2010 Florida Statutes
Contracts for reduced rates of payment; limitations; coinsurance and deductibles.
Contracts for reduced rates of payment; limitations; coinsurance and deductibles.—
As used in this section:
“Preferred provider” means any licensed health care provider with which the insurer has directly or indirectly contracted for an alternative or a reduced rate of payment, which shall include any health care provider listed in s. 627.419(3) and (4) and shall provide reasonable access to such health care providers.
“Preferred provider network” means a group of licensed health care providers with each of which the insurer has directly or indirectly contracted for alternative or reduced rates of payment. If an insurer negotiates with providers practicing as a group, the insurer may contract with the group.
Any insurer issuing a policy of health insurance in this state, which insurance includes coverage for the services of a preferred provider, must provide each policyholder and certificateholder with a current list of preferred providers and must make the list available for public inspection during regular business hours at the principal office of the insurer within the state.
A policy may limit payments regardless of the providers chosen by an insured and may offer alternative or reduced rates to an insured who selects preferred providers.
Any policy that provides schedules of payments for services provided by preferred providers that differ from the schedules of payments for services provided by nonpreferred providers is subject to the following limitations:
The amount of any annual deductible per covered person or per family for treatment in a facility that is not a preferred provider may not exceed four times the amount of a corresponding annual deductible for treatment in a facility that is a preferred provider.
If the policy has no deductible for treatment in a preferred provider facility, the deductible for treatment received in a facility that is not a preferred provider facility may not exceed $500 per covered person per visit.
The amount of any annual deductible per covered person or per family for treatment, other than inpatient treatment, by a provider that is not a preferred provider may not exceed four times the amount of a corresponding annual deductible for treatment, other than inpatient treatment, by a preferred provider.
If the policy has no deductible for treatment by a preferred provider, the annual deductible for treatment received from a provider which is not a preferred provider shall not exceed $500 per covered person.
The percentage amount of any coinsurance to be paid by an insured to a provider that is not a preferred provider may not exceed by more than 50 percentage points the percentage amount of any coinsurance payment to be paid to a preferred provider.
The amount of any deductible and payment of coinsurance paid by the insured must be applied to the reduced charge negotiated between the insurer and the preferred provider.
Notwithstanding the limitations of deductibles and coinsurance provisions in this section, an insurer may require the insured to pay a reasonable copayment per visit for inpatient or outpatient services.
If any service or treatment is not within the scope of services provided by the network of preferred providers, but is within the scope of services or treatment covered by the policy, the service or treatment shall be reimbursed at a rate not less than 10 percentage points lower than the percentage rate paid to preferred providers. The reimbursement rate must be applied to the usual and customary charges in the area.
Any policy issued under this section which does not provide direct patient access to a dermatologist must conform to the requirements of s. 627.6472(16). This subsection shall not be construed to affect the amount the insured or patient must pay as a deductible or coinsurance amount authorized under this section.
If psychotherapeutic services are covered by a policy issued by the insurer, the insurer shall provide eligibility criteria for each group of health care providers licensed under chapter 458, chapter 459, chapter 490, or chapter 491, which include psychotherapy within the scope of their practice as provided by law, or for any person who is certified as an advanced registered nurse practitioner in psychiatric mental health under s. 464.012. When psychotherapeutic services are covered, eligibility criteria shall be established by the insurer to be included in the insurer’s criteria for selection of network providers. The insurer may not discriminate against a health care provider by excluding such practitioner from its provider network solely on the basis of the practitioner’s license.
ss. 8, 12, ch. 91-296; ss. 126, 149, ch. 92-33; s. 114, ch. 92-318; s. 1, ch. 96-344; s. 3, ch. 99-393.
Former s. 627.4134.