This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h0659c.IBS
DATE: 1/26/2024
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 659 Health Plans
SPONSOR(S): Abbott and others
TIED BILLS: IDEN./SIM. BILLS: SB 584
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Select Committee on Health Innovation 14 Y, 0 N Lloyd Calamas
2) Insurance & Banking Subcommittee 15 Y, 0 N Lloyd Lloyd
3) Health Care Appropriations Subcommittee
4) Health & Human Services Committee
SUMMARY ANALYSIS
The Agency for Health Care Administration (AHCA) contracts with a third-party resolution organization for the
review of the claim disputes between health care providers, health insurers and health maintenance
organizations under the Statewide Provider and Health Plan Claim Dispute Resolution Program (Program).
Claims are reviewed by the organization and then submitted to the AHCA with a payment recommendation
based on desk reviews by the third-party resolution organization and, if requested, a review of evidence and
additional documentation in a hearing. Acting as an alternative dispute resolution process for eligible heath
care providers and insurers, the AHCA issues any final order after receipt of the recommendation and the non-
prevailing party or parties has 35 days to pay. Non-prevailing parties are also responsible for review costs
incurred by the review organization; their share of any costs from a hearing; and, subject to a penalty of up to
$500 and being reported to their licensing authority for untimely payment.
The bill prohibits a health plan, i.e., a health maintenance organization, preferred provider organization,
prepaid health plan, exclusive provider organization, major medical expense health insurer, or group or
individual health insurers, from declining to participate in the Program. If the health plan fails to timely pay an
order under the Program, they are subject to penalty up to $500 and reporting to their licensing authority.
The bill also creates new requirements for standardized identification cards for insureds that clearly identifies
whether or not the plan is subject to state regulation and which provides the insured with quick access
information to the consumer services website of the Department of Financial Services’ Division of Consumer
Services website.
The bill has an indeterminate fiscal impact on state and local governments and the private sector.
The bill provides an effective date of January 1, 2025. STORAGE NAME: h0659c.IBS PAGE: 2
DATE: 1/26/2024
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Statewide Provider and Health Plan Claim Dispute Resolution Program
The Statewide Provider and Health Plan Claim Dispute Resolution Program (Program) assists
contracted and non-contracted providers and managed care organizations with the resolution of claim
disputes.
1
The Agency for Health Care Administration (AHCA) contracts with a third-party resolution
organization (MAXIMUS) for the timely review, consideration, and recommendation for these filed claim
disputes. The Program serves as a modified alternative dispute resolution process for health plans
2
and
providers who have payment disputes. Typically, these payment disputes are between larger facilities
and smaller providers who do not have an existing contractual relationship. The program was designed
to resolve only disputes between providers, health maintenance organizations (HMOs), prepaid health
clinics, exclusive provider organizations, prepaid health plans, medical expense insurance policies,
preferred provider organizations, and Statewide Medicaid Managed Care Plans.
3
The existing contract
language has been repeated in the 2023-2024 re-procurement of the SMMC contracts.
Certain types of claims are excluded from consideration such as those related to interest payments, or
claims that do not meet a minimum aggregate threshold as established by agency rule.
4
A physician or
health care facility filing an appeal must aggregate claims for one or more patients from the same
insurer, which is also referred to as batching of claims.
Claims are also excluded if:
Related to an internal Medicare managed care organization;
Part of a reconsideration of a claim appeal through the Medicare appeals process;
Related to a health plan not regulated in Florida;
Is the basis for an action pending in state or federal court;
Part of a Medicaid Fair Hearing Process pursued under 42 C.F.R. ss. 431.220 et seq.; or,
Is the subject to a binding-claim-dispute-resolution process provided by contract entered into
prior to October 1, 2000, between the provider and managed care organization.
5
MAXIMUS operated a toll-free hotline to provide information and dispute application forms to interested
parties while the contractor. The contract was a “no cost” contract to the state in that MAXIMUS was
paid by the users of the Program. Costs for the Program were to be set by the AHCA through the
rulemaking process. The final rule established that the non-prevailing party would pay the review costs.
If both parties prevailed in parts of the action, then the costs of the review fee are required to be
apportioned based on the final judgement.6
When a claim is received, it is investigated either through a desk review of the documentation
submitted by the parties or sometimes through the involvement of other experts. Either party may call
1
S. 408.7057. F.S.
2
“Health plan” means a health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid
health plan authorized under s. 409.912, an exclusive provider organization certified under s. 627.6472, or a major
medical expense health insurance policy, as defined in s. 627.643(2)(e), offered by a group or an individual health insurer
licensed pursuant to chapter 624, including a preferred provider organization under s. 627.6471. S. 408.7057(1)(b), F.S.
3
Infra, note 10.
4
See 59A-12.030, Statewide Provider and Health Plan Claim Dispute Resolution Program. The jurisdictional threshold
amounts are the minimum, aggregate amount that a claim or claims must total for consideration by the Program. For
health plan contracted hospitals, the threshold is $25,000 and for non-contracted hospitals, the threshold is $10,000.
5
S. 408.7057(2)(b)1.-7, F.S.
6
Rule 59A-12.030(4)(a), F.A.C. STORAGE NAME: h0659c.IBS PAGE: 3
DATE: 1/26/2024
an evidentiary hearing to review the evidence and call witnesses.
7
Each party pays for the costs of their
own witnesses, but the parties share the cost of the hearing equally.
8
The AHCA’s responsibility is to issue a final order adopting the recommendation of the resolution entity.
The failure of the non-prevailing party to pay the ordered review cost within 35 days of the agency’s
order subjects the nonpaying party to a penalty of not more than $500 per day until the penalty is paid.
9
The chart below shows the volume of claims received by the Program and the status of claims at the
end of each reporting year. The total number of claims filed with the system has dramatically increased
in the past two years.
10
Currently, the Program does not have a vendor to process claims. The contract with previous third-
party administrator ended June 30, 2023 and the AHCA has started a new procurement for a
replacement vendor. No new claims are being accepted until a new vendor is in place.
Federal External Review Process
As part of the federal Patient Protection and Affordable Care Act (PPACA), patients were to be
provided both an internal and external appeals process for review of unpaid claims.
11
For states which
did not have an external review process that met those standards or if the individual was in a certain
type of plan such as a self-insured plan, then the federal external review process would apply. Similarly,
for claims disputes between providers and facilities, for disputes between providers and facilities.
12
Standard Health Plan Identification Cards
The No Surprises Act addressed many health care transparency and consumer empowerment
provisions which ensure that the patient receives accurate and up to date information from his or her
insurer on a consistent basis allowing the patient to make better informed health care choices. One
provision included in the No Surprises Act addresses the standard content to be included on every
group or individual health plan identification card whether the card is a physical card or digital.
Current law addresses information on both health plan and prescription benefits cards. For prescription
drug cards, a list of requirements includes the name of the claims processor, the processor’s address
7
59A-12.030, F.A.C.(7).
8
Id.
9
S. 408.7057(5), F.S.
10
Agency for Health Care Administration, Statewide Health Provider and HealthPlan Claim Dispute Resolution Program,
available at https://ahca.myflorida.com/health-care-policy-and-oversight/bureau-of-health-facility-regulation/certificate-of-
need-and-commercial-managed-care-unit/commercial-managed-care/statewide-provider-and-health-plan-claim-dispute-
resolution-program (last visited January 10, 2024). Chart created from data retrieved from individual Annual Reports from
2019 through 2022.
11
Public Law 111-148 (March 10, 2010) and Public Law 111-152 (March 30, 2010).
12
Sec. 340B of the Public Health Service Act (42 U.S.C. 256b) (PHSA), as amended. Highest Claim
(aggregated)
2019 74 45 7 19 $675,209
2020 68 41 13 19 $669,012
2021 111 73 13 19 $2,320,399
2022 563 443 7 19$1,001,694,838
Year
Claims
Received
Claims
Reviewed
Claims
Withdrawn
Claims
Ineligible/
Dismissed
Statewide Provider Health Plan Claim Dispute Program - Trends STORAGE NAME: h0659c.IBS PAGE: 4
DATE: 1/26/2024
and the help desk phone number; the insured’s prescription group number, identification number and
name; and any other information helpful to the timely processing of a claim. Information can be
embedded on the card or through a magnetic stripe.
13
The HMOs must provide information in a readily
identifiable manner or have the information be embedded on the card such that it can be easily
accessed through a magnetic reader or smart card also. The information may also be provided through
other electronic technology.
14
Beginning January 1, 2022, the law required health plans and insurers to include the following minimum
information on the insured’s card:
Any deductible applicable to coverage.
Any out of pocket maximum applicable to the coverage.
A telephone number and website address that individuals can use to find consumer assistance
information and facilities and providers under contract with the plan.
15
Effect of Proposed Changes
Statewide Provider and Health Plan Claim Dispute Resolution Program Authority
The bill requires health plans to participate in the Statewide Provider and Health Plan Claim Dispute
Resolution Program. The proposed changes provide the AHCA with the necessary authority to assess
sanctions on non-responsive participants and to implement final orders once issued. A health plan must
comply with any orders within 35 days, subject to a $500, per day, penalty. If a health plan fails to
timely pay a resolved provider claim, AHCA is required to inform the applicable licensing authority, e.g.,
the Office of Insurance Regulation.
Standard Health Plan Identification Cards
The requirements to incorporate certain standardized components to any hard copy or digital health
insurance benefits card became effective under the No Surprises Act in 2022. The bill enhances those
provisions for any plan subject to state regulation.
For the card, the bill requires:
The letters “FL” on the back, left-hand side of the card; and
A quick response code (QR) on the card which directs the insured or subscriber to a consumer
services website of the Division of Consumer Services of the Department of Financial Services.
On the website, requirements for posting information will depend on the type of plan and may include:
The name of the regulatory entity with relevant contact information, including a telephone
number or website hyperlink; and
A notice that if the letters “FL” are not included, that the plan may not be regulated by the State
of Florida and direct the consumer to the Division of Consumer Services website.
These changes are effective with any identification cards issues or reissued on or after January 1,
2025.
The bill provides an effective date of January 1, 2025.
B. SECTION DIRECTORY:
13
Ch. 627.4302, F.S.
14
Ch. 641.31(42), F.S. Similar provisions for identification cards issued under individual coverage can be found at
627.642, F.S., and at 627.657, F.S. for group health insurance policies.
15
42 U.S.C. 300gg-111(e). STORAGE NAME: h0659c.IBS PAGE: 5
DATE: 1/26/2024
Section 1: Amends s. 408.7057, F.S., relating to statewide provider and health plan claim dispute
resolution program..
Section 2: Amends s. 627.4302, F.S relating to identification cards for processing prescription drug
claims.
Section 3: Amends s. 627.642, F.S. relating to outline of coverage .
Section 4: Amends s. 627.657, F.S. relating to provisions of group health insurance policies.
Section 5: Amends s. 641.31, F.S. relating to health maintenance contracts.
Section 6: Providing an effective date of January 1, 2025.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
The bill authorizes the AHCA to assess a penalty on non-prevailing providers who fail to pay the
required amount within 35 days of a final order. The amount of the penalty must be established by
rule and may not exceed $500 per day. Any fees collected would be additional revenue to the
AHCA. The total amount that could be collected is indeterminate.
16
2. Expenditures:
None.
17
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
If local governments are operating self-funded health coverage, those local governments may incur
costs related to the new identification cards.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
Health plans will incur indeterminable, but likely insignificant, costs associated with reformatting
identification cards and websites to comply with the bill.
18
This is also true for reimbursement disputes
to the extent that they either realize increased payments due upon receipt of a determination or incur
penalties for failure to timely pay awards. Providers who do not prevail in awards may incur
indeterminable costs to the extent that determinations award no additional or lower payments then
those sought, in addition to any penalties for untimely payments of costs awarded against them.
D. FISCAL COMMENTS:
None.
III. COMMENTS
A. CONSTITUTIONAL ISSUES:
1. Applicability of Municipality/County Mandates Provision:
Not applicable. This bill does not appear to affect county or municipal governments.
2. Other:
16
Florida Agency for Health Care Administration, Agency Analysis of 2024 House Bill 659, p. 4 (Dec. 4, 2023).
17
Id.
18
Id. STORAGE NAME: h0659c.IBS PAGE: 6
DATE: 1/26/2024
The federal process has been challenged in different jurisdictions from the amount of the filing fees
to how claims are batched together and reviewed. The federal portal has opened and closed several
times during these different legal challenges and federal CMS has recently re-opened the portal and
began processing claim requests.
B. RULE-MAKING AUTHORITY:
None provided by the bill.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES