This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives.
STORAGE NAME: h1219.IBS
DATE: 1/30/2024
HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: HB 1219 Dental Insurance Claims
SPONSOR(S): Black
TIED BILLS: IDEN./SIM. BILLS: SB 892
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Insurance & Banking Subcommittee Herrera Lloyd
2) Select Committee on Health Innovation
3) Commerce Committee
SUMMARY ANALYSIS
Health insurance serves a vital role in protecting individuals from financial hardships caused by accidents,
illnesses, or disabilities. Managed care, often utilized by health insurers through preferred provider
organizations (PPOs) and health maintenance organizations (HMOs), integrates healthcare delivery and
financing to provide cost-effective medical services within controlled networks.
In Florida, the Office of Insurance Regulation (OIR), overseen by the Financial Services Commission (FSC),
supervises insurance entities, examining insurers and ensuring compliance with regulations, including market
conduct examinations. Both HMOs and Prepaid Limited Health Service Organizations (PLHSOs) operate
within this regulatory framework.
Dental insurance is subject to regulation by OIR and the Department of Financial Services, guaranteeing
adherence to laws and fair practices. Dental plans typically cover preventive care and common procedures,
available through individual or group plans.
The bill, applicable to health insurers, PLHSOs, and HMOs, introduces the following changes:
Prohibits mandating credit card payments as the sole means of reimbursement for dental services,
along with requirements for insurers to provide written notice before electronic fund transfers, and
setting limits on associated fees.
Provides criteria for claims denial under prior authorizations, including circumstances such as benefit
limitations, inadequate documentation, and changes in patient condition.
Mandates enforcement by the OIR, stating certain specified provisions cannot be waived, and any
conflicting clauses are voided.
The bill may have a positive impact on state government revenue and local governments. It has an
indeterminate positive and negative direct economic impact on the private sector and state government
expenditures.
The bill provides an effective date of July 1, 2024.
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DATE: 1/30/2024
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Health Insurance
Health insurance is the insurance of human beings against bodily injury or disablement by accident or
sickness, including the expenses associated with such injury, disablement, or sickness.
1
Individuals
purchase health insurance coverage with the purpose of managing anticipated expenses related to
health or protecting themselves from unexpected medical bills or large health care costs. Managed
care is the most common delivery system for medical care today by health insurers.
2
Managed care
systems combine the delivery and financing of health care services by limiting the choice of doctors
and hospitals.
3
In return for this limited choice, however, medical care is less costly due to the managed
care network’s ability to control health care services. Some common forms of managed care are
preferred provider organizations
4
(PPO) and health maintenance organizations
5
(HMO).
Office of Insurance Regulation
The Office of Insurance Regulation (OIR) regulates specified insurance products, insurers and other
risk bearing entities in Florida.
6
The Financial Services Commission (FSC), composed of the
Governor, the Attorney General, the Chief Financial Officer, and the Commissioner of Agriculture,
serves as the OIR agency head for purposes of rulemaking. Further, the FSC appoints the OIR
Commissioner.
As part of their regulatory oversight, the OIR may suspend or revoke an insurer’s certificate of authority
under certain conditions.
7
The OIR is responsible for examining the affairs, transactions, accounts,
records, and assets of each insurer that holds a certificate of authority to transact insurance business in
Florida.
8
As part of the examination process, all persons being examined must make available to the
OIR the accounts, records, documents, files, information, assets, and matters in their possession or
control that relate to the subject of the examination.
9
The OIR is also authorized to conduct market
conduct examinations to determine compliance with applicable provisions of the Insurance Code.
10
The Agency for Health Care Administration
The Agency for Health Care Administration (AHCA) is the chief health policy and planning entity for the
state.
11
AHCA is responsible for health facilities licensure, inspection, and regulatory enforcement;
investigation of consumer complaints related to health care facilities and managed care plans; the
implementation of the Certificate of Need program; the operation of the Florida Center for Health
Information and Policy Analysis; the administration of the Medicaid program; the administration of the
contracts with the Florida Healthy Kids Corporation; the certification of health maintenance
organizations and prepaid health clinics; and other duties prescribed by statute or agreement.
12
The
head of AHCA is the Secretary, who is appointed by the Governor, subject to confirmation by the
Senate.
13
1
S. 624.603, F.S.
2
Florida Department of Financial Services, Health Insurance and Health Maintenance Organizations, A Guide for Consumers, available
at: https://www.myfloridacfo.com/docs-sf/consumer-services-libraries/ (last visited Jan. 26, 2024).
3
Id.
4
S. 627.6471, F.S.
5
Part I of ch. 641, F.S.
6
S. 20.121(3)(a), F.S.
7
S. 624.418, F.S
8
S. 624, 316(1)(a), F.S.
9
S. 624.318(2), F.S.
10
The Code is comprised of chs. 624-632, 634-636, 641, 642, 648, and 651, F.S. See S. 624.3161, F.S.
11
AHCA, About the Agency for Health Care Administration, https://ahca.myflorida.com/about-the-agency-for-health-care-administration
(last visited Jan. 26, 2024).
12
Id.
13
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Health Maintenance Organizations
Health Maintenance Organizations (HMOs) in Florida operate within a regulatory framework overseen
by OIR. To offer health insurance plans in Florida, HMOs must obtain a license from the OIR.
14
Managed care plans are the primary offerings of HMOs in Florida. These plans provide comprehensive
healthcare services to members for a fixed monthly premium.
15
Members typically select a primary care
physician from within the HMO's network, who serves as the main point of contact for all healthcare
needs and referrals to specialists.
16
HMOs maintain networks of healthcare providers, including primary care physicians, specialists,
hospitals, and other healthcare facilities.
17
Members are generally required to receive care from within
the HMO's network, with exceptions for emergencies or authorized out-of-network care.
18
Florida law provides various consumer protections for individuals enrolled in HMO plans, including
guaranteed access to emergency services, coverage for essential health benefits mandated by the
Affordable Care Act, and the right to appeal coverage decisions made by the HMO.
19
Prepaid Limited Health Service Organizations Contracts
Prepaid limited health service organizations (PLHSO) provide limited health services to enrollees
through an exclusive panel of providers in exchange for a prepayment authorized under ch. 636, F.S.
Limited health services include:
Ambulance;
Dental;
Vision;
Mental health;
Substance abuse;
Chiropractic;
Podiatric; and
Pharmaceutical.
Provider arrangements for prepaid limited health service organizations are authorized in s. 636.035,
F.S., and must comply with the requirements in that section.
Regulation of Dental Practice in Florida
Dental insurance in Florida operates within a regulatory framework overseen by state agencies such as
the OIR and the Florida Department of Financial Services (DFS). These agencies ensure that dental
insurance plans comply with state laws and regulations to protect consumers and ensure fair practices
within the industry.
Dental insurance typically covers a portion of the cost of preventive care, such as routine cleanings and
check-ups, as well as restorative treatments like fillings and extractions.
20
Some plans may also offer
coverage for more extensive procedures like root canals, crowns, and orthodontic treatment, although
coverage levels and limitations can vary widely depending on the specific plan.
21
14
S. 641.21(1), F.S.
15
Medicare, What’s an HMO? https://www.medicare.gov/health-drug-plans/health-plans/. (last visited Jan. 26, 2024).
16
Id.
17
S. 641.19(12), F.S.
18
Medicare, What’s an HMO?, https://www.medicare.gov/health-drug-plans/health-plans/. (last visited Jan. 26, 2024).
19
Consumer Services, Health Insurance & HMO Overview, https://www.myfloridacfo.com/division/consumers/understanding-
insurance/health-insurance-and-hmo-overview (last visited Jan. 26, 2024).
20
HealthPartners, What Does Dental Insurance Cover?, https://www.healthpartners.com/blog/what-does-dental-insurance-cover/ (last
visited Jan. 26, 2024).
21
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Consumers in Florida have the option to purchase dental insurance plans on the individual market or
through group plans offered by employers or other organizations.
22
The availability and cost of dental
insurance coverage can vary depending on factors such as age, location, and the extent of coverage
desired.
23
In addition to traditional dental insurance plans, some Florida residents may also have
access to dental discount plans or health savings accounts (HSAs) that can help offset the cost of
dental care.
24
Dentists
A dentist is licensed to examine, diagnose, treat, and care for conditions within the human oral cavity
and its adjacent tissues and structures.
25
Dentists may delegate certain tasks
26
to dental hygienists and
dental assistants, but a patient’s “dentist of record” retains primary responsibility for all dental treatment
on the patient.
27
Any person wishing to practice dentistry in this state must meet specified requirements and apply to the
Department of Health (DOH) for licensure. Applicants must sit for and pass three examinations prior to
licensure:
28
The National Board of Dental Examiners dental examination (NBDE);
A practical examination, which is the American Dental Licensing Examination developed by the
American Board of Dental Examiners, Inc.;
29
and
A written examination on Florida laws and rules regulating the practice of dentistry and dental
hygiene.
To qualify to take the Florida dental licensure examination, an applicant must be 18 years of age or
older, be a graduate of a dental school accredited by the American Dental Association or be a student
in the final year of a program at an accredited institution, and have successfully completed the NBDE
dental examination.
30
Dentists must maintain professional liability insurance or provide proof of professional responsibility. If
the dentist obtains professional liability insurance, the coverage must be at least $100,000 per claim,
with a minimum annual aggregate of at least $300,000.
31
Alternatively, a dentist may maintain an
unexpired, irrevocable letter of credit in the amount of $100,000 per claim, with a minimum aggregate
availability of credit of at least $300,000.
32
The professional liability insurance must provide coverage
for the actions of any dental hygienist supervised by the dentist.
33
However, a dentist may be exempt
from maintaining professional liability insurance if he or she:
34
Practices exclusively for the federal government or the State of Florida or its agencies or
subdivisions;
Is not practicing in this state;
Practices only in conjunction with his or her teaching duties at an accredited school of dentistry
or in its main teaching hospitals; or
Demonstrates to the Board that he or she has no malpractice exposure in this state.
22
Health Care, Dental Coverage in the Marketplace, https://www.healthcare.gov/coverage/dental-coverage/ (last visited Jan. 26, 2024).
23
Id.
24
MyBenefits, Health Savings Account, https://www.mybenefits.myflorida.com/health/savings_and_spending_accounts (last visited Jan.
26, 2024).
25
S. 466.003(2)-(3), F.S.
26
S. 466.024, F.S.
27
S. 466.018, F.S.
28
S. 466.006, F.S.
29
Rule 64B5-2.013, F.A.C.
30
S. 466.006(2), F.S.
31
Rule 64B5-17.011(1), F.A.C.
32
Rule 64B5-17.011(2), F.A.C.
33
Rule 64B5-17.011(4), F.A.C.
34
Rule 64B5-17.011(3), F.A.C. STORAGE NAME: h1219.IBS PAGE: 5
DATE: 1/30/2024
There are currently 17,193 dentists with active licenses to practice in Florida.
35
There are 41 out-of-
state registered telehealth dentists.
36
Effect of the bill
The bill, which applies to health insurers, Prepaid Limited Health Service Organizations, and Health
Maintenance Organizations (HMOs), regulates payment methods, claims denials, and provider
contracts related to dental insurance reimbursement in Florida.
Regulation of Payment Methods and Notification Requirements
The bill prohibits these entities from mandating credit card payment as the sole method of reimbursing
dentists for services provided to insured individuals. Additionally, it establishes a requirement for
insurers to provide written notice to dentists at least ten days prior to making payments through
electronic funds transfer, outlining any associated fees and presenting alternative payment methods
with clear instructions for selection. The bill imposes limitations on the fees that insurers can charge
dentists for transmitting payments through Automated Clearing House transfers, while permitting
reasonable fees for related value-added services.
Criteria for Denial of Subsequently Submitted Claims under Prior Authorization
The bill prohibits denials on any claim subsequently submitted by a dentist licensed under ch. 466 for
procedures specifically included in a prior authorization, unless certain circumstances apply for each
denied procedure. These circumstances include:
benefit limitations being reached subsequent to the issuance of the prior authorization;
inadequate documentation to support the originally authorized claim;
changes in the patient's condition or provision of new procedures post-authorization that render
the prior authorized procedure medically unnecessary;
changes in the patient's condition or provision of new procedures that would have required
disapproval under the terms and conditions of the patient's plan at the time of prior
authorization; or
denial due to reasons such as responsibility of another payor for payment, prior payment to the
dentist for the procedures in question, fraudulent claim submission, or patient ineligibility at the
time of service.
Regulation of Fee Determination and Definition of Covered Services in Provider Contracts
The bill clarifies the term “covered services” to improve readability and understandability.
Enforcement and Non-Waiver Provisions
Additionally, the bill specifies that these provisions cannot be waived or nullified by contract, and any
contractual clause conflicting with it is considered null and void. Enforcement authority is granted to the
OIR, and the FSC may adopt rules for implementation.
The bill provides an effective date of July 1, 2024.
B. SECTION DIRECTORY:
Section 1: Amends s. 627.6131, F.S., relating to payment of claims.
Section 2: Amends s. 627.6474, F.S., relating to provider contracts.
Section 3: Amends s. 636.032, F.S., relating to acceptable payments.
35
See, Department of Health License Verification web search. Available at https://mqa-
internet.doh.state.fl.us/MQASearchServices/HealthCareProviders (last visited January 26, 2024).
36
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Section 4: Amends s. 636.035, F.S., relating to provider agreements
Section 5: Amends s. 641.315, F.S., relating to provider contracts.
Section 6: Providing an effective date of July 1, 2024.
II. FISCAL ANALYSIS & ECONOMIC IMPACT STATEMENT
A. FISCAL IMPACT ON STATE GOVERNMENT:
1. Revenues:
None.
2. Expenditures:
The bill may positively affect state government expenditures by potentially reducing administrative
costs associated with overseeing dental insurance reimbursement and managing disputes related
to claims denials.
However, there could also be negative impacts on state government expenditures. For example, if
the bill increases regulatory oversight or enforcement activities by state agencies such as OIR, it
could result in additional administrative costs for the government. Moreover, if the provisions lead to
an increase in appeals or legal challenges related to denied claims, it could necessitate additional
resources for adjudication processes, potentially adding to state expenditures.
Furthermore, an increase in premium costs for state agencies providing primary dental coverage,
resulting from reimbursement requirements stipulated in the bill, could adversely affect state
government expenditures.
B. FISCAL IMPACT ON LOCAL GOVERNMENTS:
1. Revenues:
None.
2. Expenditures:
The bill could negatively impact local government expenditures due to potential increases in
premium costs for state agencies providing primary dental coverage, resulting from the
reimbursement requirements outlined in the bill.
C. DIRECT ECONOMIC IMPACT ON PRIVATE SECTOR:
The bill may have an indeterminate economic impact on the private sector. While the bill establishes
specific criteria for claims denial and service coverage, which could improve clarity for providers,
compliance may result in costs. These costs include investments in systems and staff training by
insurers, PLHSOs, and HMOs to ensure compliance.
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.
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2. Other:
None.
B. RULE-MAKING AUTHORITY:
None.
C. DRAFTING ISSUES OR OTHER COMMENTS:
None.
IV. AMENDMENTS/COMMITTEE SUBSTITUTE CHANGES