Florida Senate - 2017                                     SB 528
       By Senator Steube
       23-00732-17                                            2017528__
    1                        A bill to be entitled                      
    2         An act relating to health insurance; amending s.
    3         624.155, F.S.; providing a civil remedy for a health
    4         insurer who violates the Patient Savings Act; creating
    5         s. 627.6387, F.S.; providing a short title; providing
    6         definitions; providing health insurer website
    7         requirements; requiring an insurer to provide good
    8         faith estimates of costs for certain health care
    9         services upon request by an insured; requiring an
   10         insurer to implement a shared savings incentive
   11         program by a specified date; providing procedures and
   12         requirements; providing notification requirements;
   13         providing reporting requirements; providing penalties;
   14         requiring the Office of Insurance Regulation to make
   15         and submit an annual report; authorizing the office to
   16         adopt rules; providing an effective date.
   18  Be It Enacted by the Legislature of the State of Florida:
   20         Section 1. Subsection (1) of section 624.155, Florida
   21  Statutes, is amended to read:
   22         624.155 Civil remedy.—
   23         (1) Any person may bring a civil action against an insurer
   24  when such person is damaged:
   25         (a) By a violation of any of the following provisions by
   26  the insurer:
   27         1. Section 626.9541(1)(i), (o), or (x);
   28         2. Section 626.9551;
   29         3. Section 626.9705;
   30         4. Section 626.9706;
   31         5. Section 626.9707; or
   32         6. Section 627.7283; or
   33         7.Section 627.6387.
   34         (b) By the commission of any of the following acts by the
   35  insurer:
   36         1. Not attempting in good faith to settle claims when,
   37  under all the circumstances, it could and should have done so,
   38  had it acted fairly and honestly toward its insured and with due
   39  regard for her or his interests;
   40         2. Making claims payments to insureds or beneficiaries not
   41  accompanied by a statement setting forth the coverage under
   42  which payments are being made; or
   43         3. Except as to liability coverages, failing to promptly
   44  settle claims, when the obligation to settle a claim has become
   45  reasonably clear, under one portion of the insurance policy
   46  coverage in order to influence settlements under other portions
   47  of the insurance policy coverage.
   49  Notwithstanding the provisions of the above to the contrary, a
   50  person pursuing a remedy under this section need not prove that
   51  such act was committed or performed with such frequency as to
   52  indicate a general business practice.
   53         Section 2. Section 627.6387, Florida Statutes, is created
   54  to read:
   55         627.6387Shared savings incentive program.—
   56         (1)This section may be cited as the “Patient Savings Act”.
   57         (2)As used in this section, the term:
   58         (a)“Average price” means the average amount paid to an in
   59  network health care provider for a shoppable health care service
   60  within a 1-year period or as determined by another method
   61  approved by the Office of Insurance Regulation.
   62         (b)“Contracted amount” means the amount agreed to be paid
   63  by the health insurer pursuant to a policy, contract, or
   64  certificate of insurance to a health care provider for shoppable
   65  health care services covered by the policy, contract, or
   66  certificate of insurance, including any facility fees charged by
   67  the provider.
   68         (c)“Health care provider” means hospitals, ambulatory
   69  surgical centers, and other medical facilities licensed under
   70  chapter 395; home health agencies licensed under chapter 400;
   71  physicians licensed under chapter 458; physician assistants
   72  licensed under chapter 458 or chapter 459; osteopathic
   73  physicians licensed under chapter 459; chiropractic physicians
   74  licensed under chapter 460; podiatric physicians licensed under
   75  chapter 461; naturopaths licensed under chapter 462; dentists
   76  licensed under chapter 466; nurses licensed under part I of
   77  chapter 464; midwives licensed under chapter 467; occupational
   78  therapists licensed under chapter 468; radiological personnel
   79  certified under chapter 468; clinical laboratories licensed
   80  under chapter 483; physical therapists and physical therapist
   81  assistants licensed under chapter 486; blood banks, plasma
   82  centers, industrial clinics, and renal dialysis facilities; or
   83  professional associations, partnerships, corporations, joint
   84  ventures, or other associations for professional activity by
   85  health care providers.
   86         (d)“Health insurer” means an authorized insurer offering
   87  health insurance as defined in s. 624.603 or a health
   88  maintenance organization as defined in s. 641.19(12). The term
   89  includes a person with a self-insurance plan that provides
   90  health insurance benefits.
   91         (e)“Shared savings incentive program” means a cash
   92  incentive program established by a health insurer pursuant to
   93  this section.
   94         (f)“Shoppable health care service” means a nonemergency
   95  health care service for which an insured may receive a cash
   96  payment under a shared savings incentive program. Shoppable
   97  health care services include:
   98         1.Clinical laboratory services.
   99         2.Infusion therapy.
  100         3.Inpatient and outpatient surgical procedures.
  101         4.Obstetrical and gynecological services.
  102         5.Outpatient nonsurgical diagnostic tests and procedures.
  103         6.Physical and occupational therapy services.
  104         7.Radiology and imaging services.
  105         (3)A health insurer’s website must provide a method for an
  106  insured or prospective insured to request and obtain information
  107  on the contracted amount for shoppable health care services from
  108  a health care provider and to compare the average price among
  109  health care providers.
  110         (4)Upon the request of an insured, a health insurer must
  111  provide a good faith estimate of the contracted amount and the
  112  estimated amount of copayments, deductibles, and other cost
  113  sharing responsibilities for health care services and procedures
  114  within 2 working days after the request for both in-network and
  115  out-of-network providers. The health insurer must notify the
  116  insured that the estimate may differ from the actual amount the
  117  insured will be responsible to pay due to unforeseen
  118  circumstances that arise out of the proposed nonemergency
  119  service or procedure.
  120         (5)For the plan year beginning January 1, 2018, a health
  121  insurer must implement a shared savings incentive program to
  122  provide cash payments to an insured when the insured obtains a
  123  shoppable health care service at a price that is less than the
  124  average price for that service.
  125         (a)The amount of the shared savings incentive program
  126  payment may be calculated as a percentage between the contracted
  127  amount and the average price, or by an alternative method
  128  approved by the office.
  129         (b)The amount of the cash payment to the insured must be
  130  at least 50 percent of the health insurer’s saved costs for each
  131  shoppable health care service paid to the health care provider
  132  as compared with the average price.
  133         (c)If an insured elects to receive a shoppable health care
  134  service from an out-of-network health care provider for a price
  135  that is less than the average price, the health insurer must
  136  treat such service as if the service is provided by an in
  137  network health care provider for purposes of calculating the
  138  shared savings incentive program payment.
  139         (d)A health insurer is not required to provide a cash
  140  payment under the shared savings incentive program to an insured
  141  when the health insurer’s saved cost is $50 or less.
  142         (e)A cash payment made by an insurer in accordance with
  143  this section is not an administrative expense of the insurer for
  144  rate development or rate filing purposes.
  145         (6)The shared savings incentive program must be a
  146  component part of the policy, contract, or certificate of
  147  insurance provided by the health insurer. Annually and at the
  148  time of enrollment or renewal, a health insurer must notify its
  149  insureds of the shared savings incentive program.
  150         (7)A health insurer must file a description of the shared
  151  savings incentive program with the office on a form prescribed
  152  by the office. The office must review the filing to determine if
  153  the program complies with the requirements of this section.
  154         (8)A health insurer must file an annual report to the
  155  office of its shared savings incentive program. The report must
  156  include:
  157         (a)The total number of payments made pursuant to this
  158  section for the calendar year.
  159         (b)The shoppable health care services by category for
  160  which payments were made.
  161         (c)The average amount of payments.
  162         (d)The total amount saved by the health insurer when
  163  compared with the average prices for each shoppable health
  164  service category.
  165         (e)The total number of insureds and the percentage of
  166  total insureds who participated.
  167         (9)(a)The office may impose an administrative penalty of
  168  no more than $2,500 per violation per day upon a health insurer
  169  for failure to comply with this section. A fine imposed under
  170  this section may be in addition to other penalties or fines
  171  authorized by the insurance code.
  172         (b)If a health insurer fails to meet the filing
  173  requirements under this section and does not submit the filing
  174  within 30 days after the date the filing is due, the office may
  175  order the insurer to discontinue the issuance of policies,
  176  contracts, or certificates of insurance until the filing
  177  requirements have been fulfilled.
  178         (c)The office may revoke or suspend for at least 6 months
  179  the certificate of authority of a health insurer for failure to
  180  comply with this section.
  181         (10)The office must submit an annual report that
  182  summarizes the reports filed by health insurers required by
  183  subsection (8). The report must be delivered to the President of
  184  the Senate and the Speaker of the House of Representatives by
  185  April 1, 2019, and each year thereafter.
  186         (11)The office may adopt rules necessary to implement and
  187  enforce this section.
  188         Section 3. This act shall take effect upon becoming a law.