Florida Senate - 2016                          SENATOR AMENDMENT
       Bill No. CS/CS/CS/HB 221, 1st Eng.
       
       
       
       
       
       
                                Ì253290ÊÎ253290                         
       
                              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         627.64194Coverage 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.