Florida Senate - 2010 CS for SB 1232
By the Committee on Banking and Insurance; and Senators Fasano
and Gaetz
597-04880-10 20101232c1
1 A bill to be entitled
2 An act relating to health insurance; amending s.
3 626.9541, F.S.; authorizing an insurer offering a
4 group or individual health benefit plan to offer a
5 wellness program; authorizing rewards or incentives;
6 providing that such rewards or incentives are not
7 insurance benefits; providing for verification of a
8 member’s inability to participate for medical reasons;
9 amending s. 627.6141, F.S.; authorizing appeals from
10 denials of certain claims for certain services;
11 requiring a health insurer to conduct a retrospective
12 review of the medical necessity of a service under
13 certain circumstances; requiring the health insurer to
14 submit a written justification for a determination
15 that a service was not medically necessary; amending
16 s. 641.3156, F.S.; authorizing appeals from denials of
17 certain claims for certain services; requiring a
18 health maintenance organization to conduct a
19 retrospective review of the medical necessity of a
20 service under certain circumstances; requiring the
21 health maintenance organization to submit a written
22 justification for a determination that a service was
23 not medically necessary; providing an effective date.
24
25 Be It Enacted by the Legislature of the State of Florida:
26
27 Section 1. Subsection (3) is added to section 626.9541,
28 Florida Statutes, to read:
29 626.9541 Unfair methods of competition and unfair or
30 deceptive acts or practices defined.—
31 (3) WELLNESS PROGRAMS.—An insurer issuing a group or
32 individual health benefit plan may offer a voluntary wellness or
33 health-improvement program that allows for rewards or
34 incentives, including, but not limited to, merchandise, gift
35 cards, debit cards, premium discounts or rebates, contributions
36 towards a member’s health savings account, modifications to
37 copayment, deductible, or coinsurance amounts, or any
38 combination of these incentives, to encourage participation or
39 to reward for participation in the program. The health plan
40 member may be required to provide verification, such as a
41 statement from his or her physician, that a medical condition
42 makes it unreasonably difficult or medically inadvisable for the
43 individual to participate in the wellness program. Any reward or
44 incentive established under this section is not an insurance
45 benefit and does not violate this section. This subsection does
46 not prohibit an insurer from offering incentives or rewards to
47 members for adherence to wellness or health-improvement programs
48 if otherwise allowed by state or federal law.
49 Section 2. Section 627.6141, Florida Statutes, is amended
50 to read:
51 627.6141 Denial of claims.—
52 (1) Each claimant, or provider acting for a claimant, who
53 has had a claim denied as not medically necessary must be
54 provided an opportunity for an appeal to the insurer’s licensed
55 physician who is responsible for the medical necessity reviews
56 under the plan or is a member of the plan’s peer review group.
57 The appeal may be by telephone, and the insurer’s licensed
58 physician must respond within a reasonable time, not to exceed
59 15 business days.
60 (2) If a hospital claim or a portion of a hospital claim is
61 denied because the hospital, due to an unintentional act of
62 error or omission, failed to obtain the necessary authorization,
63 the hospital may appeal the denial to the insurer’s licensed
64 physician who is responsible for medical necessity reviews. The
65 health insurer shall conduct and complete a retrospective review
66 of the medical necessity of the service within 30 business days
67 after the submitted appeal. If the health insurer determines
68 upon review that the service was medically necessary, the
69 insurer shall reverse the denial and pay the claim. If the
70 insurer determines that the service was not medically necessary,
71 the insurer shall provide to the hospital specific written
72 clinical justification for the determination.
73 Section 3. Present subsection (3) of section 641.3156,
74 Florida Statutes, is renumbered as subsection (4), and a new
75 subsection (3) is added to that section, to read:
76 641.3156 Treatment authorization; payment of claims.—
77 (3) If a hospital claim or a portion of a hospital claim of
78 a contracted provider is denied because the hospital, due to an
79 unintentional act of error or omission, failed to obtain the
80 necessary authorization, the hospital may appeal the denial to
81 the health maintenance organization’s licensed physician who is
82 responsible for medical necessity reviews. The health
83 maintenance organization shall conduct and complete a
84 retrospective review of the medical necessity of the service
85 within 30 business days after the submitted appeal. If the
86 health maintenance organization determines upon review that the
87 service was medically necessary, the health maintenance
88 organization shall reverse the denial and pay the claim. If the
89 health maintenance organization determines that the service was
90 not medically necessary, the health maintenance organization
91 shall provide the hospital with specific written clinical
92 justification for the determination.
93 Section 4. This act shall take effect July 1, 2010.