Florida Senate - 2010 CS for SB 1232 By the Committee on Banking and Insurance; and Senators Fasano and Gaetz 597-04880-10 20101232c1 1 A bill to be entitled 2 An act relating to health insurance; amending s. 3 626.9541, F.S.; authorizing an insurer offering a 4 group or individual health benefit plan to offer a 5 wellness program; authorizing rewards or incentives; 6 providing that such rewards or incentives are not 7 insurance benefits; providing for verification of a 8 member’s inability to participate for medical reasons; 9 amending s. 627.6141, F.S.; authorizing appeals from 10 denials of certain claims for certain services; 11 requiring a health insurer to conduct a retrospective 12 review of the medical necessity of a service under 13 certain circumstances; requiring the health insurer to 14 submit a written justification for a determination 15 that a service was not medically necessary; amending 16 s. 641.3156, F.S.; authorizing appeals from denials of 17 certain claims for certain services; requiring a 18 health maintenance organization to conduct a 19 retrospective review of the medical necessity of a 20 service under certain circumstances; requiring the 21 health maintenance organization to submit a written 22 justification for a determination that a service was 23 not medically necessary; providing an effective date. 24 25 Be It Enacted by the Legislature of the State of Florida: 26 27 Section 1. Subsection (3) is added to section 626.9541, 28 Florida Statutes, to read: 29 626.9541 Unfair methods of competition and unfair or 30 deceptive acts or practices defined.— 31 (3) WELLNESS PROGRAMS.—An insurer issuing a group or 32 individual health benefit plan may offer a voluntary wellness or 33 health-improvement program that allows for rewards or 34 incentives, including, but not limited to, merchandise, gift 35 cards, debit cards, premium discounts or rebates, contributions 36 towards a member’s health savings account, modifications to 37 copayment, deductible, or coinsurance amounts, or any 38 combination of these incentives, to encourage participation or 39 to reward for participation in the program. The health plan 40 member may be required to provide verification, such as a 41 statement from his or her physician, that a medical condition 42 makes it unreasonably difficult or medically inadvisable for the 43 individual to participate in the wellness program. Any reward or 44 incentive established under this section is not an insurance 45 benefit and does not violate this section. This subsection does 46 not prohibit an insurer from offering incentives or rewards to 47 members for adherence to wellness or health-improvement programs 48 if otherwise allowed by state or federal law. 49 Section 2. Section 627.6141, Florida Statutes, is amended 50 to read: 51 627.6141 Denial of claims.— 52 (1) Each claimant, or provider acting for a claimant, who 53 has had a claim denied as not medically necessary must be 54 provided an opportunity for an appeal to the insurer’s licensed 55 physician who is responsible for the medical necessity reviews 56 under the plan or is a member of the plan’s peer review group. 57 The appeal may be by telephone, and the insurer’s licensed 58 physician must respond within a reasonable time, not to exceed 59 15 business days. 60 (2) If a hospital claim or a portion of a hospital claim is 61 denied because the hospital, due to an unintentional act of 62 error or omission, failed to obtain the necessary authorization, 63 the hospital may appeal the denial to the insurer’s licensed 64 physician who is responsible for medical necessity reviews. The 65 health insurer shall conduct and complete a retrospective review 66 of the medical necessity of the service within 30 business days 67 after the submitted appeal. If the health insurer determines 68 upon review that the service was medically necessary, the 69 insurer shall reverse the denial and pay the claim. If the 70 insurer determines that the service was not medically necessary, 71 the insurer shall provide to the hospital specific written 72 clinical justification for the determination. 73 Section 3. Present subsection (3) of section 641.3156, 74 Florida Statutes, is renumbered as subsection (4), and a new 75 subsection (3) is added to that section, to read: 76 641.3156 Treatment authorization; payment of claims.— 77 (3) If a hospital claim or a portion of a hospital claim of 78 a contracted provider is denied because the hospital, due to an 79 unintentional act of error or omission, failed to obtain the 80 necessary authorization, the hospital may appeal the denial to 81 the health maintenance organization’s licensed physician who is 82 responsible for medical necessity reviews. The health 83 maintenance organization shall conduct and complete a 84 retrospective review of the medical necessity of the service 85 within 30 business days after the submitted appeal. If the 86 health maintenance organization determines upon review that the 87 service was medically necessary, the health maintenance 88 organization shall reverse the denial and pay the claim. If the 89 health maintenance organization determines that the service was 90 not medically necessary, the health maintenance organization 91 shall provide the hospital with specific written clinical 92 justification for the determination. 93 Section 4. This act shall take effect July 1, 2010.