Florida Senate - 2014                        COMMITTEE AMENDMENT
       Bill No. SPB 7028
                              LEGISLATIVE ACTION                        
                    Senate             .             House              

    1         Senate Amendment (with title amendment)
    3         Delete everything after the enacting clause
    4  and insert:
    5         Section 1. Section 456.4501, Florida Statutes, is created
    6  to read:
    7         456.4501Short title.—Sections 465.4501-465.4506 may be
    8  cited as the “Florida Telemedicine Act.”
    9         Section 2. Section 456.4502, Florida Statutes, is created
   10  to read:
   11         456.4502Definitions.—As used in this act, the term:
   12         (1) “Act” means the Florida Telemedicine Act.
   13         (2) “Advanced communications technology” means:
   14         (a) Compressed digital interactive video, audio, or data
   15  transmissions;
   16         (b) Real-time synchronous video- or web-conferencing
   17  communications;
   18         (c) Secure web-based communications;
   19         (d) Still-image capture or asynchronous store and forward;
   20         (e) Health care service transmissions supported by mobile
   21  devices (mHealth); or
   22         (f) Other technology that facilitates access to health care
   23  services or medical specialty expertise.
   24         (3)“Distant site” means the location at which the
   25  telemedicine provider delivering the health care service is
   26  located at the time the service is provided via telemedicine.
   27         (4) “Encounter” means an examination, consultation,
   28  monitoring, or other health care service.
   29         (5) “Health care provider” means a health care practitioner
   30  or out-of-state licensed individual who provides health care
   31  services within the scope of his or her professional license.
   32         (6) “In person” means that a patient is in the physical
   33  presence of the health care provider without regard to whether
   34  portions of the encounter are conducted by other providers.
   35         (7)“Originating site” means the location of the patient
   36  receiving telemedicine services which site meets the standards
   37  of this act as verified by the telemedicine provider.
   38         (8)“Patient presenter” means an individual who has
   39  clinical background training in the use of advanced
   40  communications technology equipment and who is available at the
   41  originating site to present the patient, manage the cameras or
   42  equipment, and perform any hands-on activity necessary to
   43  successfully complete the telemedicine encounter under the
   44  direction and supervision of a telemedicine provider.
   45         (9)“Store and forward” means the type of telemedicine
   46  encounter that uses still digital images of patient data for
   47  rendering a medical opinion or diagnosis. The term includes the
   48  asynchronous transmission of clinical data from one site to
   49  another.
   50         (10) “Telehealth” means the use of advanced communications
   51  technology to provide access to health assessment, diagnosis,
   52  intervention, consultation, supervision, and information across
   53  distances. The term includes the use of remote patient
   54  monitoring devices that are used to collect and transmit data
   55  for telemonitoring and interpretation.
   56         (11)Telemedicine” means the use of advanced
   57  communications technology by a health care provider or by a
   58  health care provider acting under an appropriate delegation or
   59  supervision as may be required by the appropriate board, or the
   60  department if there is no board, to provide a health care
   61  service. Services provided through telemedicine may include
   62  patient assessment, diagnosis, consultation, treatment,
   63  prescription of medicine, transfer of medical data, or other
   64  medical-related services. The term does not include audio-only
   65  calls, e-mail messages, or facsimile transmissions. Telemedicine
   66  includes telehealth and telemonitoring.
   67         (12) “Telemedicine provider” means a health care
   68  practitioner who provides telemedicine services, or an out-of
   69  state health care provider who provides telemedicine services to
   70  a patient physically located in this state and who meets the
   71  requirements of s. 456.4503, as applicable.
   72         Section 3. Section 456.4503, Florida Statutes, is created
   73  to read:
   74         456.4503 Telemedicine requirements.—
   75         (1) An out-of-state health care provider who provides
   76  telemedicine across state lines to a patient physically located
   77  in this state must have a Florida license to practice a health
   78  care profession, except as provided under subsection (2).
   79         (2) An out-of-state physician who does not meet the
   80  requirements of subsection (1) may provide telemedicine services
   81  across state lines to patients located in this state if the
   82  physician:
   83         (a) Holds an unrestricted active license to practice
   84  allopathic or osteopathic medicine in the state of the distant
   85  site and that state’s licensure requirements meet or exceed
   86  those of this state under chapter 458 or chapter 459, as
   87  determined by the appropriate board;
   88         (b) Maintains professional liability coverage that includes
   89  coverage for telemedicine services, in an amount and manner
   90  consistent with s. 458.320 and appropriate to the physician’s
   91  scope of practice and location;
   92         (c) Has at least one of the following:
   93         1. Privileges at or is on the medical staff of an out-of
   94  state hospital that is a certified Medicare provider;
   95         2. Affiliation with an out-of-state health insurer or
   96  health plan that is also licensed in this state and that uses
   97  credentialing requirements that are equivalent to those used in
   98  this state; and
   99         (d) Practices in a state that allows Florida-licensed
  100  physicians to provide telemedicine services to patients located
  101  in that state without having to be licensed to practice medicine
  102  in that state.
  103         (3) An out-of-state physician provider authorized under
  104  subsection (2) to provide telemedicine services to patients in
  105  this state is subject to appropriate disciplinary action by a
  106  regulatory entity in this state which has regulatory
  107  jurisdiction over the hospital, insurer, or health plan
  108  affiliated with the physician as described in paragraph (2)(c).
  109  Such affiliated hospital, insurer, or health plan shall be held
  110  responsible by the appropriate state regulatory entities and
  111  other legal and regulatory authorities in this state, as
  112  applicable, for the actions of their affiliated physician
  113  providers providing telemedicine services to patients in this
  114  state.
  115         (4) The telemedicine provider and any affiliated hospital,
  116  insurer, or health plan described under paragraph (2)(c), if
  117  applicable, shall make any pertinent records available upon
  118  request of the board, the department, or other regulatory
  119  authority as applicable. Failure to comply with such request may
  120  result in the revocation of a health care practitioner’s license
  121  or imposition of a fine by the applicable board, or department
  122  if there is no board; or in the case of an affiliated hospital,
  123  insurer or health plan, a fine, a license restriction, or
  124  revocation of an affiliated entity’s authorization to conduct
  125  business in this state.
  126         (5) Venue for a civil or administrative action initiated by
  127  the telemedicine recipient, the department, or the appropriate
  128  board shall be based on the location of the patient or shall be
  129  in Leon County.
  130         (6)Physician consultations that occur on an emergency
  131  basis and that are conducted via telemedicine are exempt from
  132  subsections (1) and (2). Emergency services and care provided to
  133  relieve an emergency medical condition have the same meaning as
  134  defined under s. 395.002.
  135         (7)This section does not prohibit consultations between an
  136  out-of-state health care provider and a health care practitioner
  137  in this state or for the transmission and review of digital
  138  images, pathology specimens, test results, or other medical data
  139  by an out-of-state health care provider or other qualified
  140  providers related to the care of a patient in this state.
  141         (8)This section does not preclude a health care provider
  142  who acts within the scope of his or her Florida professional
  143  license from using the technology of telemedicine within his or
  144  her practice or under the direction and supervision of another
  145  health care provider whose scope of practice includes the use of
  146  such technology. A health care provider or patient presenter
  147  acting under the direction and supervision of a physician
  148  through the use of telemedicine may not be interpreted as
  149  practicing medicine without a license. However, a health care
  150  provider must be trained in, educated on, and knowledgeable
  151  about the procedure and technology and may not perform duties
  152  for which the practitioner does not have sufficient training,
  153  education, and knowledge. Failure to have adequate training,
  154  education, and knowledge is grounds for disciplinary action by
  155  the appropriate board, or the department if there is no board,
  156  or the affiliated regulatory entity for affiliated providers.
  157         (9)The boards, or the department if there is no board, may
  158  adopt rules to administer the requirements of this act and must
  159  repeal rules that are inconsistent with this act, including
  160  rules that prohibit the use of telemedicine in this state. The
  161  appropriate board, or the department if there is no board, may
  162  also develop standards and adopt rules relating to requirements
  163  for patient presenters. Such rules may not require the use of
  164  patient presenters in telemedicine services if special skills or
  165  training is not needed for a patient to participate in the
  166  encounter.
  167         (10) A health care practitioner who engages in telemedicine
  168  services must complete 2 hours of continuing education credit
  169  related to the provision of services through telemedicine during
  170  each license renewal period.
  171         Section 4. Section 456.4504, Florida Statutes, is created
  172  to read:
  173         456.4504 Telemedicine standards.—
  174         (1) The standard of care as provided in s. 766.102 is the
  175  same regardless of whether a health care provider provides
  176  health care services in person or by telemedicine. The
  177  applicable board for each health care provider, or the
  178  department if there is no board, may adopt rules specifically
  179  related to the standard of care for telemedicine.
  180         (2) A telemedicine provider providing telemedicine services
  181  under this act is responsible for the quality of the equipment
  182  and technology employed and for its safe use. Telemedicine
  183  equipment and advanced communications technology must, at a
  184  minimum, be able to provide the same information to the
  185  telemedicine provider as the information that would be obtained
  186  in an in-person encounter with a health care provider and enable
  187  the telemedicine provider to meet or exceed the prevailing
  188  standard of care for the practice of the profession.
  189         (3) The telemedicine provider is not required to conduct a
  190  patient history or physical examination of the patient before
  191  engaging in a telemedicine encounter if the telemedicine
  192  provider conducts a patient evaluation sufficient to meet the
  193  prevailing standard of care for the services provided.
  194         (4) Before each telemedicine encounter, the identification
  195  and location of the telemedicine provider and any other
  196  individuals present via advanced communications technology who
  197  will view the patient or the patient’s information must be
  198  identified to the patient.
  199         (5) For the purposes of this act, the nonemergency
  200  prescribing of a legend drug based solely on an electronic
  201  questionnaire without a visual examination is considered a
  202  failure to practice medicine with the level of care, skill, and
  203  treatment which is recognized by a reasonably prudent physician
  204  or other authorized practitioner and is not authorized under
  205  this act.
  206         (6) A controlled substance may not be prescribed through
  207  the use of telemedicine.
  208         (7) Medical records must be kept by each telemedicine
  209  provider that participates in a patient telemedicine encounter
  210  to the same extent as required for an in-person encounter under
  211  state and federal law. Telemedicine providers are encouraged to
  212  create electronic health records to document the encounter and
  213  to transmit information in the most efficient manner possible.
  214         (8) Any medical records generated, including records
  215  maintained via video, audio, electronic, or other means, due to
  216  a telemedicine encounter must conform to the confidentiality and
  217  recordkeeping requirements of federal law, nationally recognized
  218  health care accreditation organizations, and the laws and rules
  219  of this state regardless of where the medical records of a
  220  patient in this state are maintained.
  221         (9) Telemedicine technology used by a telemedicine provider
  222  must be encrypted and must use a recordkeeping program to verify
  223  each interaction.
  224         (10) In those situations in which a telemedicine provider
  225  uses telemedicine technology provided by a third-party vendor,
  226  the telemedicine provider must:
  227         (a) Require a business associate agreement with the third
  228  party vendor; and
  229         (b) Ensure that the third-party vendor complies with the
  230  administrative, physical, and technical safeguards and standards
  231  set forth by the Health Information Technology for Economic and
  232  Clinical Health (HITECH) Act and by federal regulations
  233  implemented pursuant to HITECH.
  234         (11) If a patient provides any of the telemedicine
  235  technology, such as a patient-owned smartphone, tablet, laptop,
  236  desktop computer, or video equipment, the telemedicine provider
  237  must take steps to ensure that such technology:
  238         (a) Complies with the administrative, physical, and
  239  technical safeguards set forth by HITECH and by federal
  240  regulations implemented pursuant to HITECH; and
  241         (b) Is appropriate for the medical discipline for which the
  242  technology is provided.
  243         Section 5. Section 456.4505, Florida Statutes, is created
  244  to read:
  245         456.4505Interstate compacts for telemedicine.—The
  246  Legislature finds that lack of access to high-quality,
  247  affordable health care services is an increasing problem, both
  248  in this state and nationwide. The Legislature finds that this
  249  problem could be alleviated by greater interstate cooperation
  250  among, and by the mobility of, health care providers through the
  251  use of telemedicine. Therefore, the executive directors of the
  252  boards, together with the department, may participate in the
  253  development of one or more interstate compacts for the provision
  254  of telemedicine services across state lines. The department
  255  shall annually submit a report on the status of any pending
  256  compacts for legislative consideration to the Governor, the
  257  President of the Senate, and the Speaker of the House of
  258  Representatives. Any finalized compacts shall be submitted by
  259  December 31 for consideration by the Legislature during the next
  260  regular legislative session. A compact negotiated or proposed by
  261  a board or the department is not valid until enacted by the
  262  Legislature.
  263         Section 6. Section 456.4506, Florida Statutes, is created
  264  to read:
  265         456.4506Telemedicine services under Medicaid.—
  266         (1)The Agency for Health Care Administration shall
  267  reimburse for Medicaid services provided through telemedicine in
  268  the same manner and equivalent to Medicaid services provided in
  269  person under parts III and IV of chapter 409, except as provided
  270  in subsection (7).
  271         (2)Telemedicine services reimbursed under Medicaid must
  272  meet the standards and requirements of this act.
  273         (3)Except as provided in subsection (7), the agency may
  274  not require in-person contact between a health care provider and
  275  Medicaid recipient as a prerequisite for payment for services
  276  appropriately provided through telemedicine in accordance with
  277  generally accepted health care practices and standards
  278  prevailing in the applicable health care community at the time
  279  the services are provided.
  280         (4) Before receipt of telemedicine services, a Medicaid
  281  recipient or the legal representative of a Medicaid recipient
  282  must provide informed consent for telemedicine services. A
  283  Medicaid recipient shall also be provided the opportunity to
  284  receive the same service through an in-person encounter.
  285         (5)A Medicaid service that is provided through a fee-for
  286  service or managed care program may not be denied as a
  287  creditable Medicaid service solely because that service is
  288  provided through telemedicine.
  289         (6)Reimbursement of telemedicine services under Medicaid
  290  shall be the amount negotiated between the parties involved to
  291  the extent permitted under state and federal law. Regardless of
  292  the reimbursement methodology or amount, telemedicine providers
  293  located at the originating site and the distant site should both
  294  receive reimbursement based on the services rendered, if any,
  295  during the telemedicine encounter.
  296         (7)If, after implementation, the agency determines that
  297  the delivery of a particular service through telemedicine is not
  298  cost-effective or does not adequately meet the clinical needs of
  299  recipients and the determination has been documented, the agency
  300  may discontinue Medicaid reimbursement for that telemedicine
  301  service.
  302         (8)The agency shall submit a report on the usage and
  303  costs, including savings, if any, associated with the provision
  304  of health care services through telemedicine under the Medicaid
  305  program by January 1, 2017, to the President of the Senate, the
  306  Speaker of the House of Representatives, and the minority
  307  leaders of the Senate and House of Representatives.
  308         (9)This section is repealed June 30, 2017.
  309         Section 7. Paragraph (i) is added to subsection (1) of
  310  section 458.311, Florida Statutes, to read:
  311         458.311 Licensure by examination; requirements; fees.—
  312         (1) Any person desiring to be licensed as a physician, who
  313  does not hold a valid license in any state, shall apply to the
  314  department on forms furnished by the department. The department
  315  shall license each applicant who the board certifies:
  316         (i) For an applicant who graduates from medical school
  317  after October 1, 2015, has completed at least 2 credit hours of
  318  medical education related to telemedicine.
  319         Section 8. Paragraph (n) is added to subsection (1) of
  320  section 459.0055, Florida Statutes, to read:
  321         459.0055 General licensure requirements.—
  322         (1) Except as otherwise provided herein, any person
  323  desiring to be licensed or certified as an osteopathic physician
  324  pursuant to this chapter shall:
  325         (n) For an applicant who graduates from medical school
  326  after October 1, 2015, have completed at least 2 credit hours of
  327  medical education related to telemedicine.
  328  Section 9. This act shall take effect October 1, 2014.
  330  ================= T I T L E  A M E N D M E N T ================
  331  And the title is amended as follows:
  332         Delete everything before the enacting clause
  333  and insert:
  334                        A bill to be entitled                      
  335         An act relating to telemedicine; creating s. 456.4501,
  336         F.S.; providing a short title; creating s. 456.4502,
  337         F.S.; defining terms applicable to the act; creating
  338         s. 456.4503, F.S.; requiring health care providers
  339         providing telemedicine services to patients in this
  340         state to be licensed in this state; providing
  341         alternative requirements for out-of-state physicians;
  342         providing for disciplining out-of-state physicians
  343         through affiliated entities operating in this state;
  344         requiring pertinent records to be made available upon
  345         request; establishing venue; providing exceptions for
  346         emergency services; providing applicability;
  347         authorizing the health care boards and the Department
  348         of Health to adopt rules; creating s. 456.4504, F.S.;
  349         providing standards and prohibitions for the provision
  350         of telemedicine services; creating s. 456.4505, F.S.;
  351         providing legislative findings; authorizing the
  352         regulatory boards and the department to participate in
  353         the development of interstate compacts for the
  354         provision of telemedicine services; requiring an
  355         annual report to the Governor and the Legislature on
  356         the status of such compacts; requiring legislative
  357         enactment of such compacts; creating s. 456.4506,
  358         F.S.; providing requirements for reimbursement of
  359         telemedicine services under the Medicaid program;
  360         requiring a report to the Legislature on the usage and
  361         costs of telemedicine in Medicaid by a certain date;
  362         providing for future repeal; amending ss. 458.311 and
  363         459.0055, F.S.; requiring an applicant for licensure
  364         as a physician who graduates after a certain date to
  365         complete 2 credit hours of medical education related
  366         to telemedicine; providing an effective date.