CS/HB 715

1	A bill to be entitled
2	An act relating to health services claims; amending s.
3	626.9541, F.S.; authorizing certain insurers to offer
4	voluntary wellness or health improvement programs that
5	provide certain rewards or incentives; providing for
6	medical verification for nonparticipation in such programs
7	for certain reasons; providing that such rewards or
8	incentives are not insurance benefits and do not
9	constitute a violation of unfair methods of competition
10	and unfair or deceptive acts or practice provisions;
11	providing construction; amending s. 627.6141, F.S.;
12	authorizing appeals from denials of certain claims for
13	certain services; requiring a health insurer to conduct a
14	retrospective review of the medical necessity of a service
15	under certain circumstances; requiring the health insurer
16	to submit a written justification for a determination that
17	a service was not medically necessary and provide a
18	process for appealing the determination; amending s.
19	627.6474, F.S.; prohibiting contracts between health
20	insurers and dentists from containing certain fee
21	requirements set by the insurer under certain
22	circumstances; providing a definition; providing
23	application; amending s. 636.035, F.S.; prohibiting
24	contracts between prepaid limited health service
25	organizations and dentists from containing certain fee
26	requirements set by the organization under certain
27	circumstances; providing a definition; providing
28	application; amending s. 641.315, F.S.; prohibiting
29	contracts between health maintenance organizations and
30	dentists from containing certain fee requirements set by
31	the organization under certain circumstances; providing a
32	definition; providing application; amending s. 641.3156,
33	F.S.; authorizing appeals from denials of certain claims
34	for certain services; requiring a health maintenance
35	organization to conduct a retrospective review of the
36	medical necessity of a service under certain
37	circumstances; requiring the health maintenance
38	organization to submit a written justification for a
39	determination that a service was not medically necessary
40	and provide a process for appealing the determination;
41	providing an effective date.
42
43	Be It Enacted by the Legislature of the State of Florida:
44
45	Section 1.  Subsection (3) is added to section 626.9541,
46	Florida Statutes, to read:
47	626.9541  Unfair methods of competition and unfair or
48	deceptive acts or practices defined.-
49	(3)  WELLNESS PROGRAMS.-Notwithstanding subsection (1), an
50	insurer issuing a group or individual health benefit plan may
51	offer a voluntary wellness or health improvement program that
52	provides for rewards or incentives, including, but not limited
53	to, merchandise; gift cards; debit cards; premium discounts or
54	rebates; contributions towards a member's health savings
55	account; modifications to copayment, deductible, or coinsurance
56	amounts; or any combination of such rewards or incentives to
57	encourage or reward participation in the program. The health
58	benefit plan member may be required to provide verification,
59	including, but not limited to, a statement from the member's
60	physician, that a medical condition makes it unreasonably
61	difficult or medically inadvisable for the individual to
62	participate in the wellness program. Any reward or incentive
63	established under this subsection is not an insurance benefit
64	and does not constitute a violation of this section. This
65	subsection does not prohibit an insurer from offering incentives
66	or rewards to members for adherence to wellness or health
67	improvement programs if otherwise authorized by state or federal
68	law.
69	Section 2.  Section 627.6141, Florida Statutes, is amended
70	to read:
71	627.6141  Denial of claims.-Each claimant, or hospital
72	provider acting for a claimant, who has had a claim denied or a
73	portion of a claim denied because the hospital failed to obtain
74	the necessary authorization due to an unintentional act or error
75	or omission as not medically necessary must be provided an
76	opportunity for an appeal to the insurer's licensed physician
77	who is responsible for the medical necessity reviews under the
78	plan or is a member of the plan's peer review group. If the
79	hospital appeals the denial, the health insurer shall conduct
80	and complete a retrospective review of the medical necessity of
81	the service within 30 business days after the submitted appeal.
82	If the insurer determines upon review that the service was
83	medically necessary, the insurer shall reverse the denial and
84	pay the claim. If the insurer determines that the service was
85	not medically necessary, the insurer shall submit to the
86	hospital specific written clinical justification for the
87	determination. The appeal may be by telephone, and the insurer's
88	licensed physician must respond within a reasonable time, not to
89	exceed 15 business days.
90	Section 3.  Section 627.6474, Florida Statutes, is amended
91	to read:
92	627.6474  Provider contracts.-
93	(1)  A health insurer may shall not require a contracted
94	health care practitioner as defined in s. 456.001(4) to accept
95	the terms of other health care practitioner contracts with the
96	insurer or any other insurer, or health maintenance
97	organization, under common management and control with the
98	insurer, including Medicare and Medicaid practitioner contracts
99	and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or
100	s. 641.315, except for a practitioner in a group practice as
101	defined in s. 456.053 who must accept the terms of a contract
102	negotiated for the practitioner by the group, as a condition of
103	continuation or renewal of the contract. Any contract provision
104	that violates this section is void. A violation of this section
105	is not subject to the criminal penalty specified in s. 624.15.
106	(2)  A contract between a health insurer and a dentist
107	licensed under chapter 466 for the provision of services to
108	patients may not contain any provision that requires the dentist
109	to provide services to the insured under such contract at a fee
110	set by the health insurer unless such services are covered
111	services under the applicable contract. As used in this
112	subsection, the term "covered services" means services
113	reimbursable under the applicable contract, subject to such
114	contractual limitations on benefits, such as deductibles,
115	coinsurance, and copayments, as may apply. This subsection
116	applies to all contracts entered into or renewed on or after
117	July 1, 2010.
118	Section 4.  Subsection (13) is added to section 636.035,
119	Florida Statutes, to read:
120	636.035  Provider arrangements.-
121	(13)  A contract between a prepaid limited health service
122	organization and a dentist licensed under chapter 466 for the
123	provision of services to subscribers of the prepaid limited
124	health service organization may not contain any provision that
125	requires the dentist to provide services to subscribers of the
126	prepaid limited health service organization at a fee set by the
127	prepaid limited health service organization unless such services
128	are covered services under the applicable contract. As used in
129	this subsection, the term "covered services" means services
130	reimbursable under the applicable contract, subject to such
131	contractual limitations on benefits, such as deductibles,
132	coinsurance, and copayments, as may apply. This subsection
133	applies to all contracts entered into or renewed on or after
134	July 1, 2010.
135	Section 5.  Subsection (11) is added to section 641.315,
136	Florida Statutes, to read:
137	641.315  Provider contracts.-
138	(11)  A contract between a health maintenance organization
139	and a dentist licensed under chapter 466 for the provision of
140	services to subscribers of the health maintenance organization
141	may not contain any provision that requires the dentist to
142	provide services to subscribers of the health maintenance
143	organization at a fee set by the health maintenance organization
144	unless such services are covered services under the applicable
145	contract. As used in this subsection, the term "covered
146	services" means services reimbursable under the applicable
147	contract, subject to such contractual limitations on subscriber
148	benefits, such as deductibles, coinsurance, and copayments, as
149	may apply. This subsection applies to all contracts entered into
150	or renewed on or after July 1, 2010.
151	Section 6.  Subsection (3) of section 641.3156, Florida
152	Statutes, is renumbered as subsection (4), and a new subsection
153	(3) is added to that section to read:
154	641.3156  Treatment authorization; payment of claims.-
155	(3)  If a hospital claim or a portion of a hospital claim
156	of a contracted hospital is denied because the hospital, due to
157	an unintentional act of error or omission, failed to obtain the
158	necessary authorization, the hospital may appeal the denial to
159	the health maintenance organization's licensed physician who is
160	responsible for medical necessity reviews. The health
161	maintenance organization shall conduct and complete a
162	retrospective review of the medical necessity of the service
163	within 30 business days after the submitted appeal. If the
164	health maintenance organization determines that the service is
165	medically necessary, the health maintenance organization shall
166	reverse the denial and pay the claim. If the health maintenance
167	organization determines that the service is not medically
168	necessary, the health maintenance organization shall provide the
169	hospital with specific written clinical justification for the
170	determination.
171	Section 7.  This act shall take effect July 1, 2010.

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