Florida Senate - 2016 CS for SB 1442
By the Committee on Health Policy; and Senator Garcia
1 A bill to be entitled
2 An act relating to out-of-network health insurance
3 coverage; amending s. 395.003, F.S.; requiring
4 hospitals, ambulatory surgical centers, specialty
5 hospitals, and urgent care centers to comply with
6 certain provisions as a condition of licensure;
7 amending s. 395.301, F.S.; requiring a hospital to
8 post certain information on its website regarding its
9 contracts with health insurers, health maintenance
10 organizations, and health care practitioners and
11 practice groups and a specified statement to patients
12 and prospective patients; amending s. 456.072, F.S.;
13 adding a ground for discipline of referring health
14 care providers by the Department of Health; creating
15 s. 627.64194, F.S.; defining terms; specifying
16 requirements for coverage provided by an insurer for
17 emergency services; providing that an insurer is
18 solely liable for payment of certain fees to a
19 provider; providing that an insured is not liable for
20 payment of certain fees; providing limitations and
21 requirements for reimbursements by an insurer to a
22 nonparticipating provider; providing applicability;
23 authorizing a nonparticipating provider or insurer to
24 initiate action in a court of competent jurisdiction
25 or through voluntary dispute resolution; amending s.
26 627.6471, F.S.; requiring an insurer that issues a
27 policy including coverage for the services of a
28 preferred provider to post certain information about
29 participating providers on its website; requiring a
30 specified disclosure to be included in policies
31 providing coverage for the services of a preferred
32 provider; providing an effective date.
34 Be It Enacted by the Legislature of the State of Florida:
36 Section 1. Paragraph (d) is added to subsection (5) of
37 section 395.003, Florida Statutes, to read:
38 395.003 Licensure; denial, suspension, and revocation.—
40 (d) A hospital, ambulatory surgical center, specialty
41 hospital, or urgent care center shall comply with the provisions
42 of ss. 627.64194 and 641.513 as a condition of licensure.
43 Section 2. Subsection (13) is added to section 395.301,
44 Florida Statutes, to read:
45 395.301 Itemized patient bill; form and content prescribed
46 by the agency; patient admission status notification.—
47 (13) A hospital shall post on its website:
48 (a) The names and hyperlinks for direct access to the
49 websites of all health insurers and health maintenance
50 organizations for which the hospital contracts as a network
51 provider or a participating provider.
52 (b) A statement that:
53 1. Services provided in the hospital by health care
54 practitioners may not be included in the hospital’s charges;
55 2. Health care practitioners who provide services in the
56 hospital may or may not participate with the same health
57 insurance plans as the hospital;
58 3. Prospective patients should contact the health care
59 practitioner arranging for the services to determine the health
60 care plans in which the health care practitioner participates.
61 (c) As applicable, the names, mailing addresses, and
62 telephone numbers of the health care practitioners and practice
63 groups that the hospital has contracted with to provide services
64 in the hospital and instruction on how to contact these health
65 care practitioners and practice groups to determine the health
66 insurers and health maintenance organizations for which the
67 hospital contracts as a network provider or a participating
69 Section 3. Paragraph (oo) is added to subsection (1) of
70 section 456.072, Florida Statutes, to read:
71 456.072 Grounds for discipline; penalties; enforcement.—
72 (1) The following acts shall constitute grounds for which
73 the disciplinary actions specified in subsection (2) may be
75 (oo) Failing to comply with the provisions of s. 627.64194
76 or s. 641.513 with such frequency as to constitute a general
77 business practice.
78 Section 4. Section 627.64194, Florida Statutes, is created
79 to read:
80 627.64194 Coverage requirements for services provided by
81 nonparticipating providers.—
82 (1) As used in this section, the term:
83 (a) “Emergency services” means the services and care to
84 treat an emergency medical condition, as defined in s. 641.47.
85 For purposes of this section, the term includes emergency
86 transportation and ambulance services, to the extent permitted
87 by applicable state and federal law.
88 (b) “Facility” means a licensed facility as defined in s.
89 395.002(16) or an urgent care center as defined in s.
91 (c) “Nonemergency services” means the services and care to
92 treat a condition other than an emergency medical condition, as
93 defined in s. 395.002(8).
94 (d) “Nonparticipating provider” means a provider who is not
95 a “preferred provider” as defined in s. 627.6471, an “exclusive
96 provider” as defined in s. 627.6472, or a facility licensed
97 under chapter 395. A provider that is employed by a facility
98 licensed under chapter 395, and that is not a “preferred
99 provider” as defined in s. 627.6471 or an “exclusive provider”
100 as defined in s. 627.6472, is a nonparticipating provider.
101 (e) “Participating provider” means a “preferred provider”
102 as defined in s. 627.6471 or an “exclusive provider” as defined
103 in s. 627.6472, but not a facility licensed under chapter 395.
104 (f) “Insured” means a person who is covered under an
105 individual or group health insurance policy delivered or issued
106 for delivery in this state by an insurer authorized to transact
107 business in the state.
108 (2) An insurer is solely liable for payment of fees to a
109 nonparticipating provider of emergency services provided to an
110 insured in accordance with the terms of the health insurance
111 policy. Such insured is not liable for payment of fees to a
112 nonparticipating provider of emergency services other than
113 applicable copayments and deductibles. An insurer must provide
114 coverage for emergency services that:
115 (a) May not require prior authorization.
116 (b) Must be provided regardless of whether the service is
117 furnished by a participating or nonparticipating provider.
118 (c) May impose a coinsurance amount, copayment, or
119 limitation of benefits requirement for a nonparticipating
120 provider only if the same requirement applies to a participating
122 (3) An insurer is solely liable for payment of fees to a
123 nonparticipating provider of nonemergency services provided to
124 an insured in accordance with the terms of the health insurance
125 policy. Such insured is not liable for payment of fees to a
126 nonparticipating provider, other than applicable copayments and
127 deductibles, for nonemergency services:
128 (a) That are provided in a facility that has a contract for
129 the nonemergency services with the insurer which the facility
130 would be otherwise obligated to provide under contract with the
131 insurer; and
132 (b) Where the insured has no ability and opportunity to
133 choose a participating provider at the facility.
135 If the insured makes an informed affirmative decision to choose
136 a nonparticipating provider instead of a participating provider
137 who is available at the facility to treat the insured, the
138 provisions of this subsection do not apply.
139 (4) An insurer must reimburse a nonparticipating provider
140 for services under subsections (2) and (3) as specified in s.
141 641.513(5) within the applicable timeframe provided by s.
143 (5) A nonparticipating provider of emergency services as
144 provided in subsection (2) or nonemergency services as provided
145 in subsection (3) may not be reimbursed an amount greater than
146 the amount provided in subsection (4) and may not collect or
147 attempt to collect from the patient, directly or indirectly, any
148 excess amount except for copays and deductibles.
149 (6) A dispute with regard to the amount of reimbursement
150 owed to the nonparticipating provider of emergency or
151 nonemergency services as provided in subsection (4) must be
152 resolved in a court of competent jurisdiction or by the
153 voluntary dispute resolution process in s. 408.7057.
154 Section 5. Subsection (2) of section 627.6471, Florida
155 Statutes, is amended, and a new subsection (7) is added to that
156 section, to read:
157 627.6471 Contracts for reduced rates of payment;
158 limitations; coinsurance and deductibles.—
159 (2) Any insurer issuing a policy of health insurance in
160 this state, which insurance includes coverage for the services
161 of a preferred provider, must provide each policyholder and
162 certificateholder with a current list of preferred providers and
163 must make the list available on its website. The list must
164 include, where applicable and reported, a listing by specialty
165 of the names, addresses, and telephone numbers of all
166 participating providers, including facilities; and in the case
167 of physicians, board certifications, languages spoken, and any
168 affiliations with participating hospitals. Information posted to
169 the insurer’s website must be updated on at least a calendar
170 month basis with additions or terminations of providers from the
171 insurer’s network or reported changes in physician’s hospital
must make the list available for public inspection
173 during regular business hours at the principal office of the
174 insurer within the state.
175 (7) Any policy issued after January 1, 2017 under this
176 section must include the following disclosure: “WARNING: LIMITED
177 BENEFITS WILL BE PAID WHEN NONPARTICIPATING PROVIDERS ARE USED.
178 You should be aware that when you elect to utilize the services
179 of a nonparticipating provider for a covered nonemergency
180 service, benefit payments to the provider are not based upon the
181 amount the provider charges. The basis of the payment will be
182 determined according to your policy’s out-of-network
183 reimbursement benefit. Nonparticipating providers may bill
184 insureds for any difference in the amount. YOU MAY BE REQUIRED
185 TO PAY MORE THAN THE COINSURANCE OR COPAYMENT. Participating
186 providers have agreed to accept discounted payments for services
187 with no additional billing to you other than coinsurance and
188 deductible amounts. You may obtain further information about the
189 providers who have contracted with your insurance plan by
190 consulting your insurer’s website or contacting your insurer or
191 agent directly.”
192 Section 6. This act shall take effect October 1, 2016.