| 1 | Representative(s) Benson, H. Gibson, Baxley, Galvano, Kendrick, |
| 2 | Garcia, Negron, and Bean offered the following: |
| 3 |
|
| 4 | Substitute Amendment for Amendment (446541) (with title |
| 5 | amendment) |
| 6 |
|
| 7 | Remove line 250 and insert: |
| 8 | Section 11. Effective July 1, 2007, and applicable to any |
| 9 | policy issued, written, or renewed on or after such date, |
| 10 | section 627.668, Florida Statutes, is amended to read: |
| 11 | 627.668 Optional coverage for mental and nervous disorders |
| 12 | required; exception.-- |
| 13 | (1) Every insurer, health maintenance organization, and |
| 14 | nonprofit hospital and medical service plan corporation |
| 15 | transacting group health insurance or providing prepaid health |
| 16 | care in this state shall make available to the policyholder as |
| 17 | part of the application, for an appropriate additional premium |
| 18 | under a group hospital and medical expense-incurred insurance |
| 19 | policy, under a group prepaid health care contract, and under a |
| 20 | group hospital and medical service plan contract, the benefits |
| 21 | or level of benefits specified in subsection (2) for the |
| 22 | necessary care and treatment of mental and nervous disorders, as |
| 23 | defined in the standard nomenclature of the American Psychiatric |
| 24 | Association, subject to the right of the applicant for a group |
| 25 | policy or contract to select any alternative benefits or level |
| 26 | of benefits as may be offered by the insurer, health maintenance |
| 27 | organization, or service plan corporation provided that, if |
| 28 | alternate inpatient, outpatient, or partial hospitalization |
| 29 | benefits are selected, such benefits shall not be less than the |
| 30 | level of benefits required under paragraph (2)(a), paragraph |
| 31 | (2)(b), or paragraph (2)(c), respectively. |
| 32 | (2) Under group policies or contracts, inpatient hospital |
| 33 | benefits, partial hospitalization benefits, and outpatient |
| 34 | benefits consisting of durational limits, dollar amounts, |
| 35 | deductibles, and coinsurance factors shall not be less favorable |
| 36 | than for physical illness generally, except that: |
| 37 | (a) Inpatient benefits may be limited to not less than 30 |
| 38 | days per benefit year as defined in the policy or contract. If |
| 39 | inpatient hospital benefits are provided beyond 30 days per |
| 40 | benefit year, the durational limits, dollar amounts, and |
| 41 | coinsurance factors thereto need not be the same as applicable |
| 42 | to physical illness generally. |
| 43 | (b) Outpatient benefits may be limited to $1,000 for |
| 44 | consultations with a licensed physician, a psychologist licensed |
| 45 | pursuant to chapter 490, a mental health counselor licensed |
| 46 | pursuant to chapter 491, a marriage and family therapist |
| 47 | licensed pursuant to chapter 491, and a clinical social worker |
| 48 | licensed pursuant to chapter 491. If benefits are provided |
| 49 | beyond the $1,000 per benefit year, the durational limits, |
| 50 | dollar amounts, and coinsurance factors thereof need not be the |
| 51 | same as applicable to physical illness generally. |
| 52 | (c) Partial hospitalization benefits shall be provided |
| 53 | under the direction of a licensed physician. For purposes of |
| 54 | this part, the term "partial hospitalization services" is |
| 55 | defined as those services offered by a program accredited by the |
| 56 | Joint Commission on Accreditation of Hospitals (JCAH) or in |
| 57 | compliance with equivalent standards. Alcohol rehabilitation |
| 58 | programs accredited by the Joint Commission on Accreditation of |
| 59 | Hospitals or approved by the state and licensed drug abuse |
| 60 | rehabilitation programs shall also be qualified providers under |
| 61 | this section. In any benefit year, if partial hospitalization |
| 62 | services or a combination of inpatient and partial |
| 63 | hospitalization are utilized, the total benefits paid for all |
| 64 | such services shall not exceed the cost of 30 days of inpatient |
| 65 | hospitalization for psychiatric services, including physician |
| 66 | fees, which prevail in the community in which the partial |
| 67 | hospitalization services are rendered. If partial |
| 68 | hospitalization services benefits are provided beyond the limits |
| 69 | set forth in this paragraph, the durational limits, dollar |
| 70 | amounts, and coinsurance factors thereof need not be the same as |
| 71 | those applicable to physical illness generally. |
| 72 | (3)(a) Every insurer and health maintenance organization |
| 73 | transacting group health insurance or providing prepaid health |
| 74 | care in this state shall make available to the policyholder, for |
| 75 | an appropriate additional premium, as part of the application |
| 76 | for a group hospital and medical expense-incurred insurance |
| 77 | policy, a group prepaid health care contract, or a group health |
| 78 | maintenance organization contract, coverage for the treatment of |
| 79 | serious mental illness, which treatment is determined to be |
| 80 | medically necessary. |
| 81 | (b) Under group policies or contracts, inpatient hospital |
| 82 | benefits, partial hospitalization benefits, and outpatient |
| 83 | benefits, consisting of durational limits, dollar amounts, |
| 84 | deductibles, and coinsurance factors, must be the same for |
| 85 | serious mental illness as for physical illness generally. |
| 86 | Notwithstanding the provisions of this subsection, an insurer or |
| 87 | health maintenance organization may limit inpatient coverage to |
| 88 | 45 days per year and may limit outpatient coverage to 60 visits |
| 89 | per year. |
| 90 | (c) This subsection does not apply to any group health |
| 91 | plan, or group health insurance covered in connection with a |
| 92 | group health plan, for any plan year of a small employer as |
| 93 | defined in s. 627.6699. |
| 94 | (d) As used in this subsection, the term "serious mental |
| 95 | illness" means the following psychiatric illnesses as defined by |
| 96 | the American Psychiatric Association in the most current edition |
| 97 | of the Diagnostic and Statistical Manual: schizophrenia, |
| 98 | schizoaffective disorder, panic disorder, bipolar affective |
| 99 | disorder, major depressive disorder, and specific obsessive- |
| 100 | compulsive disorder. |
| 101 | (e) Notwithstanding any other provisions of this section, |
| 102 | chapter 641, s. 627.6471, or s. 627.6472, an insurer or health |
| 103 | maintenance organization may require that the covered services |
| 104 | required by this section be provided by an exclusive provider of |
| 105 | health care, or a group of exclusive providers of health care, |
| 106 | which has entered into a written agreement with the insurer or |
| 107 | health maintenance organization to provide benefits under this |
| 108 | section. The insurer or health maintenance organization may make |
| 109 | the payment of such benefits, in whole or in part, contingent |
| 110 | upon the use of such exclusive providers. |
| 111 | (f) The insurer or health maintenance organization may |
| 112 | directly or indirectly enter into a capitation contract with an |
| 113 | exclusive provider of health care or a group of exclusive |
| 114 | providers of health care to provide benefits under this section. |
| 115 | In providing the benefits under this section, the insurer or |
| 116 | health maintenance organization may impose other appropriate |
| 117 | financial incentives, peer review, and utilization requirements |
| 118 | to reduce service costs and utilization without compromising |
| 119 | quality of care. |
| 120 | (g) This subsection does not apply with respect to a group |
| 121 | health plan or health insurance coverage offered in connection |
| 122 | with a group health plan if the application of this subsection |
| 123 | to a plan or coverage results in an increase in the cost under |
| 124 | the plan or coverage of more than 2 percent, as determined and |
| 125 | certified by an insurer's or health maintenance organization's |
| 126 | actuary. |
| 127 | (4)(3) Insurers must maintain strict confidentiality |
| 128 | regarding psychiatric and psychotherapeutic records submitted to |
| 129 | an insurer for the purpose of reviewing a claim for benefits |
| 130 | payable under this section. These records submitted to an |
| 131 | insurer are subject to the limitations of s. 456.057, relating |
| 132 | to the furnishing of patient records. |
| 133 | Section 12. Paragraph (i) of subsection (2) of section |
| 134 | 636.204, Florida Statutes, is amended to read: |
| 135 | 636.204 License required.-- |
| 136 | (2) An application for a license to operate as a discount |
| 137 | medical plan organization must be filed with the office on a |
| 138 | form prescribed by the commission. Such application must be |
| 139 | sworn to by an officer or authorized representative of the |
| 140 | applicant and be accompanied by the following, if applicable: |
| 141 | (i) A copy of the applicant's most recent financial |
| 142 | statements audited by an independent certified public |
| 143 | accountant. An applicant that is a subsidiary of a parent entity |
| 144 | that is publicly traded and that prepares audited financial |
| 145 | statements reflecting the consolidated operations of the parent |
| 146 | entity and the subsidiary may submit petition the office to |
| 147 | accept, in lieu of the audited financial statement of the |
| 148 | applicant, the audited financial statement of the parent entity |
| 149 | and a written guaranty by the parent entity that the minimum |
| 150 | capital requirements of the applicant required by this part will |
| 151 | be met by the parent entity. |
| 152 | Section 13. Subsection (1) of section 636.206, Florida |
| 153 | Statutes, is amended to read: |
| 154 | 636.206 Examinations and investigations.-- |
| 155 | (1) The office may examine or investigate the business and |
| 156 | affairs of any discount medical plan organization if the |
| 157 | commissioner has reason to believe that the discount medical |
| 158 | plan organization is not complying with the requirements of this |
| 159 | act. The office may order any discount medical plan organization |
| 160 | or applicant to produce any records, books, files, advertising |
| 161 | and solicitation materials, or other information and may take |
| 162 | statements under oath to determine whether the discount medical |
| 163 | plan organization or applicant is in violation of the law or is |
| 164 | acting contrary to the public interest. The expenses incurred in |
| 165 | conducting any examination or investigation must be paid by the |
| 166 | discount medical plan organization or applicant. Examinations |
| 167 | and investigations must be conducted as provided in chapter 624. |
| 168 | Section 14. Subsection (1) of section 636.210, Florida |
| 169 | Statutes, is amended to read: |
| 170 | 636.210 Prohibited activities of a discount medical plan |
| 171 | organization.-- |
| 172 | (1) A discount medical plan organization may not: |
| 173 | (a) Use in its advertisements, marketing material, |
| 174 | brochures, and discount cards the term "insurance" except as |
| 175 | otherwise provided in this part or as a disclaimer of any |
| 176 | relationship between discount medical plan organization benefits |
| 177 | and insurance; |
| 178 | (b) Use in its advertisements, marketing material, |
| 179 | brochures, and discount cards the terms "health plan," |
| 180 | "coverage," "copay," "copayments," "preexisting conditions," |
| 181 | "guaranteed issue," "premium," "PPO," "preferred provider |
| 182 | organization," or other terms in a manner that could reasonably |
| 183 | mislead a person into believing the discount medical plan was |
| 184 | health insurance; |
| 185 | (c) Have restrictions on free access to plan providers, |
| 186 | except for hospital services, including, but not limited to, |
| 187 | waiting periods and notification periods; or |
| 188 | (d) Pay providers any fees for medical services. |
| 189 | Section 15. Subsection (1) of section 636.216, Florida |
| 190 | Statutes, is amended to read: |
| 191 | 636.216 Charge or form filings.-- |
| 192 | (1) All charges to members must be filed with the office. |
| 193 | and Any charge to members greater than $30 per month or $360 per |
| 194 | year for access to healthcare services, other than those |
| 195 | provided by physicians licensed under chapters 458 and 459 or by |
| 196 | hospitals licensed under chapter 395, must be approved by the |
| 197 | office before the charges can be used. Any charge to members |
| 198 | greater than $60 dollars per month or $720 per year for |
| 199 | healthcare services that include services provided by physicians |
| 200 | licensed under chapter 458 and 459 or by hospitals licensed |
| 201 | under chapter 395 must be approved by the office before the |
| 202 | charges can be used. The discount medical plan organization has |
| 203 | the burden of proof that the charges bear a reasonable relation |
| 204 | to the benefits received by the member. |
| 205 | Section 16. Subsection (2) of section 636.218, Florida |
| 206 | Statutes, is amended to read: |
| 207 | 636.218 Annual reports.-- |
| 208 | (2) Such reports must be on forms prescribed by the |
| 209 | commission and must include: |
| 210 | (a) Audited financial statements prepared in accordance |
| 211 | with generally accepted accounting principles certified by an |
| 212 | independent certified public accountant, including the |
| 213 | organization's balance sheet, income statement, and statement of |
| 214 | changes in cash flow for the preceding year. An organization |
| 215 | that is a subsidiary of a parent entity that is publicly traded |
| 216 | and that prepares audited financial statements reflecting the |
| 217 | consolidated operations of the parent entity and the |
| 218 | organization may petition the office to accept, in lieu of the |
| 219 | audited financial statement of the organization, the audited |
| 220 | financial statement of the parent entity and a written guaranty |
| 221 | by the parent entity that the minimum capital requirements of |
| 222 | the organization required by this part will be met by the parent |
| 223 | entity. |
| 224 | (a)(b) If different from the initial application or the |
| 225 | last annual report, a list of the names and residence addresses |
| 226 | of all persons responsible for the conduct of the organization's |
| 227 | affairs, together with a disclosure of the extent and nature of |
| 228 | any contracts or arrangements between such persons and the |
| 229 | discount medical plan organization, including any possible |
| 230 | conflicts of interest. |
| 231 | (b)(c) The number of discount medical plan members in the |
| 232 | state. |
| 233 | (c)(d) Such other information relating to the performance |
| 234 | of the discount medical plan organization as is reasonably |
| 235 | required by the commission or office. |
| 236 | Section 17. Subsection (1) of section 636.220, Florida |
| 237 | Statutes, is amended to read: |
| 238 | 636.220 Minimum capital requirements.-- |
| 239 | (1) Each discount medical plan organization must at all |
| 240 | times maintain a net worth of at least $150,000 and each |
| 241 | discount medical plan organization shall certify in writing |
| 242 | under oath at licensure and annually that the minimum |
| 243 | capitalization requirements of this part are satisfied. |
| 244 | Section 18. Section 636.230, Florida Statutes, is amended |
| 245 | to read: |
| 246 | 636.230 Bundling discount medical plans with insurance |
| 247 | other products.--When a marketer or discount medical plan |
| 248 | organization sells a discount medical plan together with any |
| 249 | insurance other product, the fees for the discount medical plan |
| 250 | must be provided in writing to the member if the fees exceed $30 |
| 251 | per month for access to healthcare services other than those |
| 252 | provided by physicians licensed under chapter 458 or chapter 459 |
| 253 | or by hospitals licensed under chapter 395 or $60 dollars per |
| 254 | month for healthcare services which include services provided by |
| 255 | physicians licensed under chapter 458 or chapter 459 or by |
| 256 | hospitals licensed under chapter 395. |
| 257 | Section 19. Except as otherwise expressly provided in this |
| 258 | act, this act shall take effect January 1, 2007, |
| 259 |
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| 260 | ======= T I T L E A M E N D M E N T ======= |
| 261 | Remove line 21, and insert: |
| 262 | amending s. 627.668, F.S.; revising provisions relating to |
| 263 | required optional coverage for mental and nervous disorders; |
| 264 | providing additional requirements; specifying nonapplication; |
| 265 | providing a definition; authorizing insurers and health |
| 266 | maintenance organizations to require certain services to be |
| 267 | provided by certain exclusive providers; providing for a payment |
| 268 | of benefits contingency; authorizing insures and health |
| 269 | maintenance organizations to enter into capitation contracts |
| 270 | with exclusive providers for certain purposes; specifying |
| 271 | nonapplication to certain health plans or health insurance |
| 272 | coverages; amending s. 636.204, F.S.; revising a license |
| 273 | application provision for discount medical plan organizations |
| 274 | relating to submittal of financial statements;; amending s. |
| 275 | 636.206, F.S.; revising examination and investigative authority; |
| 276 | amending s. 636.210, F.S.; providing an exception to prohibited |
| 277 | activities; amending s. 636.216, F.S.; providing provisions |
| 278 | relating to office approval of certain charges to members of the |
| 279 | plan; amending s. 636.218, F.S.; removing certain information |
| 280 | from the annual report; amending s. 636.220, F.S.; revising |
| 281 | certain minimum capital requirements of discount medical plan |
| 282 | organizations; amending s. 636.230, F.S.; revising provisions |
| 283 | relating to the bundling of discount medical plans with |
| 284 | insurance products; providing application; providing effective |
| 285 | dates. |