Florida Senate - 2024 CS for CS for CS for SB 892
By the Committee on Fiscal Policy; the Appropriations Committee
on Agriculture, Environment, and General Government; the
Committee on Banking and Insurance; and Senator Harrell
594-03657-24 2024892c3
1 A bill to be entitled
2 An act relating to dental insurance claims; amending
3 s. 627.6131, F.S.; prohibiting a contract between a
4 health insurer and a dentist from containing certain
5 restrictions on payment methods; requiring a health
6 insurer to make certain notifications and obtain a
7 dentist’s consent before paying a claim to the dentist
8 through electronic funds transfer; providing that the
9 dentist’s consent applies to the dentist’s entire
10 practice; requiring the dentist’s consent to bear the
11 signature of the dentist; specifying the form of such
12 signature; prohibiting the insurer and dentist from
13 requiring consent on a patient-by-patient basis;
14 specifying the requirements of a certain notification;
15 prohibiting a health insurer from charging a fee to
16 transmit a payment to a dentist through Automated
17 Clearing House (ACH) transfer unless the dentist has
18 consented to such fee; providing construction;
19 authorizing the Office of Insurance Regulation of the
20 Financial Services Commission to enforce certain
21 provisions; authorizing the commission to adopt rules;
22 prohibiting a health insurer from denying claims for
23 procedures included in a prior authorization;
24 providing exceptions; providing construction;
25 authorizing the office to enforce certain provisions;
26 authorizing the commission to adopt rules; amending s.
27 627.6474, F.S.; revising the definition of the term
28 “covered services”; amending s. 636.032, F.S.;
29 prohibiting a contract between a prepaid limited
30 health service organization and a dentist from
31 containing certain restrictions on payment methods;
32 requiring the prepaid limited health service
33 organization to make certain notifications and obtain
34 a dentist’s consent before paying a claim to the
35 dentist through electronic funds transfer; providing
36 that a dentist’s consent applies to the dentist’s
37 entire practice; requiring the dentist’s consent to
38 bear the signature of the dentist; specifying the form
39 of such signature; prohibiting the limited health
40 service organization and dentist from requiring
41 consent on a patient-by-patient basis; specifying the
42 requirements of a certain notification; prohibiting a
43 prepaid limited health service organization from
44 charging a fee to transmit a payment to a dentist
45 through ACH transfer unless the dentist has consented
46 to such fee; providing construction; authorizing the
47 office to enforce certain provisions; authorizing the
48 commission to adopt rules; amending s. 636.035, F.S.;
49 revising the definition of the term “covered
50 services”; prohibiting a prepaid limited health
51 service organization from denying claims for
52 procedures included in a prior authorization;
53 providing exceptions; providing construction;
54 authorizing the office to enforce certain provisions;
55 authorizing the commission to adopt rules; amending s.
56 641.315, F.S.; revising the definition of the term
57 “covered services”; prohibiting a contract between a
58 health maintenance organization and a dentist from
59 containing certain restrictions on payment methods;
60 requiring the health maintenance organization to make
61 certain notifications and obtain a dentist’s consent
62 before paying a claim to the dentist through
63 electronic funds transfer; providing that the
64 dentist’s consent applies to the dentist’s entire
65 practice; requiring the dentist’s consent to bear the
66 signature of the dentist; specifying the form of such
67 signature; prohibiting the health maintenance
68 organization and dentist from requiring consent on a
69 patient-by-patient basis; specifying the requirements
70 of a certain notification; prohibiting a health
71 maintenance organization from charging a fee to
72 transmit a payment to a dentist through ACH transfer
73 unless the dentist has consented to such fee;
74 providing construction; authorizing the office to
75 enforce certain provisions; authorizing the commission
76 to adopt rules; prohibiting a health maintenance
77 organization from denying claims for procedures
78 included in a prior authorization; providing
79 exceptions; providing construction; authorizing the
80 office to enforce certain provisions; authorizing the
81 commission to adopt rules; providing an effective
82 date.
83
84 Be It Enacted by the Legislature of the State of Florida:
85
86 Section 1. Subsections (20) and (21) are added to section
87 627.6131, Florida Statutes, to read:
88 627.6131 Payment of claims.—
89 (20)(a) A contract between a health insurer and a dentist
90 licensed under chapter 466 for the provision of services to an
91 insured may not specify credit card payment as the only
92 acceptable method for payments from the health insurer to the
93 dentist.
94 (b) When a health insurer employs the method of claims
95 payment to a dentist through electronic funds transfer,
96 including, but not limited to, virtual credit card payment, the
97 health insurer shall notify the dentist as provided in this
98 paragraph and obtain the dentist’s consent in writing before
99 employing the electronic funds transfer. The dentist’s written
100 consent described in this paragraph applies to the dentist’s
101 entire practice. For purposes of this paragraph, the dentist’s
102 written consent, which may be given through e-mail, must bear
103 the signature of the dentist. Such signature includes an
104 electronic or digital signature if the form of signature is
105 recognized as a valid signature under applicable federal law or
106 state contract law or an act that demonstrates express consent,
107 including, but not limited to, checking a box indicating
108 consent. The insurer or dentist may not require that a dentist’s
109 consent as described in this paragraph be made on a patient-by
110 patient basis. The notification provided by the health insurer
111 to the dentist must include all of the following:
112 1. The fees, if any, associated with the electronic funds
113 transfer.
114 2. The available methods of payment of claims by the health
115 insurer, with clear instructions to the dentist on how to select
116 an alternative payment method.
117 (c) A health insurer that pays a claim to a dentist through
118 Automated Clearing House transfer may not charge a fee solely to
119 transmit the payment to the dentist unless the dentist has
120 consented to the fee.
121 (d) This subsection may not be waived, voided, or nullified
122 by contract, and any contractual clause in conflict with this
123 subsection or that purports to waive any requirements of this
124 subsection is null and void.
125 (e) The office has all rights and powers to enforce this
126 subsection as provided by s. 624.307.
127 (f) The commission may adopt rules to implement this
128 subsection.
129 (21)(a) A health insurer may not deny any claim
130 subsequently submitted by a dentist licensed under chapter 466
131 for procedures specifically included in a prior authorization
132 unless at least one of the following circumstances applies for
133 each procedure denied:
134 1. Benefit limitations, such as annual maximums and
135 frequency limitations not applicable at the time of the prior
136 authorization, are reached subsequent to issuance of the prior
137 authorization.
138 2. The documentation provided by the person submitting the
139 claim fails to support the claim as originally authorized.
140 3. Subsequent to the issuance of the prior authorization,
141 new procedures are provided to the patient or a change in the
142 condition of the patient occurs such that the prior authorized
143 procedure would no longer be considered medically necessary,
144 based on the prevailing standard of care.
145 4. Subsequent to the issuance of the prior authorization,
146 new procedures are provided to the patient or a change in the
147 patient’s condition occurs such that the prior authorized
148 procedure would at that time have required disapproval pursuant
149 to the terms and conditions for coverage under the patient’s
150 plan in effect at the time the prior authorization was issued.
151 5. The denial of the claim was due to one of the following:
152 a. Another payor is responsible for payment.
153 b. The dentist has already been paid for the procedures
154 identified in the claim.
155 c. The claim was submitted fraudulently, or the prior
156 authorization was based in whole or material part on erroneous
157 information provided to the health insurer by the dentist,
158 patient, or other person not related to the insurer.
159 d. The person receiving the procedure was not eligible to
160 receive the procedure on the date of service and the health
161 insurer did not know, and with the exercise of reasonable care
162 could not have known, of his or her ineligibility.
163 (b) This subsection may not be waived, voided, or nullified
164 by contract, and any contractual clause in conflict with this
165 subsection or that purports to waive any requirements of this
166 subsection is null and void.
167 (c) The office has all rights and powers to enforce this
168 subsection as provided by s. 624.307.
169 (d) The commission may adopt rules to implement this
170 subsection.
171 Section 2. Subsection (2) of section 627.6474, Florida
172 Statutes, is amended to read:
173 627.6474 Provider contracts.—
174 (2) A contract between a health insurer and a dentist
175 licensed under chapter 466 for the provision of services to an
176 insured may not contain a provision that requires the dentist to
177 provide services to the insured under such contract at a fee set
178 by the health insurer unless such services are covered services
179 under the applicable contract. As used in this subsection, the
180 term “covered services” means dental care services for which a
181 reimbursement is available under the insured’s contract,
182 notwithstanding or for which a reimbursement would be available
183 but for the application of contractual limitations such as
184 deductibles, coinsurance, waiting periods, annual or lifetime
185 maximums, frequency limitations, alternative benefit payments,
186 or any other limitation.
187 Section 3. Section 636.032, Florida Statutes, is amended to
188 read:
189 636.032 Acceptable payments.—
190 (1) Each prepaid limited health service organization may
191 accept from government agencies, corporations, groups, or
192 individuals payments covering all or part of the cost of
193 contracts entered into between the prepaid limited health
194 service organization and its subscribers.
195 (2)(a) A contract between a prepaid limited health service
196 organization and a dentist licensed under chapter 466 for the
197 provision of services to a subscriber may not specify credit
198 card payment as the only acceptable method for payments from the
199 prepaid limited health service organization to the dentist.
200 (b) When a prepaid limited health service organization
201 employs the method of claims payment to a dentist through
202 electronic funds transfer, including, but not limited to,
203 virtual credit card payment, the prepaid limited health service
204 organization shall notify the dentist as provided in this
205 paragraph and obtain the dentist’s consent in writing before
206 employing the electronic funds transfer. The dentist’s written
207 consent described in this paragraph applies to the dentist’s
208 entire practice. For purposes of this paragraph, the dentist’s
209 written consent, which may be given through e-mail, must bear
210 the signature of the dentist. Such signature includes an
211 electronic or digital signature if the form of signature is
212 recognized as a valid signature under applicable federal law or
213 state contract law or an act that demonstrates express consent,
214 including, but not limited to, checking a box indicating
215 consent. The prepaid limited health service organization or
216 dentist may not require that the dentist’s consent as described
217 in this paragraph be made on a patient-by-patient basis. The
218 notification provided by the prepaid limited health service
219 organization to the dentist must include all of the following:
220 1. The fees, if any, that are associated with the
221 electronic funds transfer.
222 2. The available methods of payment of claims by the
223 prepaid limited health service organization, with clear
224 instructions to the dentist on how to select an alternative
225 payment method.
226 (c) A prepaid limited health service organization that pays
227 a claim to a dentist through Automatic Clearing House transfer
228 may not charge a fee solely to transmit the payment to the
229 dentist unless the dentist has consented to the fee.
230 (d) This subsection may not be waived, voided, or nullified
231 by contract, and any contractual clause in conflict with this
232 subsection or that purports to waive any requirements of this
233 subsection is null and void.
234 (e) The office has all rights and powers to enforce this
235 subsection as provided by s. 624.307.
236 (f) The commission may adopt rules to implement this
237 subsection.
238 Section 4. Subsection (13) of section 636.035, Florida
239 Statutes, is amended, and subsection (15) is added to that
240 section, to read:
241 636.035 Provider arrangements.—
242 (13) A contract between a prepaid limited health service
243 organization and a dentist licensed under chapter 466 for the
244 provision of services to a subscriber of the prepaid limited
245 health service organization may not contain a provision that
246 requires the dentist to provide services to the subscriber of
247 the prepaid limited health service organization at a fee set by
248 the prepaid limited health service organization unless such
249 services are covered services under the applicable contract. As
250 used in this subsection, the term “covered services” means
251 dental care services for which a reimbursement is available
252 under the subscriber’s contract, notwithstanding or for which a
253 reimbursement would be available but for the application of
254 contractual limitations such as deductibles, coinsurance,
255 waiting periods, annual or lifetime maximums, frequency
256 limitations, alternative benefit payments, or any other
257 limitation.
258 (15)(a) A prepaid limited health service organization may
259 not deny any claim subsequently submitted by a dentist licensed
260 under chapter 466 for procedures specifically included in a
261 prior authorization unless at least one of the following
262 circumstances applies for each procedure denied:
263 1. Benefit limitations, such as annual maximums and
264 frequency limitations not applicable at the time of the prior
265 authorization, are reached subsequent to issuance of the prior
266 authorization.
267 2. The documentation provided by the person submitting the
268 claim fails to support the claim as originally authorized.
269 3. Subsequent to the issuance of the prior authorization,
270 new procedures are provided to the patient or a change in the
271 condition of the patient occurs such that the prior authorized
272 procedure would no longer be considered medically necessary,
273 based on the prevailing standard of care.
274 4. Subsequent to the issuance of the prior authorization,
275 new procedures are provided to the patient or a change in the
276 patient’s condition occurs such that the prior authorized
277 procedure would at that time have required disapproval pursuant
278 to the terms and conditions for coverage under the patient’s
279 plan in effect at the time the prior authorization was issued.
280 5. The denial of the dental service claim was due to one of
281 the following:
282 a. Another payor is responsible for payment.
283 b. The dentist has already been paid for the procedures
284 identified in the claim.
285 c. The claim was submitted fraudulently, or the prior
286 authorization was based in whole or material part on erroneous
287 information provided to the prepaid limited health service
288 organization by the dentist, patient, or other person not
289 related to the organization.
290 d. The person receiving the procedure was not eligible to
291 receive the procedure on the date of service and the prepaid
292 limited health service organization did not know, and with the
293 exercise of reasonable care could not have known, of his or her
294 ineligibility.
295 (b) This subsection may not be waived, voided, or nullified
296 by contract, and any contractual clause in conflict with this
297 subsection or that purports to waive any requirements of this
298 subsection is null and void.
299 (c) The office has all rights and powers to enforce this
300 subsection as provided by s. 624.307.
301 (d) The commission may adopt rules to implement this
302 subsection.
303 Section 5. Subsection (11) of section 641.315, Florida
304 Statutes, is amended, and subsections (13) and (14) are added to
305 that section, to read:
306 641.315 Provider contracts.—
307 (11) A contract between a health maintenance organization
308 and a dentist licensed under chapter 466 for the provision of
309 services to a subscriber of the health maintenance organization
310 may not contain a provision that requires the dentist to provide
311 services to the subscriber of the health maintenance
312 organization at a fee set by the health maintenance organization
313 unless such services are covered services under the applicable
314 contract. As used in this subsection, the term “covered
315 services” means dental care services for which a reimbursement
316 is available under the subscriber’s contract, notwithstanding or
317 for which a reimbursement would be available but for the
318 application of contractual limitations such as deductibles,
319 coinsurance, waiting periods, annual or lifetime maximums,
320 frequency limitations, alternative benefit payments, or any
321 other limitation.
322 (13)(a) A contract between a health maintenance
323 organization and a dentist licensed under chapter 466 for the
324 provision of services to a subscriber of the health maintenance
325 organization may not specify credit card payment as the only
326 acceptable method for payments from the health maintenance
327 organization to the dentist.
328 (b) When a health maintenance organization employs the
329 method of claims payment to a dentist through electronic funds
330 transfer, including, but not limited to, virtual credit card
331 payment, the health maintenance organization shall notify the
332 dentist as provided in this paragraph and obtain the dentist’s
333 consent in writing before employing the electronic funds
334 transfer. The dentist’s written consent described in this
335 paragraph applies to the dentist’s entire practice. For purposes
336 of this paragraph, the dentist’s written consent, which may be
337 given through e-mail, must bear the signature of the dentist.
338 Such signature includes an electronic or digital signature if
339 the form of signature is recognized as a valid signature under
340 applicable federal law or state contract law or an act that
341 demonstrates express consent, including, but not limited to,
342 checking a box indicating consent. The health maintenance
343 organization or dentist may not require a dentist’s consent as
344 described in this paragraph be made on a patient-by-patient
345 basis. The notification provided by the health maintenance
346 organization to the dentist must include all of the following:
347 1. The fees, if any, that are associated with the
348 electronic funds transfer.
349 2. The available methods of payment of claims by the health
350 maintenance organization, with clear instructions to the dentist
351 on how to select an alternative payment method.
352 (c) A health maintenance organization that pays a claim to
353 a dentist through Automated Clearing House transfer may not
354 charge a fee solely to transmit the payment to the dentist
355 unless the dentist has consented to the fee.
356 (d) This subsection may not be waived, voided, or nullified
357 by contract, and any contractual clause in conflict with this
358 subsection or which purports to waive any requirements of this
359 subsection is null and void.
360 (e) The office has all rights and powers to enforce this
361 subsection as provided by s. 624.307.
362 (f) The commission may adopt rules to implement this
363 subsection.
364 (14)(a) A health maintenance organization may not deny any
365 claim subsequently submitted by a dentist licensed under chapter
366 466 for procedures specifically included in a prior
367 authorization unless at least one of the following circumstances
368 applies for each procedure denied:
369 1. Benefit limitations, such as annual maximums and
370 frequency limitations not applicable at the time of the prior
371 authorization, are reached subsequent to issuance of the prior
372 authorization.
373 2. The documentation provided by the person submitting the
374 claim fails to support the claim as originally authorized.
375 3. Subsequent to the issuance of the prior authorization,
376 new procedures are provided to the patient or a change in the
377 condition of the patient occurs such that the prior authorized
378 procedure would no longer be considered medically necessary,
379 based on the prevailing standard of care.
380 4. Subsequent to the issuance of the prior authorization,
381 new procedures are provided to the patient or a change in the
382 patient’s condition occurs such that the prior authorized
383 procedure would at that time have required disapproval pursuant
384 to the terms and conditions for coverage under the patient’s
385 plan in effect at the time the prior authorization was issued.
386 5. The denial of the claim was due to one of the following:
387 a. Another payor is responsible for payment.
388 b. The dentist has already been paid for the procedures
389 identified in the claim.
390 c. The claim was submitted fraudulently, or the prior
391 authorization was based in whole or material part on erroneous
392 information provided to the health maintenance organization by
393 the dentist, patient, or other person not related to the
394 organization.
395 d. The person receiving the procedure was not eligible to
396 receive the procedure on the date of service and the health
397 maintenance organization did not know, and with the exercise of
398 reasonable care could not have known, of his or her
399 ineligibility.
400 (b) The subsection may not be waived, voided, or nullified
401 by contract, and any contractual clause in conflict with this
402 subsection or which purports to waive any requirements of this
403 subsection is null and void.
404 (c) The office has all rights and powers to enforce this
405 subsection as provided by s. 624.307.
406 (d) The commission may adopt rules to implement this
407 subsection.
408 Section 6. This act shall take effect January 1, 2025.