Florida Senate - 2016 COMMITTEE AMENDMENT
Bill No. CS for SB 1442
Senate . House
Comm: WD .
The Committee on Banking and Insurance (Negron) recommended the
1 Senate Amendment (with title amendment)
3 Delete lines 78 - 191
4 and insert:
5 Section 4. Subsection (11) of section 627.6131, Florida
6 Statutes, is amended to read:
7 627.6131 Payment of claims.—
8 (11) A health insurer may not retroactively deny a claim
9 because of insured ineligibility:
10 (a) At any time, if the health insurer verified the
11 eligibility of an insured at the time of treatment and provided
12 an authorization number.
13 (b) More than 1 year after the date of payment of the
15 Section 5. Section 627.64194, Florida Statutes, is created
16 to read:
17 627.64194 Coverage requirements for services provided by
18 nonparticipating providers.—
19 (1) As used in this section, the term:
20 (a) “Emergency services” means the services and care to
21 treat an emergency medical condition, as defined in s. 641.47.
22 For purposes of this section, the term includes emergency
23 transportation and ambulance services, to the extent permitted
24 by applicable state and federal law.
25 (b) “Facility” means a licensed facility as defined in s.
26 395.002(16) or an urgent care center as defined in s.
28 (c) “Nonemergency services” means the services and care to
29 treat a condition other than an emergency medical condition, as
30 defined in s. 395.002(8).
31 (d) “Nonparticipating provider” means a provider who is not
32 a “preferred provider” as defined in s. 627.6471, an “exclusive
33 provider” as defined in s. 627.6472, or a facility licensed
34 under chapter 395. A provider that is employed by a facility
35 licensed under chapter 395, and that is not a “preferred
36 provider” as defined in s. 627.6471 or an “exclusive provider”
37 as defined in s. 627.6472, is a nonparticipating provider.
38 (e) “Participating provider” means a “preferred provider”
39 as defined in s. 627.6471 or an “exclusive provider” as defined
40 in s. 627.6472, but not a facility licensed under chapter 395.
41 (f) “Insured” means a person who is covered under an
42 individual or group health insurance policy delivered or issued
43 for delivery in this state by an insurer authorized to transact
44 business in the state.
45 (2) An insurer is solely liable for payment of fees to a
46 nonparticipating provider of emergency services provided to an
47 insured in accordance with the terms of the health insurance
48 policy. Such insured is not liable for payment of fees to a
49 nonparticipating provider of emergency services other than
50 applicable copayments and deductibles. An insurer must provide
51 coverage for emergency services that:
52 (a) May not require prior authorization.
53 (b) Must be provided regardless of whether the service is
54 furnished by a participating or nonparticipating provider.
55 (c) May impose a coinsurance amount, copayment, or
56 limitation of benefits requirement for a nonparticipating
57 provider only if the same requirement applies to a participating
59 (3) An insurer is solely liable for payment of fees to a
60 nonparticipating provider of nonemergency services provided to
61 an insured in accordance with the terms of the health insurance
62 policy. Such insured is not liable for payment of fees to a
63 nonparticipating provider, other than applicable copayments and
64 deductibles, for nonemergency services:
65 (a) That are provided in a facility that has a contract for
66 the nonemergency services with the insurer which the facility
67 would be otherwise obligated to provide under contract with the
68 insurer; and
69 (b) Where the insured has no ability and opportunity to
70 choose a participating provider at the facility.
72 If the insured makes an informed affirmative decision to choose
73 a nonparticipating provider instead of a participating provider
74 who is available at the facility to treat the insured, the
75 provisions of this subsection do not apply.
76 (4) An insurer must reimburse a nonparticipating provider
77 for services under subsections (2) and (3) as specified in s.
78 641.513(5) within the applicable timeframe provided by s.
80 (5) A nonparticipating provider of emergency services as
81 provided in subsection (2) or nonemergency services as provided
82 in subsection (3) may not be reimbursed an amount greater than
83 the amount provided in subsection (4) and may not collect or
84 attempt to collect from the patient, directly or indirectly, any
85 excess amount except for copays and deductibles.
86 (6) A dispute with regard to the amount of reimbursement
87 owed to the nonparticipating provider of emergency or
88 nonemergency services as provided in subsection (4) must be
89 resolved in a court of competent jurisdiction or by the
90 voluntary dispute resolution process in s. 408.7057.
91 Section 6. Subsection (2) of section 627.6471, Florida
92 Statutes, is amended, and a new subsection (7) is added to that
93 section, to read:
94 627.6471 Contracts for reduced rates of payment;
95 limitations; coinsurance and deductibles.—
96 (2) Any insurer issuing a policy of health insurance in
97 this state, which insurance includes coverage for the services
98 of a preferred provider, must provide each policyholder and
99 certificateholder with a current list of preferred providers and
100 must make the list available on its website. The list must
101 include, where applicable and reported, a listing by specialty
102 of the names, addresses, and telephone numbers of all
103 participating providers, including facilities; and in the case
104 of physicians, board certifications, languages spoken, and any
105 affiliations with participating hospitals. Information posted to
106 the insurer’s website must be updated on at least a calendar
107 month basis with additions or terminations of providers from the
108 insurer’s network or reported changes in physician’s hospital
must make the list available for public inspection
110 during regular business hours at the principal office of the
111 insurer within the state.
112 (7) Any policy issued after January 1, 2017 under this
113 section must include the following disclosure: “WARNING: LIMITED
114 BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED.
115 You should be aware that when you elect to utilize the services
116 of a nonparticipating provider for a covered nonemergency
117 service, benefit payments to the provider are not based upon the
118 amount the provider charges. The basis of the payment will be
119 determined according to your policy’s out-of-network
120 reimbursement benefit. Nonparticipating providers may bill
121 insureds for any difference in the amount. YOU MAY BE REQUIRED
122 TO PAY MORE THAN THE COINSURANCE OR COPAYMENT. Participating
123 providers have agreed to accept discounted payments for services
124 with no additional billing to you other than coinsurance and
125 deductible amounts. You may obtain further information about the
126 providers who have contracted with your insurance plan by
127 consulting your insurer’s website or contacting your insurer or
128 agent directly.”
129 Section 7. Subsection (10) of section 641.3155, Florida
130 Statutes, is amended to read:
131 641.3155 Prompt payment of claims.—
132 (10) A health maintenance organization may not
133 retroactively deny a claim because of subscriber ineligibility:
134 (a) At any time, if the health maintenance organization
135 verified the eligibility of an insured at the time of treatment
136 and provided an authorization number.
137 (b) More than 1 year after the date of payment of the
140 ================= T I T L E A M E N D M E N T ================
141 And the title is amended as follows:
142 Delete lines 2 - 32
143 and insert:
144 An act relating to health care services; amending s.
145 395.003, F.S.; requiring hospitals, ambulatory
146 surgical centers, specialty hospitals, and urgent care
147 centers to comply with certain provisions as a
148 condition of licensure; amending s. 395.301, F.S.;
149 requiring a hospital to post certain information on
150 its website regarding its contracts with health
151 insurers, health maintenance organizations, and health
152 care practitioners and practice groups and a specified
153 statement to patients and prospective patients;
154 amending s. 456.072, F.S.; adding a ground for
155 discipline of referring health care providers by the
156 Department of Health; amending s. 627.6131, F.S.;
157 prohibiting a health insurer from retroactively
158 denying a claim under specified circumstances;
159 creating s. 627.64194, F.S.; defining terms;
160 specifying requirements for coverage provided by an
161 insurer for emergency services; providing that an
162 insurer is solely liable for payment of certain fees
163 to a provider; providing that an insured is not liable
164 for payment of certain fees; providing limitations and
165 requirements for reimbursements by an insurer to a
166 nonparticipating provider; providing applicability;
167 authorizing a nonparticipating provider or insurer to
168 initiate action in a court of competent jurisdiction
169 or through voluntary dispute resolution; amending s.
170 627.6471, F.S.; requiring an insurer that issues a
171 policy including coverage for the services of a
172 preferred provider to post certain information about
173 participating providers on its website; requiring a
174 specified disclosure to be included in policies
175 providing coverage for the services of a preferred
176 provider; amending s. 641.3155, F.S.; prohibiting a
177 health maintenance organization from retroactively
178 denying a claim under specified circumstances;
179 providing an effective date.