Bill Amendment: FL S0784 | 2015 | Regular Session
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: Health Care
Status: 2015-05-01 - Died in Appropriations [S0784 Detail]
Download: Florida-2015-S0784-Senate_Committee_Amendment_932076.html
Bill Title: Health Care
Status: 2015-05-01 - Died in Appropriations [S0784 Detail]
Download: Florida-2015-S0784-Senate_Committee_Amendment_932076.html
Florida Senate - 2015 COMMITTEE AMENDMENT
Bill No. SB 784
Ì9320761Î932076
LEGISLATIVE ACTION
Senate . House
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The Committee on Banking and Insurance (Montford) recommended
the following:
1 Senate Amendment (with title amendment)
2
3 Delete lines 254 - 491
4 and insert:
5 condition for the covered patient.
6 (a) For purposes of this section, the term, “a coverage
7 limitation imposed at the point of service” means a limitation
8 that is not universally applicable to all covered lives, but
9 instead depends on an insurer’s consideration of specific
10 patient characteristics and conditions that have been reported
11 by a physician in the process of providing medical care.
12 (b) The term “sufficient clinical evidence” means:
13 1. A body of research consisting of well-controlled studies
14 conducted by independent researchers and published in peer
15 reviewed journals or comparable publications which consistently
16 support the treatment protocol or other coverage limitation as a
17 best practice for the specific diagnosis or combination of
18 presenting complaints.
19 2. Results of a multivariate predictive model which
20 indicate that the probability of achieving desired outcomes is
21 not negatively altered or delayed by adherence to the proposed
22 protocol.
23 (2) The Clinical Practices Review Commission established
24 under s. 402.90 shall determine whether sufficient clinical
25 evidence exists for a proposed coverage limitation imposed by
26 the insurer at the point of service. In each instance in which
27 the commission finds that sufficient clinical evidence exists to
28 support a coverage limitation, the office shall approve the
29 coverage limitation.
30 (3) If an insurer, without the approval of the office,
31 imposes a coverage limitation at the point of service,
32 including, but not limited to, a prior authorization procedure,
33 step therapy requirement, treatment protocol, or other
34 utilization management procedure that restricts access to
35 covered services, the insurer and its chief medical officer
36 shall be liable for any injuries or damages, as defined in s.
37 766.202, and economic damages, as defined in s. 768.81(1)(b),
38 that result from the restricted access to services determined
39 medically necessary by the physician treating the patient. An
40 insurer that imposes such a coverage limitation at the point of
41 service shall establish reserves sufficient to pay for such
42 damages.
43 Section 5. Subsection (2) of section 627.642, Florida
44 Statutes, is amended to read:
45 627.642 Outline of coverage.—
46 (2) The outline of coverage must shall contain:
47 (a) A statement identifying the applicable category of
48 coverage afforded by the policy, based on the minimum basic
49 standards set forth in the rules issued to effect compliance
50 with s. 627.643.
51 (b) A brief description of the principal benefits and
52 coverage provided in the policy.
53 (c) A summary statement of the principal exclusions and
54 limitations or reductions contained in the policy, including,
55 but not limited to, preexisting conditions, probationary
56 periods, elimination periods, deductibles, coinsurance, and any
57 age limitations or reductions.
58 (d) A summary statement identifying specific prescription
59 drugs that are subject to prior authorization, step therapy, or
60 any other coverage limitation and the applicable coverage
61 limitation policy or protocol. The insurer shall post the
62 summary statement at a prominent and readily accessible location
63 on the Internet.
64 (e) A summary statement identifying any specific diagnostic
65 or therapeutic procedures that are subject to prior
66 authorization or other coverage limitations and the applicable
67 coverage limitation policy or protocol. The insurer shall post
68 the summary statement at a prominent and readily accessible
69 location on the Internet.
70 (f)(d) A summary statement of the renewal and cancellation
71 provisions, including any reservation of the insurer of a right
72 to change premiums.
73 (g)(e) A statement that the outline contains a summary only
74 of the details of the policy as issued or of the policy as
75 applied for and that the issued policy should be referred to for
76 the actual contractual governing provisions.
77 (h)(f) When home health care coverage is provided, a
78 statement that such benefits are provided in the policy.
79 Section 6. Subsection (2) of section 627.6471, Florida
80 Statutes, is amended to read:
81 627.6471 Contracts for reduced rates of payment;
82 limitations; coinsurance and deductibles.—
83 (2) An Any insurer issuing a policy of health insurance in
84 this state that, which insurance includes coverage for the
85 services of a preferred provider, must provide each policyholder
86 and certificateholder with a current list of preferred
87 providers, and must make the list available for public
88 inspection during regular business hours at the principal office
89 of the insurer within the state, and must post a link to the
90 list of preferred providers on the home page of the insurer’s
91 website. Such insurer must post on its website a change to the
92 list of preferred providers within 10 business days after such
93 change.
94 Section 7. Subsection (4) of section 627.651, Florida
95 Statutes, is amended to read:
96 627.651 Group contracts and plans of self-insurance must
97 meet group requirements.—
98 (4) This section does not apply to any plan that which is
99 established or maintained by an individual employer in
100 accordance with the Employee Retirement Income Security Act of
101 1974, Pub. L. No. 93-406, or to a multiple-employer welfare
102 arrangement as defined in s. 624.437(1), except that a multiple
103 employer welfare arrangement shall comply with ss. 627.419,
104 627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121,
105 627.66122, 627.6615, 627.6616, and 627.662(8) 627.662(7). This
106 subsection does not allow an authorized insurer to issue a group
107 health insurance policy or certificate which does not comply
108 with this part.
109 Section 8. Present subsections (7) through (14) of section
110 627.662, Florida Statutes, are redesignated as subsections (8)
111 through (15), respectively, and a new subsection (7) is added to
112 that section, to read:
113 627.662 Other provisions applicable.—The following
114 provisions apply to group health insurance, blanket health
115 insurance, and franchise health insurance:
116 (7) Section 627.642(2)(d) and (e), relating to coverage
117 limitations on prescription drugs and diagnostic or therapeutic
118 procedures.
119 Section 9. Paragraph (b) of subsection (12) of section
120 627.6699, Florida Statutes, is amended to read:
121 627.6699 Employee Health Care Access Act.—
122 (12) STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED HEALTH
123 BENEFIT PLANS.—
124 (b)1. Each small employer carrier issuing new health
125 benefit plans shall offer to any small employer, upon request, a
126 standard health benefit plan, a basic health benefit plan, and a
127 high deductible plan that meets the requirements of a health
128 savings account plan as defined by federal law or a health
129 reimbursement arrangement as authorized by the Internal Revenue
130 Service, which that meet the criteria set forth in this section.
131 2. For purposes of this subsection, the terms “standard
132 health benefit plan,” “basic health benefit plan,” and “high
133 deductible plan” mean policies or contracts that a small
134 employer carrier offers to eligible small employers which that
135 contain:
136 a. An exclusion for services that are not medically
137 necessary or that are not covered preventive health services;
138 and
139 b. A procedure for preauthorization or prior authorization
140 by the small employer carrier, or its designees;
141 c. A summary statement identifying specific prescription
142 drugs that are subject to prior authorization, step therapy, or
143 any other coverage limitation and the applicable coverage
144 limitation policy or protocol. The carrier shall post the
145 summary statement in a prominent and readily accessible location
146 on the Internet; and
147 d. A summary statement identifying any specific diagnostic
148 or therapeutic procedures subject to prior authorization or
149 other coverage limitations and the applicable coverage
150 limitation policy or protocol. The carrier shall post the
151 summary statement in a prominent and readily accessible location
152 on the Internet.
153 3. A small employer carrier may include the following
154 managed care provisions in the policy or contract to control
155 costs:
156 a. A preferred provider arrangement or exclusive provider
157 organization or any combination thereof, in which a small
158 employer carrier enters into a written agreement with the
159 provider to provide services at specified levels of
160 reimbursement or to provide reimbursement to specified
161 providers. Any such written agreement between a provider and a
162 small employer carrier must contain a provision under which the
163 parties agree that the insured individual or covered member has
164 no obligation to make payment for any medical service rendered
165 by the provider which is determined not to be medically
166 necessary. A carrier may use preferred provider arrangements or
167 exclusive provider arrangements to the same extent as allowed in
168 group products that are not issued to small employers.
169 b. A procedure for utilization review by the small employer
170 carrier or its designees.
171
172 This subparagraph does not prohibit a small employer carrier
173 from including in its policy or contract additional managed care
174 and cost containment provisions, subject to the approval of the
175 office, which have potential for controlling costs in a manner
176 that does not result in inequitable treatment of insureds or
177 subscribers. The carrier may use such provisions to the same
178 extent as authorized for group products that are not issued to
179 small employers.
180 4. The standard health benefit plan shall include:
181 a. Coverage for inpatient hospitalization;
182 b. Coverage for outpatient services;
183 c. Coverage for newborn children pursuant to s. 627.6575;
184 d. Coverage for child care supervision services pursuant to
185 s. 627.6579;
186 e. Coverage for adopted children upon placement in the
187 residence pursuant to s. 627.6578;
188 f. Coverage for mammograms pursuant to s. 627.6613;
189 g. Coverage for children with disabilities handicapped
190 children pursuant to s. 627.6615;
191 h. Emergency or urgent care out of the geographic service
192 area; and
193 i. Coverage for services provided by a hospice licensed
194 under s. 400.602 in cases where such coverage would be the most
195 appropriate and the most cost-effective method for treating a
196 covered illness.
197 5. The standard health benefit plan and the basic health
198 benefit plan may include a schedule of benefit limitations for
199 specified services and procedures. If the committee develops
200 such a schedule of benefits limitation for the standard health
201 benefit plan or the basic health benefit plan, a small employer
202 carrier offering the plan must offer the employer an option for
203 increasing the benefit schedule amounts by 4 percent annually.
204 6. The basic health benefit plan must shall include all of
205 the benefits specified in subparagraph 4.; however, the basic
206 health benefit plan must shall place additional restrictions on
207 the benefits and utilization and may also impose additional cost
208 containment measures.
209 7. Sections 627.419(2), (3), and (4), 627.6574, 627.6612,
210 627.66121, 627.66122, 627.6616, 627.6618, 627.668, and 627.66911
211 apply to the standard health benefit plan and to the basic
212 health benefit plan. However, notwithstanding such said
213 provisions, the plans may specify limits on the number of
214 authorized treatments, if such limits are reasonable and do not
215 discriminate against any type of provider.
216 8. The high-deductible high deductible plan associated with
217 a health savings account or a health reimbursement arrangement
218 must shall include all the benefits specified in subparagraph 4.
219 9. Each small employer carrier that provides for inpatient
220 and outpatient services by allopathic hospitals may provide as
221 an option of the insured similar inpatient and outpatient
222 services by hospitals accredited by the American Osteopathic
223 Association if when such services are available and the
224 osteopathic hospital agrees to provide the service.
225 Section 10. Subsection (4) of section 641.31, Florida
226 Statutes, is amended and subsection (44) is added to that
227 section, to read:
228 641.31 Health maintenance contracts.—
229 (4) Each Every health maintenance contract, certificate, or
230 member handbook must shall clearly state all of the services to
231 which a subscriber is entitled under the contract and must
232 include a clear and understandable statement of any limitations
233 on the benefits, services, or kinds of services to be provided,
234 including any copayment feature or schedule of benefits required
235 by the contract or by any insurer or entity that which is
236 underwriting any of the services offered by the health
237 maintenance organization. The contract, certificate, or member
238 handbook must shall also state where and in what manner the
239 comprehensive health care services may be obtained. The health
240 maintenance organization shall prominently post the statement
241 regarding limitations on benefits, services, or kinds of
242 services provided on its website in a readily accessible
243 location on the Internet. The statement must include, but need
244 not be limited to:
245 (a) The identification of specific prescription drugs that
246 are subject to prior authorization, step therapy, or any other
247 coverage limitation and the applicable coverage limitation
248 policy or protocol.
249 (b) The identification of any specific diagnostic or
250 therapeutic procedures that are subject to prior authorization
251 or other coverage limitations and the applicable coverage
252 limitation policy or protocol.
253 (44) Health maintenance organizations are prohibited from
254 establishing prior authorization procedures, step therapy
255 requirements, treatment protocols, or other utilization
256 management procedures that restrict access to covered services
257 unless expressly authorized to do so under this subsection. A
258 coverage limitation imposed by a health maintenance organization
259 at the point of service must be supported, as determined by the
260 Clinical Practices Review Commission established pursuant to s.
261 402.90, by sufficient clinical evidence, as defined in s.
262 627.6051(1), which demonstrates that the limitation does not
263 inhibit the timely diagnosis or optimal treatment of the
264 specific illness or condition for the covered patient. For
265 purposes of this subsection, the term, “a coverage limitation
266 imposed by a health maintenance organization at the point of
267 service” means a limitation that is not universally applicable
268 to all covered lives, but instead depends on a health
269 maintenance organization’s consideration of specific patient
270 characteristics and conditions that have been reported by a
271 physician in the process of providing medical care.
272 Section 11. Subsection (10) of section 641.3155, Florida
273 Statutes, is amended to read:
274 641.3155 Prompt payment of claims.—
275 (10) A health maintenance organization may not
276 retroactively deny a claim because of subscriber ineligibility
277 more than 1 year after the date of payment of the claim and may
278 not retroactively deny a claim because of subscriber
279 ineligibility at any time if the health maintenance organization
280 verified the eligibility of a subscriber at the time of
281 treatment and has provided an authorization number.
282
283 ================= T I T L E A M E N D M E N T ================
284 And the title is amended as follows:
285 Delete lines 23 - 62
286 and insert:
287 limitation at the point of service; defining the terms
288 “a coverage limitation imposed at the point of
289 service” and “sufficient clinical evidence”; requiring
290 the commission to determine whether sufficient
291 clinical evidence exists and the Office of Insurance
292 Regulation to approve coverage limitations if the
293 commission determines that such evidence exists;
294 providing for the liability of a health insurer and
295 its chief medical officer for injuries and damages
296 resulting from restricted access to services if the
297 insurer has imposed coverage limitations without the
298 approval of the office; requiring insurers to
299 establish reserves to pay for such damages; amending
300 ss. 627.642 and 627.6699, F.S.; requiring an outline
301 of coverage and certain plans offered by a small
302 employer carrier to include summary statements
303 identifying specific prescription drugs and procedures
304 that are subject to specified restrictions and
305 limitations; requiring insurers and small employer
306 carriers to post the summaries on the Internet;
307 amending s. 627.6471, F.S.; requiring an insurer to
308 post a link to the list of preferred providers on its
309 website and to update the list within 10 business days
310 after a change; amending s. 627.651, F.S.; conforming
311 a cross-reference; amending s. 627.662, F.S.;
312 specifying that specified provisions relating to
313 coverage limitations on prescription drugs and
314 diagnostic or therapeutic procedures apply to group
315 health insurance, blanket health insurance, and
316 franchise health insurance; amending s. 641.31, F.S.;
317 requiring a health maintenance contract summary
318 statement to include a statement of any limitations on
319 benefits, the identification of specific prescription
320 drugs, and certain procedures that are subject to
321 specified restrictions and limitations; requiring a
322 health maintenance organization to post the summaries
323 on the Internet; prohibiting a health maintenance
324 organization from establishing certain procedures and
325 requirements that restrict access to covered services;
326 requiring a coverage limitation to be supported, as
327 determined by the commission, by clinical evidence
328 demonstrating that the limitation does not inhibit the
329 diagnosis or treatment of the patient; defining the
330 term “a coverage limitation imposed at the point of
331 service”; amending s. 641.3155, F.S.; prohibiting the
332 retroactive denial of a claim because of subscriber
333 ineligibility at any time if the health maintenance
334 organization verified the eligibility of such
335 subscriber at the time of treatment and provided an
336 authorization number; providing an effective date.
