Florida Senate - 2015                        COMMITTEE AMENDMENT
       Bill No. SB 784
       
       
       
       
       
       
                                Ì9320761Î932076                         
       
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                  Comm: RCS            .                                
                  03/04/2015           .                                
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       The Committee on Banking and Insurance (Montford) recommended
       the following:
       
    1         Senate Amendment (with title amendment)
    2  
    3         Delete lines 254 - 491
    4  and insert:
    5         condition for the covered patient.
    6         (a) For purposes of this section, the term, “a coverage
    7  limitation imposed at the point of service” means a limitation
    8  that is not universally applicable to all covered lives, but
    9  instead depends on an insurer’s consideration of specific
   10  patient characteristics and conditions that have been reported
   11  by a physician in the process of providing medical care.
   12         (b) The term “sufficient clinical evidence” means:
   13         1. A body of research consisting of well-controlled studies
   14  conducted by independent researchers and published in peer
   15  reviewed journals or comparable publications which consistently
   16  support the treatment protocol or other coverage limitation as a
   17  best practice for the specific diagnosis or combination of
   18  presenting complaints.
   19         2. Results of a multivariate predictive model which
   20  indicate that the probability of achieving desired outcomes is
   21  not negatively altered or delayed by adherence to the proposed
   22  protocol.
   23         (2) The Clinical Practices Review Commission established
   24  under s. 402.90 shall determine whether sufficient clinical
   25  evidence exists for a proposed coverage limitation imposed by
   26  the insurer at the point of service. In each instance in which
   27  the commission finds that sufficient clinical evidence exists to
   28  support a coverage limitation, the office shall approve the
   29  coverage limitation.
   30         (3) If an insurer, without the approval of the office,
   31  imposes a coverage limitation at the point of service,
   32  including, but not limited to, a prior authorization procedure,
   33  step therapy requirement, treatment protocol, or other
   34  utilization management procedure that restricts access to
   35  covered services, the insurer and its chief medical officer
   36  shall be liable for any injuries or damages, as defined in s.
   37  766.202, and economic damages, as defined in s. 768.81(1)(b),
   38  that result from the restricted access to services determined
   39  medically necessary by the physician treating the patient. An
   40  insurer that imposes such a coverage limitation at the point of
   41  service shall establish reserves sufficient to pay for such
   42  damages.
   43         Section 5. Subsection (2) of section 627.642, Florida
   44  Statutes, is amended to read:
   45         627.642 Outline of coverage.—
   46         (2) The outline of coverage must shall contain:
   47         (a) A statement identifying the applicable category of
   48  coverage afforded by the policy, based on the minimum basic
   49  standards set forth in the rules issued to effect compliance
   50  with s. 627.643.
   51         (b) A brief description of the principal benefits and
   52  coverage provided in the policy.
   53         (c) A summary statement of the principal exclusions and
   54  limitations or reductions contained in the policy, including,
   55  but not limited to, preexisting conditions, probationary
   56  periods, elimination periods, deductibles, coinsurance, and any
   57  age limitations or reductions.
   58         (d)A summary statement identifying specific prescription
   59  drugs that are subject to prior authorization, step therapy, or
   60  any other coverage limitation and the applicable coverage
   61  limitation policy or protocol. The insurer shall post the
   62  summary statement at a prominent and readily accessible location
   63  on the Internet.
   64         (e)A summary statement identifying any specific diagnostic
   65  or therapeutic procedures that are subject to prior
   66  authorization or other coverage limitations and the applicable
   67  coverage limitation policy or protocol. The insurer shall post
   68  the summary statement at a prominent and readily accessible
   69  location on the Internet.
   70         (f)(d) A summary statement of the renewal and cancellation
   71  provisions, including any reservation of the insurer of a right
   72  to change premiums.
   73         (g)(e) A statement that the outline contains a summary only
   74  of the details of the policy as issued or of the policy as
   75  applied for and that the issued policy should be referred to for
   76  the actual contractual governing provisions.
   77         (h)(f) When home health care coverage is provided, a
   78  statement that such benefits are provided in the policy.
   79         Section 6. Subsection (2) of section 627.6471, Florida
   80  Statutes, is amended to read:
   81         627.6471 Contracts for reduced rates of payment;
   82  limitations; coinsurance and deductibles.—
   83         (2) An Any insurer issuing a policy of health insurance in
   84  this state that, which insurance includes coverage for the
   85  services of a preferred provider, must provide each policyholder
   86  and certificateholder with a current list of preferred
   87  providers, and must make the list available for public
   88  inspection during regular business hours at the principal office
   89  of the insurer within the state, and must post a link to the
   90  list of preferred providers on the home page of the insurer’s
   91  website. Such insurer must post on its website a change to the
   92  list of preferred providers within 10 business days after such
   93  change.
   94         Section 7. Subsection (4) of section 627.651, Florida
   95  Statutes, is amended to read:
   96         627.651 Group contracts and plans of self-insurance must
   97  meet group requirements.—
   98         (4) This section does not apply to any plan that which is
   99  established or maintained by an individual employer in
  100  accordance with the Employee Retirement Income Security Act of
  101  1974, Pub. L. No. 93-406, or to a multiple-employer welfare
  102  arrangement as defined in s. 624.437(1), except that a multiple
  103  employer welfare arrangement shall comply with ss. 627.419,
  104  627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
  105  627.66122, 627.6615, 627.6616, and 627.662(8) 627.662(7). This
  106  subsection does not allow an authorized insurer to issue a group
  107  health insurance policy or certificate which does not comply
  108  with this part.
  109         Section 8. Present subsections (7) through (14) of section
  110  627.662, Florida Statutes, are redesignated as subsections (8)
  111  through (15), respectively, and a new subsection (7) is added to
  112  that section, to read:
  113         627.662 Other provisions applicable.—The following
  114  provisions apply to group health insurance, blanket health
  115  insurance, and franchise health insurance:
  116         (7) Section 627.642(2)(d) and (e), relating to coverage
  117  limitations on prescription drugs and diagnostic or therapeutic
  118  procedures.
  119         Section 9. Paragraph (b) of subsection (12) of section
  120  627.6699, Florida Statutes, is amended to read:
  121         627.6699 Employee Health Care Access Act.—
  122         (12) STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED HEALTH
  123  BENEFIT PLANS.—
  124         (b)1. Each small employer carrier issuing new health
  125  benefit plans shall offer to any small employer, upon request, a
  126  standard health benefit plan, a basic health benefit plan, and a
  127  high deductible plan that meets the requirements of a health
  128  savings account plan as defined by federal law or a health
  129  reimbursement arrangement as authorized by the Internal Revenue
  130  Service, which that meet the criteria set forth in this section.
  131         2. For purposes of this subsection, the terms “standard
  132  health benefit plan,” “basic health benefit plan,” and “high
  133  deductible plan” mean policies or contracts that a small
  134  employer carrier offers to eligible small employers which that
  135  contain:
  136         a. An exclusion for services that are not medically
  137  necessary or that are not covered preventive health services;
  138  and
  139         b. A procedure for preauthorization or prior authorization
  140  by the small employer carrier, or its designees;
  141         c. A summary statement identifying specific prescription
  142  drugs that are subject to prior authorization, step therapy, or
  143  any other coverage limitation and the applicable coverage
  144  limitation policy or protocol. The carrier shall post the
  145  summary statement in a prominent and readily accessible location
  146  on the Internet; and
  147         d. A summary statement identifying any specific diagnostic
  148  or therapeutic procedures subject to prior authorization or
  149  other coverage limitations and the applicable coverage
  150  limitation policy or protocol. The carrier shall post the
  151  summary statement in a prominent and readily accessible location
  152  on the Internet.
  153         3. A small employer carrier may include the following
  154  managed care provisions in the policy or contract to control
  155  costs:
  156         a. A preferred provider arrangement or exclusive provider
  157  organization or any combination thereof, in which a small
  158  employer carrier enters into a written agreement with the
  159  provider to provide services at specified levels of
  160  reimbursement or to provide reimbursement to specified
  161  providers. Any such written agreement between a provider and a
  162  small employer carrier must contain a provision under which the
  163  parties agree that the insured individual or covered member has
  164  no obligation to make payment for any medical service rendered
  165  by the provider which is determined not to be medically
  166  necessary. A carrier may use preferred provider arrangements or
  167  exclusive provider arrangements to the same extent as allowed in
  168  group products that are not issued to small employers.
  169         b. A procedure for utilization review by the small employer
  170  carrier or its designees.
  171  
  172  This subparagraph does not prohibit a small employer carrier
  173  from including in its policy or contract additional managed care
  174  and cost containment provisions, subject to the approval of the
  175  office, which have potential for controlling costs in a manner
  176  that does not result in inequitable treatment of insureds or
  177  subscribers. The carrier may use such provisions to the same
  178  extent as authorized for group products that are not issued to
  179  small employers.
  180         4. The standard health benefit plan shall include:
  181         a. Coverage for inpatient hospitalization;
  182         b. Coverage for outpatient services;
  183         c. Coverage for newborn children pursuant to s. 627.6575;
  184         d. Coverage for child care supervision services pursuant to
  185  s. 627.6579;
  186         e. Coverage for adopted children upon placement in the
  187  residence pursuant to s. 627.6578;
  188         f. Coverage for mammograms pursuant to s. 627.6613;
  189         g. Coverage for children with disabilities handicapped
  190  children pursuant to s. 627.6615;
  191         h. Emergency or urgent care out of the geographic service
  192  area; and
  193         i. Coverage for services provided by a hospice licensed
  194  under s. 400.602 in cases where such coverage would be the most
  195  appropriate and the most cost-effective method for treating a
  196  covered illness.
  197         5. The standard health benefit plan and the basic health
  198  benefit plan may include a schedule of benefit limitations for
  199  specified services and procedures. If the committee develops
  200  such a schedule of benefits limitation for the standard health
  201  benefit plan or the basic health benefit plan, a small employer
  202  carrier offering the plan must offer the employer an option for
  203  increasing the benefit schedule amounts by 4 percent annually.
  204         6. The basic health benefit plan must shall include all of
  205  the benefits specified in subparagraph 4.; however, the basic
  206  health benefit plan must shall place additional restrictions on
  207  the benefits and utilization and may also impose additional cost
  208  containment measures.
  209         7. Sections 627.419(2), (3), and (4), 627.6574, 627.6612,
  210  627.66121, 627.66122, 627.6616, 627.6618, 627.668, and 627.66911
  211  apply to the standard health benefit plan and to the basic
  212  health benefit plan. However, notwithstanding such said
  213  provisions, the plans may specify limits on the number of
  214  authorized treatments, if such limits are reasonable and do not
  215  discriminate against any type of provider.
  216         8. The high-deductible high deductible plan associated with
  217  a health savings account or a health reimbursement arrangement
  218  must shall include all the benefits specified in subparagraph 4.
  219         9. Each small employer carrier that provides for inpatient
  220  and outpatient services by allopathic hospitals may provide as
  221  an option of the insured similar inpatient and outpatient
  222  services by hospitals accredited by the American Osteopathic
  223  Association if when such services are available and the
  224  osteopathic hospital agrees to provide the service.
  225         Section 10. Subsection (4) of section 641.31, Florida
  226  Statutes, is amended and subsection (44) is added to that
  227  section, to read:
  228         641.31 Health maintenance contracts.—
  229         (4) Each Every health maintenance contract, certificate, or
  230  member handbook must shall clearly state all of the services to
  231  which a subscriber is entitled under the contract and must
  232  include a clear and understandable statement of any limitations
  233  on the benefits, services, or kinds of services to be provided,
  234  including any copayment feature or schedule of benefits required
  235  by the contract or by any insurer or entity that which is
  236  underwriting any of the services offered by the health
  237  maintenance organization. The contract, certificate, or member
  238  handbook must shall also state where and in what manner the
  239  comprehensive health care services may be obtained. The health
  240  maintenance organization shall prominently post the statement
  241  regarding limitations on benefits, services, or kinds of
  242  services provided on its website in a readily accessible
  243  location on the Internet. The statement must include, but need
  244  not be limited to:
  245         (a)The identification of specific prescription drugs that
  246  are subject to prior authorization, step therapy, or any other
  247  coverage limitation and the applicable coverage limitation
  248  policy or protocol.
  249         (b)The identification of any specific diagnostic or
  250  therapeutic procedures that are subject to prior authorization
  251  or other coverage limitations and the applicable coverage
  252  limitation policy or protocol.
  253         (44)Health maintenance organizations are prohibited from
  254  establishing prior authorization procedures, step therapy
  255  requirements, treatment protocols, or other utilization
  256  management procedures that restrict access to covered services
  257  unless expressly authorized to do so under this subsection. A
  258  coverage limitation imposed by a health maintenance organization
  259  at the point of service must be supported, as determined by the
  260  Clinical Practices Review Commission established pursuant to s.
  261  402.90, by sufficient clinical evidence, as defined in s.
  262  627.6051(1), which demonstrates that the limitation does not
  263  inhibit the timely diagnosis or optimal treatment of the
  264  specific illness or condition for the covered patient. For
  265  purposes of this subsection, the term, “a coverage limitation
  266  imposed by a health maintenance organization at the point of
  267  service” means a limitation that is not universally applicable
  268  to all covered lives, but instead depends on a health
  269  maintenance organization’s consideration of specific patient
  270  characteristics and conditions that have been reported by a
  271  physician in the process of providing medical care.
  272         Section 11. Subsection (10) of section 641.3155, Florida
  273  Statutes, is amended to read:
  274         641.3155 Prompt payment of claims.—
  275         (10) A health maintenance organization may not
  276  retroactively deny a claim because of subscriber ineligibility
  277  more than 1 year after the date of payment of the claim and may
  278  not retroactively deny a claim because of subscriber
  279  ineligibility at any time if the health maintenance organization
  280  verified the eligibility of a subscriber at the time of
  281  treatment and has provided an authorization number.
  282  
  283  ================= T I T L E  A M E N D M E N T ================
  284  And the title is amended as follows:
  285         Delete lines 23 - 62
  286  and insert:
  287         limitation at the point of service; defining the terms
  288         “a coverage limitation imposed at the point of
  289         service” and “sufficient clinical evidence”; requiring
  290         the commission to determine whether sufficient
  291         clinical evidence exists and the Office of Insurance
  292         Regulation to approve coverage limitations if the
  293         commission determines that such evidence exists;
  294         providing for the liability of a health insurer and
  295         its chief medical officer for injuries and damages
  296         resulting from restricted access to services if the
  297         insurer has imposed coverage limitations without the
  298         approval of the office; requiring insurers to
  299         establish reserves to pay for such damages; amending
  300         ss. 627.642 and 627.6699, F.S.; requiring an outline
  301         of coverage and certain plans offered by a small
  302         employer carrier to include summary statements
  303         identifying specific prescription drugs and procedures
  304         that are subject to specified restrictions and
  305         limitations; requiring insurers and small employer
  306         carriers to post the summaries on the Internet;
  307         amending s. 627.6471, F.S.; requiring an insurer to
  308         post a link to the list of preferred providers on its
  309         website and to update the list within 10 business days
  310         after a change; amending s. 627.651, F.S.; conforming
  311         a cross-reference; amending s. 627.662, F.S.;
  312         specifying that specified provisions relating to
  313         coverage limitations on prescription drugs and
  314         diagnostic or therapeutic procedures apply to group
  315         health insurance, blanket health insurance, and
  316         franchise health insurance; amending s. 641.31, F.S.;
  317         requiring a health maintenance contract summary
  318         statement to include a statement of any limitations on
  319         benefits, the identification of specific prescription
  320         drugs, and certain procedures that are subject to
  321         specified restrictions and limitations; requiring a
  322         health maintenance organization to post the summaries
  323         on the Internet; prohibiting a health maintenance
  324         organization from establishing certain procedures and
  325         requirements that restrict access to covered services;
  326         requiring a coverage limitation to be supported, as
  327         determined by the commission, by clinical evidence
  328         demonstrating that the limitation does not inhibit the
  329         diagnosis or treatment of the patient; defining the
  330         term “a coverage limitation imposed at the point of
  331         service”; amending s. 641.3155, F.S.; prohibiting the
  332         retroactive denial of a claim because of subscriber
  333         ineligibility at any time if the health maintenance
  334         organization verified the eligibility of such
  335         subscriber at the time of treatment and provided an
  336         authorization number; providing an effective date.