Florida Senate - 2014                        COMMITTEE AMENDMENT
       Bill No. SPB 7028
                              LEGISLATIVE ACTION                        
                    Senate             .             House              
                   Comm: WD            .                                
                  03/04/2014           .                                

    1         Senate Substitute for Amendment (484228) (with title
    2  amendment)
    4         Delete everything after the enacting clause
    5  and insert:
    6         Section 1. Section 456.4501, Florida Statutes, is created
    7  to read:
    8         456.4501Short title.—Sections 465.4501-465.4506 may be
    9  cited as the “Florida Telemedicine Act.”
   10         Section 2. Section 456.4502, Florida Statutes, is created
   11  to read:
   12         456.4502Definitions.—As used in this act, the term:
   13         (1) “Act” means the Florida Telemedicine Act.
   14         (2) “Advanced communications technology” means:
   15         (a) Compressed digital interactive video, audio, or data
   16  transmissions;
   17         (b) Real-time synchronous video- or web-conferencing
   18  communications;
   19         (c) Secure web-based communications;
   20         (d) Still-image capture or asynchronous store and forward;
   21         (e) Health care service transmissions supported by mobile
   22  devices (mHealth); or
   23         (f) Other technology that facilitates access to health care
   24  services or medical specialty expertise.
   25         (3)“Distant site” means the location at which the
   26  telemedicine provider delivering the health care service is
   27  located at the time the service is provided via telemedicine.
   28         (4) “Encounter” means an examination, consultation,
   29  monitoring, or other health care service.
   30         (5) “Health care provider” means a health care practitioner
   31  or out-of-state licensed individual who provides health care
   32  services within the scope of his or her professional license.
   33         (6) “In person” means that a patient is in the physical
   34  presence of the health care provider without regard to whether
   35  portions of the encounter are conducted by other providers.
   36         (7)“Originating site” means the location of the patient
   37  receiving telemedicine services which site meets the standards
   38  of this act as verified by the telemedicine provider.
   39         (8)“Patient presenter” means an individual who has
   40  clinical background training in the use of advanced
   41  communications technology equipment and who is available at the
   42  originating site to present the patient, manage the cameras or
   43  equipment, and perform any hands-on activity necessary to
   44  successfully complete the telemedicine encounter under the
   45  direction and supervision of a telemedicine provider.
   46         (9)“Store and forward” means the type of telemedicine
   47  encounter that uses still images of patient data for rendering a
   48  medical opinion or diagnosis. The term includes the asynchronous
   49  transmission of clinical data from one site to 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 practice of medicine through
   57  the use of advanced communications technology by a telemedicine
   58  provider at a distant site in compliance with federal and state
   59  privacy and confidentiality requirements and encryption
   60  standards. Services provided through telemedicine may include
   61  patient assessment, diagnosis, consultation, treatment,
   62  prescription of medicine, transfer of medical data, or other
   63  medical-related services. The term does not include audio-only
   64  calls, e-mail messages, or facsimile transmissions. Telemedicine
   65  includes telehealth and telemonitoring.
   66         (12) “Telemedicine provider” means a physician licensed
   67  under chapter 458 or chapter 459 who provides telemedicine
   68  services, or an out-of-state physician who provides telemedicine
   69  services to a patient physically located in this state and who
   70  meets the requirements of s. 456.4503, as applicable.
   71         Section 3. Section 456.4503, Florida Statutes, is created
   72  to read:
   73         456.4503 Telemedicine requirements.—
   74         (1) An out-of-state physician who provides telemedicine
   75  across state lines to a patient physically located in this state
   76  must have a Florida license to practice medicine as provided
   77  under chapter 458 or chapter 459, except as provided under
   78  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 one of the following:
   93         1. Privileges at or is on the medical staff of an out-of
   94  state hospital affiliated with a Florida hospital licensed under
   95  chapter 395; or
   96         2. Affiliation with an out-of-state health insurer or
   97  health plan that is also authorized to conduct business in this
   98  state pursuant to chapter 627 or chapter 641; 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 authorized under subsection
  104  (2) to provide telemedicine services to patients in this state
  105  is subject to appropriate disciplinary action by a regulatory
  106  entity in this state which has regulatory jurisdiction over the
  107  hospital, insurer, or health plan affiliated with the physician
  108  as described in paragraph (2)(c). Such affiliated hospital,
  109  insurer, or health plan shall be held responsible by the
  110  appropriate state regulatory entities and other legal and
  111  regulatory authorities in this state, as applicable, for the
  112  actions of their affiliated physicians providing telemedicine
  113  services to patients in this state.
  114         (4) The telemedicine provider and any affiliated hospital,
  115  insurer, or health plan described under paragraph (2)(c), if
  116  applicable, shall make any pertinent records available upon
  117  request of the board, the department, or other regulatory
  118  authority as applicable. Failure to comply with such request may
  119  result in the revocation of the physician’s license or
  120  imposition of a fine by the applicable board or department; or,
  121  in the case of an affiliated hospital, insurer, or health plan,
  122  a fine, a license restriction, or revocation of the affiliated
  123  entity’s authorization to conduct business in this state.
  124         (5) Venue for a civil or administrative action initiated by
  125  the telemedicine recipient, the department, or the appropriate
  126  board shall be based on the location of the patient or shall be
  127  in Leon County.
  128         (6)Physician consultations that occur on an emergency
  129  basis and that are conducted via telemedicine are exempt from
  130  subsections (1) and (2). Emergency services and care provided to
  131  relieve an emergency medical condition have the same meaning as
  132  provided in s. 395.002.
  133         (7)This section does not prohibit consultations between an
  134  out-of-state health care provider and a health care practitioner
  135  in this state or for the transmission and review of digital
  136  images, pathology specimens, test results, or other medical data
  137  by an out-of-state health care provider or other qualified
  138  providers related to the care of a patient in this state.
  139         (8)The boards, or the department if there is no board, may
  140  adopt rules to administer the requirements of this act and must
  141  repeal rules that are inconsistent with this act, including
  142  rules that prohibit the use of telemedicine in this state. The
  143  appropriate board, or the department if there is no board, may
  144  also develop standards and adopt rules relating to requirements
  145  for patient presenters. Such rules may not require the use of
  146  patient presenters in telemedicine services if special skills or
  147  training is not needed for a patient to participate in the
  148  encounter.
  149         (9) A health care practitioner who participates in
  150  telemedicine services must complete 2 hours of continuing
  151  education credit related to the provision of services through
  152  telemedicine during each license renewal period.
  153         Section 4. Section 456.4504, Florida Statutes, is created
  154  to read:
  155         456.4504 Telemedicine standards.—
  156         (1) The standard of care as provided in s. 766.102 is the
  157  same regardless of whether the physician provides health care
  158  services in person or by telemedicine. The applicable board may
  159  adopt rules specifically related to the standard of care for
  160  telemedicine.
  161         (2) A telemedicine provider providing telemedicine services
  162  under this act is responsible for the quality of the equipment
  163  and technology employed and for its safe use. Telemedicine
  164  equipment and advanced communications technology must, at a
  165  minimum, be able to provide the same information to the
  166  telemedicine provider as the information that would be obtained
  167  in an in-person encounter with a physician and must enable the
  168  telemedicine provider to meet or exceed the prevailing standard
  169  of care for the practice of the profession.
  170         (3) The telemedicine provider is not required to conduct a
  171  patient history or physical examination of the patient before
  172  engaging in a telemedicine encounter if the telemedicine
  173  provider conducts a patient evaluation sufficient to meet the
  174  prevailing standard of care for the services provided.
  175         (4) Before each telemedicine encounter, the identification
  176  and location of the telemedicine provider and all other
  177  individuals present via advanced communications technology who
  178  will view the patient or the patient’s information must be
  179  identified to the patient.
  180         (5) For the purposes of this act, the nonemergency
  181  prescribing of a legend drug based solely on an electronic
  182  questionnaire without a visual examination is considered a
  183  failure to practice medicine with the level of care, skill, and
  184  treatment which is recognized by a reasonably prudent physician
  185  or other authorized practitioner and is not authorized under
  186  this act.
  187         (6) A controlled substance may not be prescribed through
  188  the use of telemedicine.
  189         (7) Medical records must be kept by each telemedicine
  190  provider that participates in a patient telemedicine encounter
  191  to the same extent as required for an in-person encounter under
  192  state and federal law. Telemedicine providers are encouraged to
  193  create electronic health records to document the encounter and
  194  to transmit information in the most efficient manner possible.
  195         (8) Any medical records generated, including records
  196  maintained via video, audio, electronic, or other means, due to
  197  a telemedicine encounter must conform to the confidentiality and
  198  recordkeeping requirements of federal law and nationally
  199  recognized health care accreditation organizations and the laws
  200  and rules of this state, regardless of where the medical records
  201  of a patient in this state are maintained.
  202         (9) Telemedicine technology used by a telemedicine provider
  203  must be encrypted and must use a recordkeeping program to verify
  204  each interaction.
  205         (10) In those situations in which a telemedicine provider
  206  uses telemedicine technology provided by a third-party vendor,
  207  the telemedicine provider must:
  208         (a) Require a business associate agreement with the third
  209  party vendor; and
  210         (b) Ensure that the third-party vendor complies with the
  211  administrative, physical, and technical safeguards and standards
  212  set forth by the Health Information Technology for Economic and
  213  Clinical Health (HITECH) Act and by federal regulations
  214  implemented pursuant to HITECH.
  215         (11) If a patient provides any of the telemedicine
  216  technology, such as a patient-owned smartphone, tablet, laptop,
  217  desktop computer, or video equipment, the telemedicine provider
  218  must take steps to ensure that such technology:
  219         (a) Complies with the administrative, physical, and
  220  technical safeguards set forth by HITECH and by federal
  221  regulations implemented pursuant to HITECH; and
  222         (b) Is appropriate for the medical discipline for which the
  223  technology is provided.
  224         Section 5. Section 456.4505, Florida Statutes, is created
  225  to read:
  226         456.4505Interstate compacts for telemedicine.—The
  227  Legislature finds that lack of access to high-quality,
  228  affordable health care services is an increasing problem, both
  229  in this state and nationwide. The Legislature finds that this
  230  problem could be alleviated by greater interstate cooperation
  231  among, and by the mobility of, health care providers through the
  232  use of telemedicine. Therefore, the executive directors of the
  233  boards, together with the department, may participate in the
  234  development of one or more interstate compacts for the provision
  235  of telemedicine services across state lines. The department
  236  shall annually submit a report on the status of any pending
  237  compacts for legislative consideration to the Governor, the
  238  President of the Senate, and the Speaker of the House of
  239  Representatives. Any finalized compacts shall be submitted by
  240  December 31 for consideration by the Legislature during the next
  241  regular legislative session. A compact negotiated or proposed by
  242  a board or the department is not valid until enacted by the
  243  Legislature.
  244         Section 6. Section 456.4506, Florida Statutes, is created
  245  to read:
  246         456.4506Telemedicine services under Medicaid.—
  247         (1)The Agency for Health Care Administration shall
  248  reimburse for Medicaid services provided through telemedicine in
  249  the same manner and equivalent to Medicaid services provided in
  250  person under parts III and IV of chapter 409, except as provided
  251  in subsection (7).
  252         (2)Telemedicine services reimbursed under Medicaid must
  253  meet the standards and requirements of this act.
  254         (3)Except as provided in subsection (7), the agency may
  255  not require in-person contact between a physician and Medicaid
  256  recipient as a prerequisite for payment for services
  257  appropriately provided through telemedicine in accordance with
  258  generally accepted health care practices and standards
  259  prevailing in the applicable health care community at the time
  260  the services are provided.
  261         (4) Before receipt of telemedicine services, a Medicaid
  262  recipient or the legal representative of a Medicaid recipient
  263  must provide informed consent for telemedicine services. A
  264  Medicaid recipient shall also be provided the opportunity to
  265  receive the same service through an in-person encounter.
  266         (5)A Medicaid service that is provided through a fee-for
  267  service or managed care program may not be denied as a
  268  creditable Medicaid service solely because that service is
  269  provided through telemedicine.
  270         (6)Reimbursement of telemedicine services under Medicaid
  271  shall be the amount negotiated between the parties involved to
  272  the extent permitted under state and federal law. Regardless of
  273  the reimbursement methodology or amount, telemedicine providers
  274  located at the originating site and the distant site should both
  275  receive reimbursement based on the services rendered, if any,
  276  during the telemedicine encounter.
  277         (7)If, after implementation, the agency determines that
  278  the delivery of a particular service through telemedicine is not
  279  cost-effective or does not adequately meet the clinical needs of
  280  recipients and the determination has been documented, the agency
  281  may discontinue Medicaid reimbursement for that telemedicine
  282  service.
  283         (8)The agency shall submit a report on the usage and
  284  costs, including savings, if any, associated with the provision
  285  of health care services through telemedicine under the Medicaid
  286  program by January 1, 2017, to the President of the Senate, the
  287  Speaker of the House of Representatives, and the minority
  288  leaders of the Senate and the House of Representatives.
  289         (9)This section is repealed June 30, 2017.
  290         Section 7. Paragraph (i) is added to subsection (1) of
  291  section 458.311, Florida Statutes, to read:
  292         458.311 Licensure by examination; requirements; fees.—
  293         (1) Any person desiring to be licensed as a physician, who
  294  does not hold a valid license in any state, shall apply to the
  295  department on forms furnished by the department. The department
  296  shall license each applicant who the board certifies:
  297         (i) For an applicant who graduates from medical school
  298  after October 1, 2015, has completed at least 2 credit hours of
  299  medical education related to telemedicine.
  300         Section 8. Paragraph (n) is added to subsection (1) of
  301  section 459.0055, Florida Statutes, to read:
  302         459.0055 General licensure requirements.—
  303         (1) Except as otherwise provided herein, any person
  304  desiring to be licensed or certified as an osteopathic physician
  305  pursuant to this chapter shall:
  306         (n) For an applicant who graduates from medical school
  307  after October 1, 2015, have completed at least 2 credit hours of
  308  medical education related to telemedicine.
  309         Section 9. This act shall take effect October 1, 2014.
  311  ================= T I T L E  A M E N D M E N T ================
  312  And the title is amended as follows:
  313         Delete everything before the enacting clause
  314  and insert:
  315                        A bill to be entitled                      
  316         An act relating to telemedicine; creating s. 456.4501,
  317         F.S.; providing a short title; creating s. 456.4502,
  318         F.S.; defining terms applicable to the act; creating
  319         s. 456.4503, F.S.; requiring physicians providing
  320         telemedicine services to patients in this state to be
  321         licensed in this state; providing alternative
  322         requirements for out-of-state physicians; providing
  323         for disciplining out-of-state physicians through
  324         affiliated entities operating in this state; requiring
  325         pertinent records to be made available upon request;
  326         establishing venue; providing exceptions for emergency
  327         services; providing applicability; authorizing the
  328         licensing boards and the Department of Health to adopt
  329         rules; creating s. 456.4504, F.S.; providing standards
  330         and prohibitions for the provision of telemedicine
  331         services; prohibiting nonemergency prescribing of a
  332         legend drug without a physical examination;
  333         prohibiting the prescription of a controlled substance
  334         using telemedicine; creating s. 456.4505, F.S.;
  335         providing legislative findings; authorizing the
  336         regulatory boards and the department to participate in
  337         the development of interstate compacts for the
  338         provision of telemedicine services; requiring an
  339         annual report to the Governor and the Legislature on
  340         the status of such compacts; requiring legislative
  341         enactment of such compacts; creating s. 456.4506,
  342         F.S.; providing requirements for reimbursement of
  343         telemedicine services under the Medicaid program;
  344         requiring a report to the Legislature on the usage and
  345         costs of telemedicine in Medicaid by a certain date;
  346         providing for future repeal; amending ss. 458.311 and
  347         459.0055, F.S.; requiring an applicant for licensure
  348         as a physician who graduates after a certain date to
  349         complete 2 credit hours of medical education related
  350         to telemedicine; providing an effective date.