FL
Florida House Bill H1351

Florida 2023 Regular Session

Florida House Bill H1351 Compare Versions

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1010 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
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1414 A bill to be entitled 1
1515 An act relating to savings and out -of-pocket expenses 2
16-in health insurance; amending ss. 395.107, 395.301, 3
17-458.323, 459.012, 460.41, and 461.009, F.S.; requiring 4
18-certain licensed facilities and physicians to provide 5
19-specific pricing and cost -obligation information to 6
20-patients; amending s. 627.6471, F.S.; requiring a 7
21-health insurer, effective on a specified date, to 8
22-apply the payment for a service that a nonpreferre d 9
23-provider provided to an insured toward the insured's 10
24-deductible and out-of-pocket maximum as if the service 11
25-had been provided by a preferred provider, if specific 12
26-conditions are met; providing effective dates. 13
27- 14
28-Be It Enacted by the Legislature of the State of Florida: 15
29- 16
30- Section 1. Subsection (3) of section 395.107, Florida 17
31-Statutes, is amended to read: 18
32- 395.107 Facilities; publishing and posting schedule of 19
33-charges; penalties; cost-sharing obligation information .— 20
34- (3)(a) The schedule of charges must describe the medical 21
35-services in language comprehensible to a layperson. The schedule 22
36-must include the prices charged to an uninsured person paying 23
37-for such services by cash, check, credit card, or debit card. 24
38- (b) The schedule must be posted in a co nspicuous place in 25
16+in health insurance; amending ss. 627.6387, 627.6648, 3
17+and 641.31076, F.S.; revising the definition of the 4
18+term "shoppable health care service"; requiring, 5
19+rather than authorizing, individual health insurers, 6
20+group health insurers, and health maintenance 7
21+organizations, respectively, to offer shared savings 8
22+incentive programs; revising the minimum amount of 9
23+shared savings incentives; amending s. 627.6471, F.S.; 10
24+conforming provisions to changes made by the act; 11
25+requiring individual health insurers to apply payments 12
26+for services by nonpreferred providers toward 13
27+insureds' annual deductibles and out -of-pocket limits 14
28+under certain circumstances; creating s. 627.65613, 15
29+F.S.; defining the term "preferred provider"; 16
30+requiring group health insurers to apply payments for 17
31+services by nonpreferred providers toward insureds' 18
32+annual deductibles and out -of-pocket limits under 19
33+certain circumstances; amending s. 641.31, F.S.; 20
34+requiring health maintenance organizations to apply 21
35+payments for services by out -of-network providers 22
36+toward subscribers' annual deductibles and out -of-23
37+pocket limits under certain circumstances; defining 24
38+the terms "in-network provider" and "out -of-network 25
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4747 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
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51-the reception area and must include, but is not limited to, the 26
52-50 services most frequently provided. The schedule may group 27
53-services by three price levels, listing services in each price 28
54-level. The posting may be a sign, which must be a t least 15 29
55-square feet in size, or may be through an electronic messaging 30
56-board. 31
57- (c) If a facility is affiliated with a licensed hospital 32
58-under this chapter, the schedule must include text that notifies 33
59-the insured patients whether the charges for medica l services 34
60-received at the center will be the same as, or more than, 35
61-charges for medical services received at the affiliated 36
62-hospital. 37
63- (d) The text notifying the patient of the schedule of 38
64-charges shall be in a font size equal to or greater than the 39
65-font size used for prices and must be in a contrasting color. 40
66-The text that notifies the insured patients whether the charges 41
67-for medical services received at the center will be the same as, 42
68-or more than, charges for medical services received at the 43
69-affiliated hospital shall be included in all media and Internet 44
70-advertisements for the center and in language comprehensible to 45
71-a layperson. 46
72- (e) At the point of sale, each center shall disclose to 47
73-the patient whether his or her cost -sharing obligation exceeds 48
74-the retail price of services in the absence of health insurance 49
75-coverage. 50
51+provider"; providing an effective date. 26
52+ 27
53+Be It Enacted by the Legislature of the State of Florida: 28
54+ 29
55+ Section 1. Paragraph (e) of subsection (2) and subsection 30
56+(3) of section 627.6387, Florida Statutes, are amended to read: 31
57+ 627.6387 Shared savings incentive program. — 32
58+ (2) As used in this section, the term: 33
59+ (e) "Shoppable health care service" means a lower -cost, 34
60+high-quality nonemergency health care service for which a shared 35
61+savings incentive is avai lable for insureds under a health 36
62+insurer's shared savings incentive program. Shoppable health 37
63+care services may be provided within or outside this state and 38
64+include, but are not limited to: 39
65+ 1. Clinical laboratory services. 40
66+ 2. Infusion therapy. 41
67+ 3. Inpatient and outpatient surgical procedures. 42
68+ 4. Obstetrical and gynecological services. 43
69+ 5. Inpatient and outpatient nonsurgical diagnostic tests 44
70+and procedures. 45
71+ 6. Physical and occupational therapy services. 46
72+ 7. Radiology and imaging services. 47
73+ 8. Prescription drugs. 48
74+ 9. Services provided through telehealth. 49
75+ 10. The items and services listed in Table 1 —500 Items and 50
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8484 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
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88- Section 2. Subsection (7) is added to section 395.301, 51
89-Florida Statutes, to read: 52
90- 395.301 Price transparency; itemized patient statement or 53
91-bill; patient admission status notificat ion.— 54
92- (7) A licensed facility shall disclose to a patient or a 55
93-prospective patient whether his or her cost -sharing 56
94-responsibilities exceed the retail price of services in the 57
95-absence of health insurance coverage. 58
96- Section 3. Section 458.323, Florida S tatutes, is amended 59
97-to read: 60
98- 458.323 Itemized patient billing. — 61
99- (1) Whenever a physician licensed under this chapter 62
100-renders professional services to a patient, the physician is 63
101-required, upon request, to submit to the patient, the patient's 64
102-insurer, or the administrative agency for any federal or state 65
103-health program under which the patient is entitled to benefits 66
104-an itemized statement of the specific services rendered and the 67
105-charge for each, no later than the physician's next regular 68
106-billing cycle which follows the fifth day after the rendering of 69
107-professional services. A physician may not condition the 70
108-furnishing of an itemized statement upon prior payment of the 71
109-bill. 72
110- (2) Upon request, and on or before the day of services 73
111-being rendered, a physician shall provide an insured patient 74
112-with information regarding the applicable Current Procedural 75
88+Services List as published in Volume 85, No. 219 of the Federal 51
89+Register, pages 72182 -72190 (2020). 52
90+ 11.10. Any additional services published by the Agency for 53
91+Health Care Administration that have the most significant price 54
92+variation pursuant to s. 408.05(3)(m). 55
93+ (3) A health insurer shall may offer a shared savings 56
94+incentive program to provide incentives to an insured when the 57
95+insured obtains a shoppable health care service from the health 58
96+insurer's shared savings list. An insured may not be required to 59
97+participate in a shared savings incentive program. In offering a 60
98+shared savings incentive program, a health insurer that offers a 61
99+shared savings incentive program must: 62
100+ (a) Establish the program as a component part of the 63
101+policy or certificate of insurance provided by the health 64
102+insurer and notify the insureds and the office at least 30 days 65
103+before program termination. 66
104+ (b) File a description of the program on a form prescribed 67
105+by commission rule. The office must review the filing and 68
106+determine whether the shared savings incentive program complies 69
107+with this section. 70
108+ (c) Notify an insured annually and at the time of renewal, 71
109+and an applicant for insurance at the time of enrollment, of the 72
110+availability of the shared savings incentive program and the 73
111+procedure to participate in the program. 74
112+ (d) Publish on a web page easily accessible to insureds 75
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121121 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
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125-Terminology (CPT) codes for the scheduled services and the 76
126-physician's retail price in the absence of health insurance 77
127-coverage for the scheduled ser vices. 78
128- Section 4. Section 459.012, Florida Statutes, is amended 79
129-to read: 80
130- 459.012 Itemized patient statement. — 81
131- (1) Whenever an osteopathic physician licensed under this 82
132-chapter renders professional services to a patient, the 83
133-osteopathic physician is required, upon request, to submit to 84
134-the patient, the patient's insurer, or the administrative agency 85
135-for any federal or state health program under which the patient 86
136-is entitled to benefits an itemized statement of the specific 87
137-services rendered and the c harge for each, no later than the 88
138-osteopathic physician's next regular billing cycle which follows 89
139-the fifth day after the rendering of professional services. An 90
140-osteopathic physician may not condition the furnishing of an 91
141-itemized statement upon prior pay ment of the bill. 92
142- (2) Whenever the itemized statement is submitted to the 93
143-patient's insurer or the administrative agency, a copy of the 94
144-itemized statement shall simultaneously be provided to the 95
145-patient. Such copy of the itemized statement which is sent to 96
146-the patient shall, in boldfaced letters, state that: "THIS IS A 97
147-DUPLICATE COPY OF A STATEMENT SUBMITTED TO YOUR INSURER OR OTHER 98
148-AGENCY." 99
149- (3) Upon request, and on or before the day of services 100
125+and to applicants for insurance a list of shoppable health care 76
126+services and health care providers and the shared savings 77
127+incentive amount applicable for each service. A shared savings 78
128+incentive may not be less than 25 percent of the difference in 79
129+cost compared to the second-lowest cost in-network amount paid 80
130+for that service in the rating area savings generated by the 81
131+insured's participation in any shared savings incentive offered 82
132+by the health insurer . The baseline for the savings calculation 83
133+is the average in-network amount paid for that service in the 84
134+most recent 12-month period or some other methodology 85
135+established by the health insurer and approved by the office. 86
136+ (e) At least quarterly, credit or deposit the shared 87
137+savings incentive amount to the insured's accoun t as a return or 88
138+reduction in premium, or credit the shared savings incentive 89
139+amount to the insured's flexible spending account, health 90
140+savings account, or health reimbursement account, or reward the 91
141+insured directly with cash or a cash equivalent. 92
142+ (f) Submit an annual report to the office within 90 93
143+business days after the close of each plan year. At a minimum, 94
144+the report must include the following information: 95
145+ 1. The number of insureds who participated in the program 96
146+during the plan year and the number of instances of 97
147+participation. 98
148+ 2. The total cost of services provided as a part of the 99
149+program. 100
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158158 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
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162-being rendered, an osteopathic physician shall provide an 101
163-insured patient with information regarding the applicable 102
164-Current Procedural Terminology ( CPT) codes for the scheduled 103
165-services and the physician's retail price in the absence of 104
166-health insurance coverage for the scheduled services. 105
167- Section 5. Section 460.41, Florida Statutes, is amended to 106
168-read: 107
169- 460.41 Itemized patient billing ; cost-sharing obligation 108
170-information.— 109
171- (1) Whenever a chiropractic physician licensed under this 110
172-chapter renders professional services to a patient, the 111
173-chiropractic physicia n shall submit to the patient, to the 112
174-patient's insurer, or to the administrative agency for any 113
175-federal or state health program under which the patient is 114
176-entitled to benefits an itemized statement of the specific 115
177-services rendered and the charge for each , no later than the 116
178-chiropractic physician's next regular billing cycle which 117
179-follows the fifth day after the rendering of professional 118
180-services. A chiropractic physician may not condition the 119
181-furnishing of an itemized statement upon prior payment of the 120
182-bill. 121
183- (2) At the point of sale, a chiropractic physician shall 122
184-disclose to a patient whether his or her cost -sharing obligation 123
185-exceeds the retail price of professional services in the absence 124
186-of health insurance coverage. 125
162+ 3. The total value of the shared savings incentive 101
163+payments made to insureds participating in the program and the 102
164+values distributed as premium reductions, credits to flexible 103
165+spending accounts, credits to health savings accounts, or 104
166+credits to health reimbursement accounts. 105
167+ 4. An inventory of the shoppable health care services 106
168+offered by the health insurer. 107
169+ Section 2. Subsection (7) of section 627.647 1, Florida 108
170+Statutes, is renumbered as subsection (8), subsection (4) is 109
171+amended, and a new subsection (7) is added to that section, to 110
172+read: 111
173+ 627.6471 Contracts for reduced rates of payment; 112
174+limitations; coinsurance and deductibles. — 113
175+ (4) Except as otherwise provided in subsection (7), any 114
176+policy that provides schedules of payments for services provided 115
177+by preferred providers that differ from the schedules of 116
178+payments for services provided by nonpreferred providers is 117
179+subject to the following limitations: 118
180+ (a) The amount of any annual deductible per covered person 119
181+or per family for treatment in a facility that is not a 120
182+preferred provider may not exceed four times the amount of a 121
183+corresponding annual deductible for treatment in a facility that 122
184+is a preferred provider. 123
185+ (b) If the policy has no deductible for treatment in a 124
186+preferred provider facility, the deductible for treatment 125
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195195 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
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199- Section 6. Section 461.009, Florida Statutes, is amended 126
200-to read: 127
201- 461.009 Itemized patient billing ; cost-sharing obligation 128
202-information.— 129
203- (1) Whenever a podiatric physician licensed under this 130
204-chapter renders professional services to a patient, the 131
205-podiatric physician is required , upon request, to submit to the 132
206-patient, to the patient's insurer, or to the administrative 133
207-agency for any federal or state health program under which the 134
208-patient is entitled to benefits, an itemized statement of the 135
209-specific services rendered and the cha rge for each, no later 136
210-than the podiatric physician's next regular billing cycle which 137
211-follows the fifth day after the rendering of professional 138
212-services. A podiatric physician may not condition the furnishing 139
213-of an itemized statement upon prior payment of the bill. 140
214- (2) At the point of sale, a podiatric physician shall 141
215-disclose to the patient whether his or her cost -sharing 142
216-obligation exceeds the retail price of professional services in 143
217-the absence of health insurance coverage. 144
218- Section 7. Effective Ja nuary 1, 2024, subsection (7) of 145
219-section 627.6471, Florida Statutes, is renumbered as subsection 146
220-(8), subsection (4) is amended, a new subsection (7) is added to 147
221-that section, to read: 148
222- 627.6471 Contracts for reduced rates of payment; 149
223-limitations; coinsur ance and deductibles. — 150
199+received in a facility that is not a preferred provider facility 126
200+may not exceed $500 per covered person per visit. 127
201+ (c) The amount of any annual deductible per covered person 128
202+or per family for treatment, other than inpatient treatment, by 129
203+a provider that is not a preferred provider may not exceed four 130
204+times the amount of a corresponding annual deductible for 131
205+treatment, other than inpatient treatment, by a preferred 132
206+provider. 133
207+ (d) If the policy has no deductible for treatment by a 134
208+preferred provider, the annual deductible for treatment received 135
209+from a provider which is not a preferred provider shall not 136
210+exceed $500 per covered pers on. 137
211+ (e) The percentage amount of any coinsurance to be paid by 138
212+an insured to a provider that is not a preferred provider may 139
213+not exceed by more than 50 percentage points the percentage 140
214+amount of any coinsurance payment to be paid to a preferred 141
215+provider. 142
216+ (f) The amount of any deductible and payment of 143
217+coinsurance paid by the insured must be applied to the reduced 144
218+charge negotiated between the insurer and the preferred 145
219+provider. 146
220+ (g) Notwithstanding the limitations of deductibles and 147
221+coinsurance provisions in this section, an insurer may require 148
222+the insured to pay a reasonable copayment per visit for 149
223+inpatient or outpatient services. 150
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232232 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
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236- (4) Except as otherwise provided in subsection (7), any 151
237-policy that provides schedules of payments for services rendered 152
238-provided by preferred providers that differ from the schedules 153
239-of payments for services rendered provided by nonpreferred 154
240-providers is subject to the following limitations: 155
241- (a) The amount of any annual deductible per covered person 156
242-or per family for treatment in a facility that is not a 157
243-preferred provider may not exceed four times the amount of a 158
244-corresponding annual deductible for treatment in a facility that 159
245-is a preferred provider. 160
246- (b) If the policy has no deductible for treatment in a 161
247-preferred provider facility, the deductible for treatment 162
248-received in a facility that is not a preferred provider facility 163
249-may not exceed $500 per covered person per visit. 164
250- (c) The amount of any annual deductible per covered person 165
251-or per family for treatment, other than inpatient treatment, by 166
252-a provider that is not a preferred provider may not exceed four 167
253-times the amount of a corresponding annual deductible for 168
254-treatment, other than inpatient treatment, by a preferred 169
255-provider. 170
256- (d) If the policy has no deductible for treatment by a 171
257-preferred provider, the annual deductible for treatment received 172
258-from a provider which is n ot a preferred provider shall not 173
259-exceed $500 per covered person. 174
260- (e) The percentage amount of any coinsurance to be paid by 175
236+ (h) If any service or treatment is not within the scope of 151
237+services provided by the network of preferred providers, but is 152
238+within the scope of services or treatment covered by the policy, 153
239+the service or treatment shall be reimbursed at a rate not less 154
240+than 10 percentage points lower than the percentage rate paid to 155
241+preferred providers. The reimbursement rate must be applied to 156
242+the usual and customary charges in the area. 157
243+ (7) Notwithstanding any other provision of law, any 158
244+insurer issuing a policy of health insurance in this state shall 159
245+apply the payment for a service rendered to an insured by a 160
246+nonpreferred provider toward the insured's annual deductible and 161
247+out-of-pocket limitation as if the service had been rendered by 162
248+a preferred provider if all of the following apply: 163
249+ (a) The insured requests that the insurer apply the 164
250+payment for the service rendered to the insured b y the 165
251+nonpreferred provider toward the insured's annual deductible and 166
252+out-of-pocket limitation. 167
253+ (b) The service rendered to the insured by the 168
254+nonpreferred provider is a service within the scope of services 169
255+covered under the insured's policy. 170
256+ (c) The amount that the nonpreferred provider charged the 171
257+insured for the service is the same or less than: 172
258+ 1. The lowest cost that the insured's preferred provider 173
259+network charges for the service in the relevant rating area; or 174
260+ 2. The 25th percentile of the statewide average amount for 175
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269269 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
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273-an insured to a provider that is not a preferred provider may 176
274-not exceed by more than 50 percentage points the percentage 177
275-amount of any coinsurance payment to be paid to a preferred 178
276-provider. 179
277- (f) The amount of any deductible and payment of 180
278-coinsurance paid by the insured must be applied to the reduced 181
279-charge negotiated between the insurer and the preferred 182
280-provider. 183
281- (g) Notwithstanding the limitations of deductibles and 184
282-coinsurance provisions in this section, an insurer may require 185
283-the insured to pay a reasonable copayment per visit for 186
284-inpatient or outpatient services. 187
285- (h) If any service or treatment is not within the scope of 188
286-services rendered provided by the network of preferred 189
287-providers, but is within the scope of services or treatment 190
288-covered by the policy, the service or treatment shall be 191
289-reimbursed at a rate not less than 10 percentage points lower 192
290-than the percentage r ate paid to preferred providers. The 193
291-reimbursement rate must be applied to the usual and customary 194
292-charges in the area. 195
293- (7) An insurer issuing a health insurance policy in this 196
294-state must apply the payment for a service that a nonpreferred 197
295-provider rendered to an insured toward the insured's deductible 198
296-and out-of-pocket maximum as if the service had been rendered by 199
297-a preferred provider, if all of the following apply: 200
273+the service based on the data reported on the Florida Health 176
274+Price Finder website. 177
275+ Section 3. Section 627.65613, Florida Statutes, is created 178
276+to read: 179
277+ 627.65613 Nonpreferred provider service s; deductibles and 180
278+out-of-pocket limitations.— 181
279+ (1) As used in this section, the term "preferred provider" 182
280+means any licensed health care provider, including, but not 183
281+limited to, an optometrist, a podiatric physician, and a 184
282+chiropractic physician, with wh om the insurer has directly or 185
283+indirectly contracted for an alternative or a reduced rate of 186
284+payment. 187
285+ (2) Notwithstanding any other provision of law, any 188
286+insurer issuing a policy of health insurance in this state shall 189
287+apply the payment for a service ren dered to an insured by a 190
288+nonpreferred provider toward the insured's annual deductible and 191
289+out-of-pocket limitation as if the service had been rendered by 192
290+a preferred provider if all of the following apply: 193
291+ (a) The insured requests that the insurer apply the 194
292+payment for the service rendered to the insured by the 195
293+nonpreferred provider toward the insured's annual deductible and 196
294+out-of-pocket limitation. 197
295+ (b) The service rendered to the insured by the 198
296+nonpreferred provider is a service within the scope of se rvices 199
297+covered under the insured's policy. 200
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310- (a) The insured requests that the insurer apply the 201
311-payment for the service the nonpre ferred provider rendered to 202
312-the insured toward the insured's deductible and out -of-pocket 203
313-maximum. 204
314- (b) The service the nonpreferred provider rendered to the 205
315-insured is a service within the scope of services covered under 206
316-the insured's policy. 207
317- (c) The amount the nonpreferred provider charged the 208
318-insured for the service is the same or less than: 209
319- 1. The lowest cost that the insured's preferred provider 210
320-network charges for the service in the relevant rating area; or 211
321- 2. The 25th percentile of the statewide average amount for 212
322-the service, based on data reported on the Agency for Health 213
323-Care Administration's Internet -based platform under s. 214
324-408.05(3)(c). 215
325- Section 8. Except as otherwise expressly provided in this 216
326-act, this act shall take effect July 1, 2023. 217
310+ (c) The amount that the nonpreferred provider charged the 201
311+insured for the service is the same or less than: 202
312+ 1. The lowest cost that the insured's preferred provider 203
313+network charges for the service in the relev ant rating area; or 204
314+ 2. The 25th percentile of the statewide average amount for 205
315+the service based on the data reported on the Florida Health 206
316+Price Finder website. 207
317+ Section 4. Paragraph (e) of subsection (2) and subsection 208
318+(3) of section 627.6648, Flori da Statutes, are amended to read: 209
319+ 627.6648 Shared savings incentive program. — 210
320+ (2) As used in this section, the term: 211
321+ (e) "Shoppable health care service" means a lower -cost, 212
322+high-quality nonemergency health care service for which a shared 213
323+savings incentive is available for insureds under a health 214
324+insurer's shared savings incentive program. Shoppable health 215
325+care services may be provided within or outside this state and 216
326+include, but are not limited to: 217
327+ 1. Clinical laboratory services. 218
328+ 2. Infusion therapy. 219
329+ 3. Inpatient and outpatient surgical procedures. 220
330+ 4. Obstetrical and gynecological services. 221
331+ 5. Inpatient and outpatient nonsurgical diagnostic tests 222
332+and procedures. 223
333+ 6. Physical and occupational therapy services. 224
334+ 7. Radiology and imaging ser vices. 225
335+
336+HB 1351 2023
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338+
339+
340+CODING: Words stricken are deletions; words underlined are additions.
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343+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
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346+
347+ 8. Prescription drugs. 226
348+ 9. Services provided through telehealth. 227
349+ 10. The items and services listed in Table 1 —500 Items and 228
350+Services List as published in Volume 85, No. 219 of the Federal 229
351+Register, pages 72182 -72190 (2020). 230
352+ 11.10. Any additional services published by the Agency for 231
353+Health Care Administration that have the most significant price 232
354+variation pursuant to s. 408.05(3)(m). 233
355+ (3) A health insurer shall may offer a shared savings 234
356+incentive program to provide incentives to an insured wh en the 235
357+insured obtains a shoppable health care service from the health 236
358+insurer's shared savings list. An insured may not be required to 237
359+participate in a shared savings incentive program. In offering a 238
360+shared savings incentive program, a health insurer that offers a 239
361+shared savings incentive program must: 240
362+ (a) Establish the program as a component part of the 241
363+policy or certificate of insurance provided by the health 242
364+insurer and notify the insureds and the office at least 30 days 243
365+before program termination. 244
366+ (b) File a description of the program on a form prescribed 245
367+by commission rule. The office must review the filing and 246
368+determine whether the shared savings incentive program complies 247
369+with this section. 248
370+ (c) Notify an insured annually and at the time of ren ewal, 249
371+and an applicant for insurance at the time of enrollment, of the 250
372+
373+HB 1351 2023
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375+
376+
377+CODING: Words stricken are deletions; words underlined are additions.
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379+Page 11 of 17
380+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
381+
382+
383+
384+availability of the shared savings incentive program and the 251
385+procedure to participate in the program. 252
386+ (d) Publish on a web page easily accessible to insureds 253
387+and to applicants for ins urance a list of shoppable health care 254
388+services and health care providers and the shared savings 255
389+incentive amount applicable for each service. A shared savings 256
390+incentive may not be less than 25 percent of the difference in 257
391+cost compared to the second -lowest cost in-network amount paid 258
392+for that service in the rating area savings generated by the 259
393+insured's participation in any shared savings incentive offered 260
394+by the health insurer . The baseline for the savings calculation 261
395+is the average in-network amount paid for that service in the 262
396+most recent 12-month period or some other methodology 263
397+established by the health insurer and approved by the office. 264
398+ (e) At least quarterly, credit or deposit the shared 265
399+savings incentive amount to the insured's account as a retur n or 266
400+reduction in premium, or credit the shared savings incentive 267
401+amount to the insured's flexible spending account, health 268
402+savings account, or health reimbursement account, or reward the 269
403+insured directly with cash or a cash equivalent. 270
404+ (f) Submit an annual report to the office within 90 271
405+business days after the close of each plan year. At a minimum, 272
406+the report must include the following information: 273
407+ 1. The number of insureds who participated in the program 274
408+during the plan year and the number of instance s of 275
409+
410+HB 1351 2023
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412+
413+
414+CODING: Words stricken are deletions; words underlined are additions.
415+hb1351-00
416+Page 12 of 17
417+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
418+
419+
420+
421+participation. 276
422+ 2. The total cost of services provided as a part of the 277
423+program. 278
424+ 3. The total value of the shared savings incentive 279
425+payments made to insureds participating in the program and the 280
426+values distributed as premium reductions, credits to flexible 281
427+spending accounts, credits to health savings accounts, or 282
428+credits to health reimbursement accounts. 283
429+ 4. An inventory of the shoppable health care services 284
430+offered by the health insurer. 285
431+ Section 5. Subsection (2) of section 641.31, Florida 286
432+Statutes, is amended to read: 287
433+ 641.31 Health maintenance contracts. — 288
434+ (2)(a) The rates charged by any health maintenance 289
435+organization to its subscribers shall not be excessive, 290
436+inadequate, or unfairly discriminatory or follow a rating 291
437+methodology that is inconsistent, indeterminate, or ambiguous or 292
438+encourages misrepresentation or misunderstanding. The 293
439+commission, in accordance with generally accepted actuarial 294
440+practice as applied to health maintenance organizations, may 295
441+define by rule what constitutes exc essive, inadequate, or 296
442+unfairly discriminatory rates and may require whatever 297
443+information it deems necessary to determine that a rate or 298
444+proposed rate meets the requirements of this subsection. 299
445+ (b) Notwithstanding any other provision of law, a health 300
446+
447+HB 1351 2023
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449+
450+
451+CODING: Words stricken are deletions; words underlined are additions.
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454+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
455+
456+
457+
458+maintenance organization entering into a contract in this state 301
459+with a subscriber shall apply the payment for a service rendered 302
460+to the subscriber by an out -of-network provider toward the 303
461+subscriber's annual deductible and out -of-pocket limitation as 304
462+if the service had been rendered by an in -network provider if 305
463+all of the following apply: 306
464+ 1. The subscriber requests that the health maintenance 307
465+organization apply the payment for the service rendered to the 308
466+subscriber by the out -of-network provider toward the 309
467+subscriber's annual deductible and out of -pocket limitation. 310
468+ 2. The service rendered to the subscriber by the out -of-311
469+network provider is a service within the scope of services 312
470+covered under the subscriber's contract. 313
471+ 3. The amount that the out -of-network provider charged the 314
472+subscriber for the service is the same or less than: 315
473+ a. The lowest cost that the subscriber's provider network 316
474+charges for the service in the relevant rating area; or 317
475+ b. The 25th percentile of the statewide average amount for 318
476+the service based on the data reported on the Florida Health 319
477+Price Finder website. 320
478+ 321
479+As used in this paragraph, the term "in -network provider" means 322
480+a health care provider that is in the health maintenance 323
481+organization's provider network, and the term "out -of-network 324
482+provider" means a health care provider that is not in the health 325
483+
484+HB 1351 2023
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487+
488+CODING: Words stricken are deletions; words underlined are additions.
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491+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
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493+
494+
495+maintenance organization's provider network. 326
496+ Section 6. Paragraph (e) of subsection (2) and subsection 327
497+(3) of section 641.31076, Florida Statutes, are amended to read: 328
498+ 641.31076 Shared savings incentive program. — 329
499+ (2) As used in this section, the term: 330
500+ (e) "Shoppable health care service" means a lower -cost, 331
501+high-quality nonemergency health care service for which a shared 332
502+savings incentive is available for subscribers under a h ealth 333
503+maintenance organization's shared savings incentive program. 334
504+Shoppable health care services may be provided within or outside 335
505+this state and include, but are not limited to: 336
506+ 1. Clinical laboratory services. 337
507+ 2. Infusion therapy. 338
508+ 3. Inpatient and outpatient surgical procedures. 339
509+ 4. Obstetrical and gynecological services. 340
510+ 5. Inpatient and outpatient nonsurgical diagnostic tests 341
511+and procedures. 342
512+ 6. Physical and occupational therapy services. 343
513+ 7. Radiology and imaging services. 344
514+ 8. Prescription drugs. 345
515+ 9. Services provided through telehealth. 346
516+ 10. The items and services listed in Table 1 —500 Items and 347
517+Services List as published in Volume 85, No. 219 of the Federal 348
518+Register, pages 72182 -72190 (2020). 349
519+ 11.10. Any additional services published b y the Agency for 350
520+
521+HB 1351 2023
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523+
524+
525+CODING: Words stricken are deletions; words underlined are additions.
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528+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
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530+
531+
532+Health Care Administration that have the most significant price 351
533+variation pursuant to s. 408.05(3)(m). 352
534+ (3) A health maintenance organization shall may offer a 353
535+shared savings incentive program to provide incentives to a 354
536+subscriber when the subscriber obtains a shoppable health care 355
537+service from the health maintenance organization's shared 356
538+savings list. A subscriber may not be required to participate in 357
539+a shared savings incentive program. In offering a shared savings 358
540+incentive program, a health maintenance organization that offers 359
541+a shared savings incentive program must: 360
542+ (a) Establish the program as a component part of the 361
543+contract of coverage provided by the health maintenance 362
544+organization and notify the subscribers and the office at leas t 363
545+30 days before program termination. 364
546+ (b) File a description of the program on a form prescribed 365
547+by commission rule. The office must review the filing and 366
548+determine whether the shared savings incentive program complies 367
549+with this section. 368
550+ (c) Notify a subscriber annually and at the time of 369
551+renewal, and an applicant for coverage at the time of 370
552+enrollment, of the availability of the shared savings incentive 371
553+program and the procedure to participate in the program. 372
554+ (d) Publish on a web page easily accessib le to subscribers 373
555+and to applicants for coverage a list of shoppable health care 374
556+services and health care providers and the shared savings 375
557+
558+HB 1351 2023
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560+
561+
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565+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
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567+
568+
569+incentive amount applicable for each service. A shared savings 376
570+incentive may not be less than 25 percent of the difference in 377
571+cost compared to the second -lowest cost in-network amount paid 378
572+for that service in the rating area savings generated by the 379
573+subscriber's participation in any shared savings incentive 380
574+offered by the health maintenance organization . The baseline for 381
575+the savings calculation is the average in -network amount paid 382
576+for that service in the most recent 12 -month period or some 383
577+other methodology established by the health maintenance 384
578+organization and approved by the office. 385
579+ (e) At least quarterly, credit or deposit the shared 386
580+savings incentive amount to the subscriber's account as a return 387
581+or reduction in premium, or credit the shared savings incentive 388
582+amount to the subscriber's flexible spending account, health 389
583+savings account, or health reimbursement accoun t, or reward the 390
584+subscriber directly with cash or a cash equivalent. 391
585+ (f) Submit an annual report to the office within 90 392
586+business days after the close of each plan year. At a minimum, 393
587+the report must include the following information: 394
588+ 1. The number of subscribers who participated in the 395
589+program during the plan year and the number of instances of 396
590+participation. 397
591+ 2. The total cost of services provided as a part of the 398
592+program. 399
593+ 3. The total value of the shared savings incentive 400
594+
595+HB 1351 2023
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602+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
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604+
605+
606+payments made to subscrib ers participating in the program and 401
607+the values distributed as premium reductions, credits to 402
608+flexible spending accounts, credits to health savings accounts, 403
609+or credits to health reimbursement accounts. 404
610+ 4. An inventory of the shoppable health care servic es 405
611+offered by the health maintenance organization. 406
612+ Section 7. This act shall take effect July 1, 2023. 407