Senate Bill sb0344
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Florida Senate - 2005 SB 344
By Senator Campbell
32-228-05
1 A bill to be entitled
2 An act relating to health insurance coverage
3 for infertility; creating ss. 627.64062 and
4 627.65742, F.S., and amending s. 641.31, F.S.;
5 requiring coverage by health insurance
6 policies, group, franchise, and blanket health
7 insurance policies, and health maintenance
8 contracts for diagnosis and treatment of
9 infertility under certain circumstances;
10 providing requirements and criteria; providing
11 limitations; providing definitions; providing
12 an exception for certain religious
13 organizations; providing application; excluding
14 payments for donor eggs or certain medical
15 services; amending ss. 627.651, 627.6515, and
16 627.6699, F.S.; providing for application to
17 group contracts and plans of self insurance,
18 out-of-state groups, and standard, basic, and
19 limited health benefit plans; providing an
20 effective date.
21
22 Be It Enacted by the Legislature of the State of Florida:
23
24 Section 1. Section 627.64062, Florida Statutes, is
25 created to read:
26 627.64062 Diagnosis and treatment of infertility.--
27 (1) Any health insurance policy that provides coverage
28 for pregnancy-related benefits must also cover the diagnosis
29 and treatment of infertility, including all nonexperimental
30 assisted reproductive technology procedures and artificial
31 insemination with partner or donor sperm.
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Florida Senate - 2005 SB 344
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1 (2) The coverage required under this section must
2 conform to the following:
3 (a) Coverage shall be subject to any deductible and
4 coinsurance conditions and all other terms and conditions
5 applicable to other benefits.
6 (b) Coverage for a procedure for in vitro
7 fertilization, gamete intrafallopian transfer, or zygote
8 intrafallopian transfer shall be required only if the covered
9 individual:
10 1. Has been unable to carry a pregnancy to live birth;
11 2. Has been unable to carry a pregnancy to live birth
12 through less costly medically appropriate infertility
13 treatments for which coverage is available under the policy,
14 plan, or contract; or
15 3. Has not undergone four complete oocyte retrievals.
16 (c) To undergo in vitro fertilization, gamete
17 intrafallopian transfer, or zygote intrafallopian transfer:
18 1. A second opinion confirming the need for the
19 procedure must have been provided by a certified reproductive
20 endocrinologist who is actively experienced in assisted
21 reproductive technologies but is not in the same medical
22 practice group as the treating physician.
23 2. The procedure must be performed at medical
24 facilities that conform to the standards of the American
25 Society for Reproductive Medicine, the Society for Assisted
26 Reproductive Technology, and the American College of
27 Obstetricians and Gynecologists.
28 3. The laboratory or facility used to support
29 performance of the procedure must have received accreditation
30 from the Reproductive Laboratory Accreditation Program of the
31 College of American Pathologists or another accreditation
2
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1 organization approved by the Society for Assisted Reproductive
2 Medicine.
3 (d) The medical practice group of the service provider
4 must include at least one certified reproductive
5 endocrinologist or a physician with fellowship training and
6 subspecialty board eligibility in reproductive endocrinology
7 and infertility.
8 (3) As used in this section, the term:
9 (a) "Pregnancy-related benefits" means benefits that
10 cover any related medical condition that may be associated
11 with pregnancy, including complications of pregnancy.
12 (b) "Infertility" means a disease or condition
13 affecting the reproductive system which interferes with the
14 ability of a man or woman to achieve a pregnancy or of a woman
15 to carry a pregnancy to live birth. The term excludes a
16 failure to conceive which has a duration of less than 12
17 months unless medical history and physical findings dictate
18 earlier evaluation and treatment.
19 (c) "Nonexperimental procedure" means any clinical
20 treatment or procedure that the American Society for
21 Reproductive Medicine or the American College of Obstetricians
22 and Gynecologists recognizes as safe and effective.
23 (4) This section does not apply to any health
24 insurance policy that is purchased by a group, order, or other
25 entity that is directly affiliated with a bona fide religious
26 denomination that includes, as an integral part of its beliefs
27 and practices, the tenet that drug therapy for infertility or
28 in vitro fertilization services are contrary to the moral
29 principles that the denomination considers to be an essential
30 part of its beliefs.
31
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Florida Senate - 2005 SB 344
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1 (5) This section applies to coverage and benefits for
2 the state group insurance program under s. 110.123.
3 (6) This section does not require coverage or payment
4 for donor eggs or for medical services provided to a surrogate
5 for purposes of child birth.
6 Section 2. Subsection (4) of section 627.651, Florida
7 Statutes, is amended to read:
8 627.651 Group contracts and plans of self-insurance
9 must meet group requirements.--
10 (4) This section does not apply to any plan which is
11 established or maintained by an individual employer in
12 accordance with the Employee Retirement Income Security Act of
13 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
14 arrangement as defined in s. 624.437(1), except that a
15 multiple-employer welfare arrangement shall comply with ss.
16 627.419, 627.657, 627.65742, 627.6575, 627.6578, 627.6579,
17 627.6612, 627.66121, 627.66122, 627.6615, 627.6616, and
18 627.662(7). This subsection does not allow an authorized
19 insurer to issue a group health insurance policy or
20 certificate which does not comply with this part.
21 Section 3. Subsection (2) of section 627.6515, Florida
22 Statutes, is amended to read:
23 627.6515 Out-of-state groups.--
24 (2) Except as otherwise provided in this part, this
25 part does not apply to a group health insurance policy issued
26 or delivered outside this state under which a resident of this
27 state is provided coverage if:
28 (a) The policy is issued to an employee group the
29 composition of which is substantially as described in s.
30 627.653; a labor union group or association group the
31 composition of which is substantially as described in s.
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1 627.654; an additional group the composition of which is
2 substantially as described in s. 627.656; a group insured
3 under a blanket health policy when the composition of the
4 group is substantially in compliance with s. 627.659; a group
5 insured under a franchise health policy when the composition
6 of the group is substantially in compliance with s. 627.663;
7 an association group to cover persons associated in any other
8 common group, which common group is formed primarily for
9 purposes other than providing insurance; a group that is
10 established primarily for the purpose of providing group
11 insurance, provided the benefits are reasonable in relation to
12 the premiums charged thereunder and the issuance of the group
13 policy has resulted, or will result, in economies of
14 administration; or a group of insurance agents of an insurer,
15 which insurer is the policyholder;
16 (b) Certificates evidencing coverage under the policy
17 are issued to residents of this state and contain in
18 contrasting color and not less than 10-point type the
19 following statement: "The benefits of the policy providing
20 your coverage are governed primarily by the law of a state
21 other than Florida"; and
22 (c) The policy provides the benefits specified in ss.
23 627.419, 627.6574, 627.65742, 627.6575, 627.6579, 627.6612,
24 627.66121, 627.66122, 627.6613, 627.667, 627.6675, 627.6691,
25 and 627.66911.
26 Section 4. Section 627.65742, Florida Statutes, is
27 created to read:
28 627.65742 Diagnosis and treatment of infertility.--
29 (1) Any group, franchise, or blanket health insurance
30 policy that provides coverage for pregnancy-related benefits
31 must also cover the diagnosis and treatment of infertility,
5
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1 including all nonexperimental assisted reproductive technology
2 procedures and artificial insemination with partner or donor
3 sperm.
4 (2) The coverage required under this section must
5 conform to the following:
6 (a) Coverage may not be subject to copayments or
7 deductible requirements that are greater than those applied to
8 pregnancy-related benefits under the insured's policy, plan,
9 or contract.
10 (b) Coverage for a procedure for in vitro
11 fertilization, gamete intrafallopian transfer, or zygote
12 intrafallopian transfer shall be required only if the covered
13 individual:
14 1. Has been unable to carry a pregnancy to live birth;
15 2. Has been unable to carry a pregnancy to live birth
16 through less costly medically appropriate infertility
17 treatments for which coverage is available under the policy,
18 plan, or contract; or
19 3. Has not undergone four complete oocyte retrievals.
20 (c) To undergo in vitro fertilization, gamete
21 intrafallopian transfer, or zygote intrafallopian transfer:
22 1. A second opinion confirming the need for the
23 procedure must have been provided by a certified reproductive
24 endocrinologist who is actively experienced in assisted
25 reproductive technologies but is not in the same medical
26 practice group as the treating physician.
27 2. The procedure must be performed at medical
28 facilities that conform to the standards of the American
29 Society for Reproductive Medicine, the Society for Assisted
30 Reproductive Technology, and the American College of
31 Obstetricians and Gynecologists.
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Florida Senate - 2005 SB 344
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1 3. The laboratory or facility used to support
2 performance of the procedure must have received accreditation
3 from the Reproductive Laboratory Accreditation Program of the
4 College of American Pathologists or another accreditation
5 organization approved by the Society for Assisted Reproductive
6 Medicine.
7 (d) The medical practice group of the service provider
8 must include at least one certified reproductive
9 endocrinologist or a physician with fellowship training and
10 subspecialty board eligibility in reproductive endocrinology
11 and infertility.
12 (3) As used in this section, the term:
13 (a) "Pregnancy-related benefits" means benefits that
14 cover any related medical condition that may be associated
15 with pregnancy, including complications of pregnancy.
16 (b) "Infertility" means a disease or condition
17 affecting the reproductive system that interferes with the
18 ability of a man or woman to achieve a pregnancy or of a woman
19 to carry a pregnancy to live birth. The term excludes a
20 failure to conceive which has a duration of less than 12
21 months unless medical history and physical findings dictate
22 earlier evaluation and treatment.
23 (c) "Nonexperimental procedure" means any clinical
24 treatment or procedure that the American Society for
25 Reproductive Medicine or the American College of Obstetricians
26 and Gynecologists recognizes as safe and effective.
27 (4) This section does not apply to any group,
28 franchise, or blanket health insurance policy that is
29 purchased by a group, order, or other entity that is directly
30 affiliated with a bona fide religious denomination that
31 includes, as an integral part of its beliefs and practices,
7
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Florida Senate - 2005 SB 344
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1 the tenet that drug therapy for infertility or in vitro
2 fertilization services are contrary to the moral principles
3 that the denomination considers to be an essential part of its
4 beliefs.
5 (5) This section does not require coverage or payment
6 for donor eggs or for medical services provided to a surrogate
7 for purposes of child birth.
8 Section 5. Paragraph (b) of subsection (12) of section
9 627.6699, Florida Statutes, is amended to read:
10 627.6699 Employee Health Care Access Act.--
11 (12) STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED
12 HEALTH BENEFIT PLANS.--
13 (b)1. Each small employer carrier issuing new health
14 benefit plans shall offer to any small employer, upon request,
15 a standard health benefit plan, a basic health benefit plan,
16 and a high deductible plan that meets the requirements of a
17 health savings account plan as defined by federal law or a
18 health reimbursement arrangement as authorized by the Internal
19 Revenue Service, that meet the criteria set forth in this
20 section.
21 2. For purposes of this subsection, the terms
22 "standard health benefit plan," "basic health benefit plan,"
23 and "high deductible plan" mean policies or contracts that a
24 small employer carrier offers to eligible small employers that
25 contain:
26 a. An exclusion for services that are not medically
27 necessary or that are not covered preventive health services;
28 and
29 b. A procedure for preauthorization by the small
30 employer carrier, or its designees.
31
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1 3. A small employer carrier may include the following
2 managed care provisions in the policy or contract to control
3 costs:
4 a. A preferred provider arrangement or exclusive
5 provider organization or any combination thereof, in which a
6 small employer carrier enters into a written agreement with
7 the provider to provide services at specified levels of
8 reimbursement or to provide reimbursement to specified
9 providers. Any such written agreement between a provider and a
10 small employer carrier must contain a provision under which
11 the parties agree that the insured individual or covered
12 member has no obligation to make payment for any medical
13 service rendered by the provider which is determined not to be
14 medically necessary. A carrier may use preferred provider
15 arrangements or exclusive provider arrangements to the same
16 extent as allowed in group products that are not issued to
17 small employers.
18 b. A procedure for utilization review by the small
19 employer carrier or its designees.
20
21 This subparagraph does not prohibit a small employer carrier
22 from including in its policy or contract additional managed
23 care and cost containment provisions, subject to the approval
24 of the office, which have potential for controlling costs in a
25 manner that does not result in inequitable treatment of
26 insureds or subscribers. The carrier may use such provisions
27 to the same extent as authorized for group products that are
28 not issued to small employers.
29 4. The standard health benefit plan shall include:
30 a. Coverage for inpatient hospitalization;
31 b. Coverage for outpatient services;
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1 c. Coverage for newborn children pursuant to s.
2 627.6575;
3 d. Coverage for child care supervision services
4 pursuant to s. 627.6579;
5 e. Coverage for adopted children upon placement in the
6 residence pursuant to s. 627.6578;
7 f. Coverage for mammograms pursuant to s. 627.6613;
8 g. Coverage for handicapped children pursuant to s.
9 627.6615;
10 h. Emergency or urgent care out of the geographic
11 service area; and
12 i. Coverage for services provided by a hospice
13 licensed under s. 400.602 in cases where such coverage would
14 be the most appropriate and the most cost-effective method for
15 treating a covered illness.
16 5. The standard health benefit plan and the basic
17 health benefit plan may include a schedule of benefit
18 limitations for specified services and procedures. If the
19 committee develops such a schedule of benefits limitation for
20 the standard health benefit plan or the basic health benefit
21 plan, a small employer carrier offering the plan must offer
22 the employer an option for increasing the benefit schedule
23 amounts by 4 percent annually.
24 6. The basic health benefit plan shall include all of
25 the benefits specified in subparagraph 4.; however, the basic
26 health benefit plan shall place additional restrictions on the
27 benefits and utilization and may also impose additional cost
28 containment measures.
29 7. Sections 627.419(2), (3), and (4), 627.6574,
30 627.65742, 627.6612, 627.66121, 627.66122, 627.6616, 627.6618,
31 627.668, and 627.66911 apply to the standard health benefit
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1 plan and to the basic health benefit plan. However,
2 notwithstanding said provisions, the plans may specify limits
3 on the number of authorized treatments, if such limits are
4 reasonable and do not discriminate against any type of
5 provider.
6 8. The high deductible plan associated with a health
7 savings account or a health reimbursement arrangement shall
8 include all the benefits specified in subparagraph 4.
9 9. Each small employer carrier that provides for
10 inpatient and outpatient services by allopathic hospitals may
11 provide as an option of the insured similar inpatient and
12 outpatient services by hospitals accredited by the American
13 Osteopathic Association when such services are available and
14 the osteopathic hospital agrees to provide the service.
15 Section 6. Subsection (41) is added to section 641.31,
16 Florida Statutes, to read:
17 641.31 Health maintenance contracts.--
18 (41)(a) Any health maintenance contract that provides
19 coverage for pregnancy-related benefits must also cover the
20 diagnosis and treatment of infertility, including all
21 nonexperimental assisted reproductive technology procedures
22 and artificial insemination with partner or donor sperm.
23 (b) The coverage required under this subsection must
24 conform to the following:
25 1. Coverage shall be subject to any deductible and
26 coinsurance conditions and all other terms and conditions
27 applicable to other benefits.
28 2. Coverage for a procedure for in vitro
29 fertilization, gamete intrafallopian transfer, or zygote
30 intrafallopian transfer shall be required only if the covered
31 individual:
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1 a. Has been unable to carry a pregnancy to live birth;
2 b. Has been unable to carry a pregnancy to live birth
3 through less costly medically appropriate infertility
4 treatments for which coverage is available under the policy,
5 plan, or contract; or
6 c. Has not undergone four complete oocyte retrievals.
7 3. To undergo in vitro fertilization, gamete
8 intrafallopian transfer, or zygote intrafallopian transfer:
9 a. A second opinion confirming the need for the
10 procedure must have been provided by a certified reproductive
11 endocrinologist who is actively experienced in assisted
12 reproductive technologies but is not in the same medical
13 practice group as the treating physician.
14 b. The procedure must be performed at medical
15 facilities that conform to the standards of the American
16 Society for Reproductive Medicine, the Society for Assisted
17 Reproductive Technology, and the American College of
18 Obstetricians and Gynecologists.
19 c. The laboratory or facility used to support
20 performance of the procedure must have received accreditation
21 from the Reproductive Laboratory Accreditation Program of the
22 College of American Pathologists or another accreditation
23 organization approved by the Society for Assisted Reproductive
24 Medicine.
25 4. The medical practice group of the service provider
26 must include at least one certified reproductive
27 endocrinologist or a physician with fellowship training and
28 subspecialty board eligibility in reproductive endocrinology
29 and infertility.
30 (c) As used in this subsection, the term:
31
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Florida Senate - 2005 SB 344
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1 1. "Pregnancy-related benefits" means benefits that
2 cover any related medical condition that may be associated
3 with pregnancy, including complications of pregnancy.
4 2. "Infertility" means a disease or condition
5 affecting the reproductive system which interferes with the
6 ability of a man or woman to achieve a pregnancy or of a woman
7 to carry a pregnancy to live birth. The term excludes a
8 failure to conceive which has a duration of less than 12
9 months unless medical history and physical findings dictate
10 earlier evaluation and treatment.
11 3. "Nonexperimental procedure" means any clinical
12 treatment or procedure that the American Society for
13 Reproductive Medicine or the American College of Obstetricians
14 and Gynecologists recognizes as safe and effective.
15 (d) This subsection does not apply to any health
16 maintenance contract that is purchased by a group, order, or
17 other entity that is directly affiliated with a bona fide
18 religious denomination that includes, as an integral part of
19 its beliefs and practices, the tenet that drug therapy for
20 infertility or in vitro fertilization services are contrary to
21 the moral principles that the denomination considers to be an
22 essential part of its beliefs.
23 (e) This subsection applies to coverage and benefits
24 for the state group insurance program under s. 110.123.
25 (f) This subsection does not require coverage or
26 payment for donor eggs or for medical services provided to a
27 surrogate for purposes of child birth.
28 Section 7. This act shall take effect October 1, 2005.
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2 SENATE SUMMARY
3 Requires coverage by health insurance policies, group,
franchise, and blanket health insurance policies, and
4 health maintenance contracts for diagnosis and treatment
of infertility. Provides an exception for religious
5 organizations. Applies the requirement to group contracts
and plans of self-insurance, out-of-state groups, and
6 standard, basic, and limited health benefit plans. (See
bill for details.)
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