Amendment
Bill No. 0805

Amendment No. 042245

CHAMBER ACTION
Senate		House
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1	Representative(s) Kendrick offered the following:
2
3	Amendment (with title amendment)
4	Between line(s) 200 and 201, insert:
5	Section 5.  Effective July 1, 2007, and applicable to any
6	policy issued, written, or renewed on or after such date,
7	section 627.668, Florida Statutes, is amended to read:
8	627.668  Optional coverage for mental and nervous disorders
9	required; exception.--
10	(1)  Every insurer, health maintenance organization, and
11	nonprofit hospital and medical service plan corporation
12	transacting group health insurance or providing prepaid health
13	care in this state shall make available to the policyholder as
14	part of the application, for an appropriate additional premium
15	under a group hospital and medical expense-incurred insurance
16	policy, under a group prepaid health care contract, and under a
17	group hospital and medical service plan contract, the benefits
18	or level of benefits specified in subsection (2) for the
19	necessary care and treatment of mental and nervous disorders, as
20	defined in the standard nomenclature of the American Psychiatric
21	Association, subject to the right of the applicant for a group
22	policy or contract to select any alternative benefits or level
23	of benefits as may be offered by the insurer, health maintenance
24	organization, or service plan corporation provided that, if
25	alternate inpatient, outpatient, or partial hospitalization
26	benefits are selected, such benefits shall not be less than the
27	level of benefits required under paragraph (2)(a), paragraph
28	(2)(b), or paragraph (2)(c), respectively.
29	(2)  Under group policies or contracts, inpatient hospital
30	benefits, partial hospitalization benefits, and outpatient
31	benefits consisting of durational limits, dollar amounts,
32	deductibles, and coinsurance factors shall not be less favorable
33	than for physical illness generally, except that:
34	(a)  Inpatient benefits may be limited to not less than 30
35	days per benefit year as defined in the policy or contract. If
36	inpatient hospital benefits are provided beyond 30 days per
37	benefit year, the durational limits, dollar amounts, and
38	coinsurance factors thereto need not be the same as applicable
39	to physical illness generally.
40	(b)  Outpatient benefits may be limited to $1,000 for
41	consultations with a licensed physician, a psychologist licensed
42	pursuant to chapter 490, a mental health counselor licensed
43	pursuant to chapter 491, a marriage and family therapist
44	licensed pursuant to chapter 491, and a clinical social worker
45	licensed pursuant to chapter 491. If benefits are provided
46	beyond the $1,000 per benefit year, the durational limits,
47	dollar amounts, and coinsurance factors thereof need not be the
48	same as applicable to physical illness generally.
49	(c)  Partial hospitalization benefits shall be provided
50	under the direction of a licensed physician. For purposes of
51	this part, the term "partial hospitalization services" is
52	defined as those services offered by a program accredited by the
53	Joint Commission on Accreditation of Hospitals (JCAH) or in
54	compliance with equivalent standards. Alcohol rehabilitation
55	programs accredited by the Joint Commission on Accreditation of
56	Hospitals or approved by the state and licensed drug abuse
57	rehabilitation programs shall also be qualified providers under
58	this section. In any benefit year, if partial hospitalization
59	services or a combination of inpatient and partial
60	hospitalization are utilized, the total benefits paid for all
61	such services shall not exceed the cost of 30 days of inpatient
62	hospitalization for psychiatric services, including physician
63	fees, which prevail in the community in which the partial
64	hospitalization services are rendered. If partial
65	hospitalization services benefits are provided beyond the limits
66	set forth in this paragraph, the durational limits, dollar
67	amounts, and coinsurance factors thereof need not be the same as
68	those applicable to physical illness generally.
69	(3)(a)  Every insurer and health maintenance organization
70	transacting group health insurance or providing prepaid health
71	care in this state shall make available to the policyholder, for
72	an appropriate additional premium, as part of the application
73	for a group hospital and medical expense-incurred insurance
74	policy, a group prepaid health care contract, or a group health
75	maintenance organization contract, coverage for the treatment of
76	serious mental illness, which treatment is determined to be
77	medically necessary.
78	(b)  Under group policies or contracts, inpatient hospital
79	benefits, partial hospitalization benefits, and outpatient
80	benefits, consisting of durational limits, dollar amounts,
81	deductibles, and coinsurance factors, must be the same for
82	serious mental illness as for physical illness generally.
83	Notwithstanding the provisions of this subsection, an insurer or
84	health maintenance organization may limit inpatient coverage to
85	45 days per year and may limit outpatient coverage to 60 visits
86	per year.
87	(c)  This subsection does not apply to any group health
88	plan, or group health insurance covered in connection with a
89	group health plan, for any plan year of a small employer as
90	defined in s. 627.6699.
91	(d)  As used in this subsection, the term "serious mental
92	illness" means the following psychiatric illnesses as defined by
93	the American Psychiatric Association in the most current edition
94	of the Diagnostic and Statistical Manual: schizophrenia,
95	schizoaffective disorder, panic disorder, bipolar affective
96	disorder, major depressive disorder, and specific obsessive-
97	compulsive disorder.
98	(e)  Notwithstanding any other provisions of this section,
99	chapter 641, s. 627.6471, or s. 627.6472, an insurer or health
100	maintenance organization may require that the covered services
101	required by this section be provided by an exclusive provider of
102	health care, or a group of exclusive providers of health care,
103	which has entered into a written agreement with the insurer or
104	health maintenance organization to provide benefits under this
105	section. The insurer or health maintenance organization may make
106	the payment of such benefits, in whole or in part, contingent
107	upon the use of such exclusive providers.
108	(f)  The insurer or health maintenance organization may
109	directly or indirectly enter into a capitation contract with an
110	exclusive provider of health care or a group of exclusive
111	providers of health care to provide benefits under this section.
112	In providing the benefits under this section, the insurer or
113	health maintenance organization may impose other appropriate
114	financial incentives, peer review, and utilization requirements
115	to reduce service costs and utilization without compromising
116	quality of care.
117	(g)  This subsection does not apply with respect to a group
118	health plan or health insurance coverage offered in connection
119	with a group health plan if the application of this subsection
120	to a plan or coverage results in an increase in the cost under
121	the plan or coverage of more than 2 percent, as determined and
122	certified by an insurer's or health maintenance organization's
123	actuary.
124	(4)(3)  Insurers must maintain strict confidentiality
125	regarding psychiatric and psychotherapeutic records submitted to
126	an insurer for the purpose of reviewing a claim for benefits
127	payable under this section. These records submitted to an
128	insurer are subject to the limitations of s. 456.057, relating
129	to the furnishing of patient records.
130
131	======= T I T L E  A M E N D M E N T =======
132	Remove line(s) 23 and insert:
133	insurers to implement such requirements; amending s. 627.668,
134	F.S.; revising provisions relating to required optional coverage
135	for mental and nervous disorders; providing additional
136	requirements; specifying nonapplication; providing a definition;
137	authorizing insurers and health maintenance organizations to
138	require certain services to be provided by certain exclusive
139	providers; providing for a payment of benefits contingency;
140	authorizing insures and health maintenance organizations to
141	enter into capitation contracts with exclusive providers for
142	certain purposes; specifying nonapplication to certain health
143	plans or health insurance coverages; amending s.

CODING: Words stricken are deletions; words underlined are additions.