HB 1351 2023
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A bill to be entitled 1
An act relating to savings and out -of-pocket expenses 2
in health insurance; amending ss. 627.6387, 627.6648, 3
and 641.31076, F.S.; revising the definition of the 4
term "shoppable health care service"; requiring, 5
rather than authorizing, individual health insurers, 6
group health insurers, and health maintenance 7
organizations, respectively, to offer shared savings 8
incentive programs; revising the minimum amount of 9
shared savings incentives; amending s. 627.6471, F.S.; 10
conforming provisions to changes made by the act; 11
requiring individual health insurers to apply payments 12
for services by nonpreferred providers toward 13
insureds' annual deductibles and out -of-pocket limits 14
under certain circumstances; creating s. 627.65613, 15
F.S.; defining the term "preferred provider"; 16
requiring group health insurers to apply payments for 17
services by nonpreferred providers toward insureds' 18
annual deductibles and out -of-pocket limits under 19
certain circumstances; amending s. 641.31, F.S.; 20
requiring health maintenance organizations to apply 21
payments for services by out -of-network providers 22
toward subscribers' annual deductibles and out -of-23
pocket limits under certain circumstances; defining 24
the terms "in-network provider" and "out -of-network 25
HB 1351 2023
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provider"; providing an effective date. 26
27
Be It Enacted by the Legislature of the State of Florida: 28
29
Section 1. Paragraph (e) of subsection (2) and subsection 30
(3) of section 627.6387, Florida Statutes, are amended to read: 31
627.6387 Shared savings incentive program. — 32
(2) As used in this section, the term: 33
(e) "Shoppable health care service" means a lower -cost, 34
high-quality nonemergency health care service for which a shared 35
savings incentive is avai lable for insureds under a health 36
insurer's shared savings incentive program. Shoppable health 37
care services may be provided within or outside this state and 38
include, but are not limited to: 39
1. Clinical laboratory services. 40
2. Infusion therapy. 41
3. Inpatient and outpatient surgical procedures. 42
4. Obstetrical and gynecological services. 43
5. Inpatient and outpatient nonsurgical diagnostic tests 44
and procedures. 45
6. Physical and occupational therapy services. 46
7. Radiology and imaging services. 47
8. Prescription drugs. 48
9. Services provided through telehealth. 49
10. The items and services listed in Table 1 —500 Items and 50
HB 1351 2023
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Services List as published in Volume 85, No. 219 of the Federal 51
Register, pages 72182 -72190 (2020). 52
11.10. Any additional services published by the Agency for 53
Health Care Administration that have the most significant price 54
variation pursuant to s. 408.05(3)(m). 55
(3) A health insurer shall may offer a shared savings 56
incentive program to provide incentives to an insured when the 57
insured obtains a shoppable health care service from the health 58
insurer's shared savings list. An insured may not be required to 59
participate in a shared savings incentive program. In offering a 60
shared savings incentive program, a health insurer that offers a 61
shared savings incentive program must: 62
(a) Establish the program as a component part of the 63
policy or certificate of insurance provided by the health 64
insurer and notify the insureds and the office at least 30 days 65
before program termination. 66
(b) File a description of the program on a form prescribed 67
by commission rule. The office must review the filing and 68
determine whether the shared savings incentive program complies 69
with this section. 70
(c) Notify an insured annually and at the time of renewal, 71
and an applicant for insurance at the time of enrollment, of the 72
availability of the shared savings incentive program and the 73
procedure to participate in the program. 74
(d) Publish on a web page easily accessible to insureds 75
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and to applicants for insurance a list of shoppable health care 76
services and health care providers and the shared savings 77
incentive amount applicable for each service. A shared savings 78
incentive may not be less than 25 percent of the difference in 79
cost compared to the second-lowest cost in-network amount paid 80
for that service in the rating area savings generated by the 81
insured's participation in any shared savings incentive offered 82
by the health insurer . The baseline for the savings calculation 83
is the average in-network amount paid for that service in the 84
most recent 12-month period or some other methodology 85
established by the health insurer and approved by the office. 86
(e) At least quarterly, credit or deposit the shared 87
savings incentive amount to the insured's accoun t as a return or 88
reduction in premium, or credit the shared savings incentive 89
amount to the insured's flexible spending account, health 90
savings account, or health reimbursement account, or reward the 91
insured directly with cash or a cash equivalent. 92
(f) Submit an annual report to the office within 90 93
business days after the close of each plan year. At a minimum, 94
the report must include the following information: 95
1. The number of insureds who participated in the program 96
during the plan year and the number of instances of 97
participation. 98
2. The total cost of services provided as a part of the 99
program. 100
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3. The total value of the shared savings incentive 101
payments made to insureds participating in the program and the 102
values distributed as premium reductions, credits to flexible 103
spending accounts, credits to health savings accounts, or 104
credits to health reimbursement accounts. 105
4. An inventory of the shoppable health care services 106
offered by the health insurer. 107
Section 2. Subsection (7) of section 627.647 1, Florida 108
Statutes, is renumbered as subsection (8), subsection (4) is 109
amended, and a new subsection (7) is added to that section, to 110
read: 111
627.6471 Contracts for reduced rates of payment; 112
limitations; coinsurance and deductibles. — 113
(4) Except as otherwise provided in subsection (7), any 114
policy that provides schedules of payments for services provided 115
by preferred providers that differ from the schedules of 116
payments for services provided by nonpreferred providers is 117
subject to the following limitations: 118
(a) The amount of any annual deductible per covered person 119
or per family for treatment in a facility that is not a 120
preferred provider may not exceed four times the amount of a 121
corresponding annual deductible for treatment in a facility that 122
is a preferred provider. 123
(b) If the policy has no deductible for treatment in a 124
preferred provider facility, the deductible for treatment 125
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received in a facility that is not a preferred provider facility 126
may not exceed $500 per covered person per visit. 127
(c) The amount of any annual deductible per covered person 128
or per family for treatment, other than inpatient treatment, by 129
a provider that is not a preferred provider may not exceed four 130
times the amount of a corresponding annual deductible for 131
treatment, other than inpatient treatment, by a preferred 132
provider. 133
(d) If the policy has no deductible for treatment by a 134
preferred provider, the annual deductible for treatment received 135
from a provider which is not a preferred provider shall not 136
exceed $500 per covered pers on. 137
(e) The percentage amount of any coinsurance to be paid by 138
an insured to a provider that is not a preferred provider may 139
not exceed by more than 50 percentage points the percentage 140
amount of any coinsurance payment to be paid to a preferred 141
provider. 142
(f) The amount of any deductible and payment of 143
coinsurance paid by the insured must be applied to the reduced 144
charge negotiated between the insurer and the preferred 145
provider. 146
(g) Notwithstanding the limitations of deductibles and 147
coinsurance provisions in this section, an insurer may require 148
the insured to pay a reasonable copayment per visit for 149
inpatient or outpatient services. 150
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(h) If any service or treatment is not within the scope of 151
services provided by the network of preferred providers, but is 152
within the scope of services or treatment covered by the policy, 153
the service or treatment shall be reimbursed at a rate not less 154
than 10 percentage points lower than the percentage rate paid to 155
preferred providers. The reimbursement rate must be applied to 156
the usual and customary charges in the area. 157
(7) Notwithstanding any other provision of law, any 158
insurer issuing a policy of health insurance in this state shall 159
apply the payment for a service rendered to an insured by a 160
nonpreferred provider toward the insured's annual deductible and 161
out-of-pocket limitation as if the service had been rendered by 162
a preferred provider if all of the following apply: 163
(a) The insured requests that the insurer apply the 164
payment for the service rendered to the insured b y the 165
nonpreferred provider toward the insured's annual deductible and 166
out-of-pocket limitation. 167
(b) The service rendered to the insured by the 168
nonpreferred provider is a service within the scope of services 169
covered under the insured's policy. 170
(c) The amount that the nonpreferred provider charged the 171
insured for the service is the same or less than: 172
1. The lowest cost that the insured's preferred provider 173
network charges for the service in the relevant rating area; or 174
2. The 25th percentile of the statewide average amount for 175
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the service based on the data reported on the Florida Health 176
Price Finder website. 177
Section 3. Section 627.65613, Florida Statutes, is created 178
to read: 179
627.65613 Nonpreferred provider service s; deductibles and 180
out-of-pocket limitations.— 181
(1) As used in this section, the term "preferred provider" 182
means any licensed health care provider, including, but not 183
limited to, an optometrist, a podiatric physician, and a 184
chiropractic physician, with wh om the insurer has directly or 185
indirectly contracted for an alternative or a reduced rate of 186
payment. 187
(2) Notwithstanding any other provision of law, any 188
insurer issuing a policy of health insurance in this state shall 189
apply the payment for a service ren dered to an insured by a 190
nonpreferred provider toward the insured's annual deductible and 191
out-of-pocket limitation as if the service had been rendered by 192
a preferred provider if all of the following apply: 193
(a) The insured requests that the insurer apply the 194
payment for the service rendered to the insured by the 195
nonpreferred provider toward the insured's annual deductible and 196
out-of-pocket limitation. 197
(b) The service rendered to the insured by the 198
nonpreferred provider is a service within the scope of se rvices 199
covered under the insured's policy. 200
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(c) The amount that the nonpreferred provider charged the 201
insured for the service is the same or less than: 202
1. The lowest cost that the insured's preferred provider 203
network charges for the service in the relev ant rating area; or 204
2. The 25th percentile of the statewide average amount for 205
the service based on the data reported on the Florida Health 206
Price Finder website. 207
Section 4. Paragraph (e) of subsection (2) and subsection 208
(3) of section 627.6648, Flori da Statutes, are amended to read: 209
627.6648 Shared savings incentive program. — 210
(2) As used in this section, the term: 211
(e) "Shoppable health care service" means a lower -cost, 212
high-quality nonemergency health care service for which a shared 213
savings incentive is available for insureds under a health 214
insurer's shared savings incentive program. Shoppable health 215
care services may be provided within or outside this state and 216
include, but are not limited to: 217
1. Clinical laboratory services. 218
2. Infusion therapy. 219
3. Inpatient and outpatient surgical procedures. 220
4. Obstetrical and gynecological services. 221
5. Inpatient and outpatient nonsurgical diagnostic tests 222
and procedures. 223
6. Physical and occupational therapy services. 224
7. Radiology and imaging ser vices. 225
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8. Prescription drugs. 226
9. Services provided through telehealth. 227
10. The items and services listed in Table 1 —500 Items and 228
Services List as published in Volume 85, No. 219 of the Federal 229
Register, pages 72182 -72190 (2020). 230
11.10. Any additional services published by the Agency for 231
Health Care Administration that have the most significant price 232
variation pursuant to s. 408.05(3)(m). 233
(3) A health insurer shall may offer a shared savings 234
incentive program to provide incentives to an insured wh en the 235
insured obtains a shoppable health care service from the health 236
insurer's shared savings list. An insured may not be required to 237
participate in a shared savings incentive program. In offering a 238
shared savings incentive program, a health insurer that offers a 239
shared savings incentive program must: 240
(a) Establish the program as a component part of the 241
policy or certificate of insurance provided by the health 242
insurer and notify the insureds and the office at least 30 days 243
before program termination. 244
(b) File a description of the program on a form prescribed 245
by commission rule. The office must review the filing and 246
determine whether the shared savings incentive program complies 247
with this section. 248
(c) Notify an insured annually and at the time of ren ewal, 249
and an applicant for insurance at the time of enrollment, of the 250
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availability of the shared savings incentive program and the 251
procedure to participate in the program. 252
(d) Publish on a web page easily accessible to insureds 253
and to applicants for ins urance a list of shoppable health care 254
services and health care providers and the shared savings 255
incentive amount applicable for each service. A shared savings 256
incentive may not be less than 25 percent of the difference in 257
cost compared to the second -lowest cost in-network amount paid 258
for that service in the rating area savings generated by the 259
insured's participation in any shared savings incentive offered 260
by the health insurer . The baseline for the savings calculation 261
is the average in-network amount paid for that service in the 262
most recent 12-month period or some other methodology 263
established by the health insurer and approved by the office. 264
(e) At least quarterly, credit or deposit the shared 265
savings incentive amount to the insured's account as a retur n or 266
reduction in premium, or credit the shared savings incentive 267
amount to the insured's flexible spending account, health 268
savings account, or health reimbursement account, or reward the 269
insured directly with cash or a cash equivalent. 270
(f) Submit an annual report to the office within 90 271
business days after the close of each plan year. At a minimum, 272
the report must include the following information: 273
1. The number of insureds who participated in the program 274
during the plan year and the number of instance s of 275
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participation. 276
2. The total cost of services provided as a part of the 277
program. 278
3. The total value of the shared savings incentive 279
payments made to insureds participating in the program and the 280
values distributed as premium reductions, credits to flexible 281
spending accounts, credits to health savings accounts, or 282
credits to health reimbursement accounts. 283
4. An inventory of the shoppable health care services 284
offered by the health insurer. 285
Section 5. Subsection (2) of section 641.31, Florida 286
Statutes, is amended to read: 287
641.31 Health maintenance contracts. — 288
(2)(a) The rates charged by any health maintenance 289
organization to its subscribers shall not be excessive, 290
inadequate, or unfairly discriminatory or follow a rating 291
methodology that is inconsistent, indeterminate, or ambiguous or 292
encourages misrepresentation or misunderstanding. The 293
commission, in accordance with generally accepted actuarial 294
practice as applied to health maintenance organizations, may 295
define by rule what constitutes exc essive, inadequate, or 296
unfairly discriminatory rates and may require whatever 297
information it deems necessary to determine that a rate or 298
proposed rate meets the requirements of this subsection. 299
(b) Notwithstanding any other provision of law, a health 300
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maintenance organization entering into a contract in this state 301
with a subscriber shall apply the payment for a service rendered 302
to the subscriber by an out -of-network provider toward the 303
subscriber's annual deductible and out -of-pocket limitation as 304
if the service had been rendered by an in -network provider if 305
all of the following apply: 306
1. The subscriber requests that the health maintenance 307
organization apply the payment for the service rendered to the 308
subscriber by the out -of-network provider toward the 309
subscriber's annual deductible and out of -pocket limitation. 310
2. The service rendered to the subscriber by the out -of-311
network provider is a service within the scope of services 312
covered under the subscriber's contract. 313
3. The amount that the out -of-network provider charged the 314
subscriber for the service is the same or less than: 315
a. The lowest cost that the subscriber's provider network 316
charges for the service in the relevant rating area; or 317
b. The 25th percentile of the statewide average amount for 318
the service based on the data reported on the Florida Health 319
Price Finder website. 320
321
As used in this paragraph, the term "in -network provider" means 322
a health care provider that is in the health maintenance 323
organization's provider network, and the term "out -of-network 324
provider" means a health care provider that is not in the health 325
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maintenance organization's provider network. 326
Section 6. Paragraph (e) of subsection (2) and subsection 327
(3) of section 641.31076, Florida Statutes, are amended to read: 328
641.31076 Shared savings incentive program. — 329
(2) As used in this section, the term: 330
(e) "Shoppable health care service" means a lower -cost, 331
high-quality nonemergency health care service for which a shared 332
savings incentive is available for subscribers under a h ealth 333
maintenance organization's shared savings incentive program. 334
Shoppable health care services may be provided within or outside 335
this state and include, but are not limited to: 336
1. Clinical laboratory services. 337
2. Infusion therapy. 338
3. Inpatient and outpatient surgical procedures. 339
4. Obstetrical and gynecological services. 340
5. Inpatient and outpatient nonsurgical diagnostic tests 341
and procedures. 342
6. Physical and occupational therapy services. 343
7. Radiology and imaging services. 344
8. Prescription drugs. 345
9. Services provided through telehealth. 346
10. The items and services listed in Table 1 —500 Items and 347
Services List as published in Volume 85, No. 219 of the Federal 348
Register, pages 72182 -72190 (2020). 349
11.10. Any additional services published b y the Agency for 350
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Health Care Administration that have the most significant price 351
variation pursuant to s. 408.05(3)(m). 352
(3) A health maintenance organization shall may offer a 353
shared savings incentive program to provide incentives to a 354
subscriber when the subscriber obtains a shoppable health care 355
service from the health maintenance organization's shared 356
savings list. A subscriber may not be required to participate in 357
a shared savings incentive program. In offering a shared savings 358
incentive program, a health maintenance organization that offers 359
a shared savings incentive program must: 360
(a) Establish the program as a component part of the 361
contract of coverage provided by the health maintenance 362
organization and notify the subscribers and the office at leas t 363
30 days before program termination. 364
(b) File a description of the program on a form prescribed 365
by commission rule. The office must review the filing and 366
determine whether the shared savings incentive program complies 367
with this section. 368
(c) Notify a subscriber annually and at the time of 369
renewal, and an applicant for coverage at the time of 370
enrollment, of the availability of the shared savings incentive 371
program and the procedure to participate in the program. 372
(d) Publish on a web page easily accessib le to subscribers 373
and to applicants for coverage a list of shoppable health care 374
services and health care providers and the shared savings 375
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
incentive amount applicable for each service. A shared savings 376
incentive may not be less than 25 percent of the difference in 377
cost compared to the second -lowest cost in-network amount paid 378
for that service in the rating area savings generated by the 379
subscriber's participation in any shared savings incentive 380
offered by the health maintenance organization . The baseline for 381
the savings calculation is the average in -network amount paid 382
for that service in the most recent 12 -month period or some 383
other methodology established by the health maintenance 384
organization and approved by the office. 385
(e) At least quarterly, credit or deposit the shared 386
savings incentive amount to the subscriber's account as a return 387
or reduction in premium, or credit the shared savings incentive 388
amount to the subscriber's flexible spending account, health 389
savings account, or health reimbursement accoun t, or reward the 390
subscriber directly with cash or a cash equivalent. 391
(f) Submit an annual report to the office within 90 392
business days after the close of each plan year. At a minimum, 393
the report must include the following information: 394
1. The number of subscribers who participated in the 395
program during the plan year and the number of instances of 396
participation. 397
2. The total cost of services provided as a part of the 398
program. 399
3. The total value of the shared savings incentive 400
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payments made to subscrib ers participating in the program and 401
the values distributed as premium reductions, credits to 402
flexible spending accounts, credits to health savings accounts, 403
or credits to health reimbursement accounts. 404
4. An inventory of the shoppable health care servic es 405
offered by the health maintenance organization. 406
Section 7. This act shall take effect July 1, 2023. 407