs accredited by an accrediting
99 organization whose standards incorporate comparable regulations
100 required by this state or approved by the state and licensed
101 drug abuse rehabilitation programs shall also be qualified
102 providers under this section. In a given benefit year, if
103 partial hospitalization services or a combination of inpatient
104 and partial hospitalization are used, the total benefits paid
105 for all such services may not exceed the cost of 30 days after
106 inpatient hospitalization for psychiatric services, including
107 physician fees, which prevail in the community in which the
108 partial hospitalization services are rendered. If partial
109 hospitalization services benefits are provided beyond the limits
110 set forth in this paragraph, the durational limits, dollar
111 amounts, and coinsurance factors thereof need not be the same as
112 those applicable to physical illness generally.
113 (3) Insurers must maintain strict confidentiality regarding
114 psychiatric and psychotherapeutic records submitted to an
115 insurer for the purpose of reviewing a claim for benefits
116 payable under this section. These records submitted to an
117 insurer are subject to the limitations of s. 456.057, relating
118 to the furnishing of patient records.
119 (4) Every insurer, health maintenance organization, and
120 nonprofit hospital and medical service plan corporation
121 transacting individual or group health insurance or providing
122 prepaid health care in this state shall submit an annual report
123 to the office, on or before July 1, which contains all of the
124 following information:
125 (a) A description of the process used to develop or select
126 the medical necessity criteria for:
127 1. Mental or nervous disorder benefits;
128 2. Substance use disorder benefits; and
129 3. Medical and surgical benefits.
130 (b) Identification of all nonquantitative treatment
131 limitations (NQTLs) applied to both mental or nervous disorder
132 and substance use disorder benefits and medical and surgical
133 benefits. Within any classification of benefits, there may not
134 be separate NQTLs that apply to mental or nervous disorder and
135 substance use disorder benefits but do not apply to medical and
136 surgical benefits.
137 (c) The results of an analysis demonstrating that for the
138 medical necessity criteria described in paragraph (a) and for
139 each NQTL identified in paragraph (b), as written and in
140 operation, the processes, strategies, evidentiary standards, or
141 other factors used to apply the criteria and NQTLs to mental or
142 nervous disorder and substance use disorder benefits are
143 comparable to, and are applied no more stringently than, the
144 processes, strategies, evidentiary standards, or other factors
145 used to apply the criteria and NQTLs, as written and in
146 operation, to medical and surgical benefits. At a minimum, the
147 results of the analysis must:
148 1. Identify the factors used to determine that an NQTL will
149 apply to a benefit, including factors that were considered but
150 rejected;
151 2. Identify and define the specific evidentiary standards
152 used to define the factors and any other evidentiary standards
153 relied upon in designing each NQTL;
154 3. Identify and describe the methods and analyses used,
155 including the results of the analyses, to determine that the
156 processes and strategies used to design each NQTL, as written,
157 for mental or nervous disorder and substance use disorder
158 benefits are comparable to, and no more stringently applied
159 than, the processes and strategies used to design each NQTL, as
160 written, for medical and surgical benefits;
161 4. Identify and describe the methods and analyses used,
162 including the results of the analyses, to determine that
163 processes and strategies used to apply each NQTL, in operation,
164 for mental or nervous disorder and substance use disorder
165 benefits are comparable to and no more stringently applied than
166 the processes or strategies used to apply each NQTL, in
167 operation, for medical and surgical benefits; and
168 5. Disclose the specific findings and conclusions reached
169 by the insurer, health maintenance organization, or nonprofit
170 hospital and medical service plan corporation that the results
171 of the analyses indicate that the insurer, health maintenance
172 organization, or nonprofit hospital and medical service plan
173 corporation is in compliance with this section; MHPAEA; and any
174 regulations relating to MHPAEA, including, but not limited to,
175 45 C.F.R. s. 146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s.
176 156.115(a)(3).
177 (5) The office shall implement and enforce applicable
178 provisions of MHPAEA and federal guidance or regulations
179 relating to MHPAEA, including, but not limited to, 45 C.F.R. s.
180 146.136, 45 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3),
181 and this section, which includes:
182 (a) Ensuring compliance by each insurer, health maintenance
183 organization, and nonprofit hospital and medical service plan
184 corporation transacting individual or group health insurance or
185 providing prepaid health care in this state.
186 (b) Detecting violations by any insurer, health maintenance
187 organization, or nonprofit hospital and medical service plan
188 corporation transacting individual or group health insurance or
189 providing prepaid health care in this state.
190 (c) Accepting, evaluating, and responding to complaints
191 regarding potential violations.
192 (d) Reviewing, from consumer complaints, for possible
193 parity violations regarding mental or nervous disorder and
194 substance use disorder coverage.
195 (e) Performing parity compliance market conduct
196 examinations, which include, but are not limited to, reviews of
197 medical management practices, network adequacy, reimbursement
198 rates, prior authorizations, and geographic restrictions of
199 insurers, health maintenance organizations, and nonprofit
200 hospital and medical service plan corporations transacting
201 individual or group health insurance or providing prepaid health
202 care in this state.
203 (6) No later than December 31 of each year, the office
204 shall issue a report to the Legislature which describes the
205 methodology the office is using to check for compliance with
206 MHPAEA; any federal guidance or regulations that relate to
207 MHPAEA, including, but not limited to, 45 C.F.R. s. 146.136, 45
208 C.F.R. s. 147.160, and 45 C.F.R. s. 156.115(a)(3); and this
209 section. The report must be written in nontechnical and readily
210 understandable language and must be made available to the public
211 by posting the report on the office’s website and by other means
212 the office finds appropriate.
213 Section 4. Section 627.669, Florida Statutes, is repealed.
214
215 ================= T I T L E A M E N D M E N T ================
216 And the title is amended as follows:
217 Delete lines 10 - 31
218 and insert:
219 F.S.; conforming a provision to changes made by the
220 act; transferring, renumbering, and amending s.
221 627.668, F.S.; deleting certain provisions that
222 require insurers, health maintenance organizations,
223 and nonprofit hospital and medical service plan
224 organizations transacting group health insurance or
225 providing prepaid health care to offer specified
226 optional coverage for mental and nervous disorders;
227 requiring such entities transacting individual or
228 group health insurance or providing prepaid health
229 care to comply with specified provisions prohibiting
230 the imposition of less favorable benefit limitations
231 on mental health and substance use disorder benefits
232 than on medical and surgical benefits; revising the
233 standard for defining substance use disorders;
234 requiring such entities to submit a specified annual
235 report relating to parity between such benefits to the
236 Office of Insurance Regulation; requiring the office
237 to implement and enforce specified federal provisions,
238 guidance, and regulations; specifying actions the
239 office must take relating to such implementation and
240 enforcement; requiring the office to issue a specified
241 annual report to the Legislature; repealing s.
242 627.669, F.S., relating to optional coverage required
243 for substance abuse impaired persons; providing an
244 effective