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.