| 1 | A bill to be entitled |
| 2 | An act relating to optional coverage for mental and |
| 3 | nervous disorders; amending s. 627.668, F.S.; revising |
| 4 | requirements for optional coverage for mental and nervous |
| 5 | disorders; revising certain benefits limitations; limiting |
| 6 | applicability; providing a definition; permitting benefits |
| 7 | to be provided by an exclusive provider or group of |
| 8 | exclusive providers; permitting benefits to be provided |
| 9 | through a contract with exclusive providers; providing for |
| 10 | care management; providing an exemption; providing an |
| 11 | effective date. |
| 12 |
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| 13 | Be It Enacted by the Legislature of the State of Florida: |
| 14 |
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| 15 | Section 1. Present subsection (3) of section 627.668, |
| 16 | Florida Statutes, is renumbered as subsection (4), and a new |
| 17 | subsection (3) is added to that section to read: |
| 18 | 627.668 Optional coverage for mental and nervous disorders |
| 19 | required; exception.-- |
| 20 | (3)(a) Every insurer and health maintenance organization |
| 21 | transacting group health insurance or providing prepaid health |
| 22 | care in this state shall make available to the policyholder, for |
| 23 | an appropriate additional premium, as part of the application |
| 24 | for a group hospital and medical expense-incurred insurance |
| 25 | policy under a group prepaid health care contract or a group |
| 26 | health maintenance organization contract, coverage for the |
| 27 | treatment of serious mental illness, which treatment is |
| 28 | determined to be medically necessary. |
| 29 | (b) 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 must be the same for |
| 33 | serious mental illness as for physical illness generally. |
| 34 | Notwithstanding the provisions of this subsection, an insurer or |
| 35 | health maintenance organization may limit inpatient coverage to |
| 36 | 45 days per year and may limit outpatient coverage to 60 visits |
| 37 | per year. |
| 38 | (c) This subsection does not apply to any group health |
| 39 | plan or group health insurance covered in connection with a |
| 40 | group health plan for any plan year of a small employer as |
| 41 | defined in s. 627.6699. |
| 42 | (d) As used in this subsection, the term "serious mental |
| 43 | illness" means the following psychiatric illnesses as defined by |
| 44 | the American Psychiatric Association in the most current edition |
| 45 | of the Diagnostic and Statistical Manual of Mental Disorders: |
| 46 | schizophrenia, schizoaffective disorder, panic disorder, bipolar |
| 47 | affective disorder, major depressive disorder, and obsessive- |
| 48 | compulsive disorder. |
| 49 | (e) Notwithstanding other provisions of this section, |
| 50 | chapter 641, s. 627.6471, or s. 627.6472, an insurer or health |
| 51 | maintenance organization may require that the covered services |
| 52 | required by this subsection be provided by an exclusive provider |
| 53 | of health care or a group of exclusive providers of health care |
| 54 | which has entered into a written agreement with the insurer or |
| 55 | health maintenance organization to provide benefits under this |
| 56 | subsection. The insurer or health maintenance organization may |
| 57 | condition the payment of such benefits, in whole or in part, on |
| 58 | the use of such exclusive providers. |
| 59 | (f) The insurer or health maintenance organization may |
| 60 | directly or indirectly enter into a contract with an exclusive |
| 61 | provider of health care or a group of exclusive providers of |
| 62 | health care to provide benefits under this subsection. In |
| 63 | providing benefits under this subsection, the insurer or health |
| 64 | maintenance organization may impose other appropriate financial |
| 65 | incentives, peer review, utilization requirements, and other |
| 66 | methods used for the management of benefits provided for other |
| 67 | medical conditions or by management methods unique to mental |
| 68 | health benefits to reduce service costs and utilization without |
| 69 | compromising quality of care. |
| 70 | (g) This subsection does not apply with respect to a group |
| 71 | health plan or health insurance coverage offered in connection |
| 72 | with a group health plan if the application of this subsection |
| 73 | to such plan or coverage results in an increase in the cost |
| 74 | under the plan or for such coverage of at least 2 percent, as |
| 75 | determined and certified by an insurer's or health maintenance |
| 76 | organization's actuary. |
| 77 | Section 2. This act shall take effect July 1, 2008. |