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 CS/CS/HB1219CS/HB1219 2024 A bill to be entitled An act relating to dental insurance claims;
requiring a health insurer to notifymake acertain dentistnotifications ifbefore initiatingpaying ora changingclaim electronicto fundsa transferdentist paymentthrough methodselectronic forfunds dentaltransfer; claims;
prohibiting a health insurer from charging a fee to transmit a payment to a dentist through anACH automated clearinghouse transfer unless the dentist has consented to such fee;
authorizingproviding aconstruction; health insurer to charge certain fees;
providing applicability;
providing applicability;construction;
627.6474, F.S.;
revising the definition of the term "covered services";
amending s.
requiring athe prepaid limited health service organization to notifymake acertain notifications Page 1of 1314 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 dentistbefore ifpaying initiatinga orclaim changingto electronica fundsdentist transferthrough paymentelectronic methodsfunds fortransfer; dental claims;
prohibiting a prepaid limited health service organization from charging a fee to transmit a payment to a dentist through anACH automated clearinghouse transfer unless the dentist has consented to such fee;
authorizingproviding aconstruction; prepaid limited health service organization to charge certain fees;
providing applicability;
revising the definition of the term "covered services";
providing applicability;construction;
authorizing the office to enforce certain provisions;
authorizing the commission to adopt rules;
revising the definition of the term "covered service";
requiring athe health maintenance organization to notifymake acertain dentistnotifications ifbefore initiatingpaying ora changingclaim electronicto fundsa transferdentist paymentthrough methodselectronic forfunds dentaltransfer; claims;
prohibiting a health maintenance organization from charging a fee to transmit a payment to a dentist through anACH automated clearinghouse transfer unless the dentist has consented to such fee;
authorizingproviding aconstruction; health maintenance organization to Page 2of 13 CODING:
Page 2of 14 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 chargeauthorizing the office to enforce certain fees;provisions;
providing applicability;
authorizing the office to enforce certain provisions;
providing applicability;construction;
627.6131 Payment of claims.— (20)(a) A contract between a health insurer and a dentist licensed under chapter 466 for the provision of services to an insured may not requirespecify credit card payment as the only acceptable method for payments from the health insurer to the dentist.
(b) IfAt initiatingleast or10 changingdays paymentsbefore a health insurer pays a claim to a dentist usingthrough electronic funds transfertransfer, payments, including, but not limited to, virtual credit card payments, athe health insurer shall notify the dentist in writing of all of the following:
The fees, if any, associated with the electronic funds Pagetransfer. 3of 13 CODING:
Page 3of 14 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 transfer.2.
2.The available methods of payment of claims by the health insurer, with clear instructions to the dentist on how to select an alternative payment method.
The(c) availableA methodshealth ofinsurer paymentthat ofpays claimsa byclaim theto healtha insurer,dentist withthrough clearAutomated instructionsClearing House (ACH) transfer may not charge a fee solely to transmit the dentistpayment onto howthe todentist selectunless anthe alternativedentist paymenthas method,consented ifto any.the fee.
(c)(d) AThis healthsubsection insurermay thatnot paysbe awaived, claimvoided, toor anullified dentistby throughcontract, anand automatedany clearinghousecontractual transferclause mayin notconflict chargewith athis feesubsection solelyor towhich transmitpurports the payment to thewaive dentistany unlessrequirements theof dentistthis hassubsection consentedis tonull theand fee.void.
A health insurer may charge reasonable fees for value-added services related to the transfer, including, but not limited to, transaction management, data management, and portal services.
(d) This subsection applies to contracts delivered, issued, or renewed on or after January 1, 2025.
Benefit limitations, such as annual maximums and frequency limitations not applicable at the time of the prior authorization, are reached subsequent to issuance of the prior Pageauthorization. 4of 13 CODING:
2.
The documentation provided by the person submitting the Page 4of 14 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 authorization.claim fails to support the claim as originally authorized.
2.
The documentation provided by the person submitting the claim fails to support the claim as originally authorized.
Subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care.
The person receiving the procedure was not eligible to receive the procedure on the date of service.service, and the health insurer did not know, and with the exercise of reasonable care could not have known, of his or her ineligibility.
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hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 e.(b) This subsection may not be waived, voided, or nullified by contract, and any contractual clause in conflict with this subsection or which purports to waive any requirements of this subsection is null and void.
The services were provided during the grace period established under s.
627.608 or applicable federal regulations, and the health insurer notified the dentist that the patient was in the grace period when the dentist requested eligibility or enrollment verification from the health insurer, if such request was made.
(b) This subsection applies to contracts delivered, issued, or renewed on or after January 1, 2025.
SectionSubsection 636.032,(2) of section 627.6474, Florida Statutes, is amended to read:
636.032627.6474 AcceptableProvider payments.—contracts.— (1)(2) EachA prepaidcontract limitedbetween a health serviceinsurer organizationand maya acceptdentist fromlicensed governmentunder agencies,chapter corporations,466 groups,for orthe individualsprovision paymentsof coveringservices allto oran partinsured ofmay thenot costcontain ofa contractsprovision enteredthat intorequires betweenthe dentist to provide services to the prepaidinsured limitedunder such contract at a fee set by the health serviceinsurer organizationunless andsuch itsservices subscribers.are covered services under the applicable contract.
(2)(a)As Aused contractin betweenthis asubsection, prepaidthe limitedterm health"covered serviceservices" organizationmeans anddental care services for which a dentistreimbursement licensedis available under chapterthe 466insured's contract, notwithstanding or for thewhich provisiona ofreimbursement serviceswould tobe aavailable subscriberbut mayfor notthe requireapplication creditof cardcontractual paymentlimitations, such as thedeductibles, onlycoinsurance, acceptablewaiting methodperiods, forannual paymentsor fromlifetime themaximums, prepaidfrequency limitedlimitations, healthalternative servicebenefit organizationpayments, toor theany dentist.other limitation.
PageSection 6of3. 13 CODING:
Section 636.032, Florida Statutes, is amended Page 6of 14 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 (b) If initiating or changing payments to aread: dentist using electronic funds transfer payments, including, but not limited to, virtual credit card payments, a prepaid limited health service organization shall notify the dentist in writing of all of the following:
636.032 Acceptable payments.— (1) Each prepaid limited health service organization may accept from government agencies, corporations, groups, or individuals payments covering all or part of the cost of contracts entered into between the prepaid limited health service organization and its subscribers.
(2)(a) A contract between a prepaid limited health service organization and a dentist licensed under chapter 466 for the provision of services to a subscriber may not specify credit card payment as the only acceptable method for payments from the prepaid limited health service organization to the dentist.
(b) At least 10 days before a prepaid limited health service organization pays a claim to a dentist through electronic funds transfer, including, but not limited to, virtual credit card payments, the prepaid limited health service organization shall notify the dentist in writing of all of the following:
The available methods of payment of claims by the prepaid limited health service organization, with clear instructions to the dentist on how to select an alternative payment method,method. if any.
(c) A prepaid limited health service organization that paysPage a7of claim14 toCODING: a dentist through an automated clearinghouse transfer may not charge a fee solely to transmit the payment to the dentist unless the dentist has consented to the fee.
AWords prepaidstrickenare limiteddeletions; health service organization may charge reasonable fees for value-added services related to the transfer, including, but not limited to, transaction management, data management, and portal services.
(d)words Thisunderlined subsectionare appliesadditions. to contracts delivered, issued, or renewed on or after January 1, 2025.
hb1219-01-c1 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 CS/HB1219 2024 pays a claim to a dentist through Automatic Clearing House (ACH) transfer may not charge a fee solely to transmit the payment to the dentist unless the dentist has consented to the fee.
(d) This subsection may not be waived, voided, or nullified by contract, and any contractual clause in conflict with this subsection or which purports to waive any requirements of this subsection is null and void.
PageSection 7of4. 13 CODING:
Subsection (13) of section 636.035, Florida Statutes, is amended, and subsection (15) is added to that section, to read:
636.035 Provider arrangements.— (13) A contract between a prepaid limited health service organization and a dentist licensed under chapter 466 for the provision of services to a subscriber of the prepaid limited health service organization may not contain a provision that requires the dentist to provide services to the subscriber of the prepaid limited health service organization at a fee set by the prepaid limited health service organization unless such services are covered services under the applicable contract.
As used in this subsection, the term "covered services" means dental care services for which a reimbursement is available Page 8of 14 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 Sectionunder 3.the subscriber's contract, notwithstanding or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
Subsection(15)(a) (15)A isprepaid addedlimited tohealth sectionservice 636.035,organization Floridamay Statutes,not todeny read:any claim subsequently submitted by a dentist licensed under chapter 466 for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:
636.035 Provider arrangements.— (15)(a) A prepaid limited health service organization may not deny any claim subsequently submitted by a dentist licensed under chapter 466 for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:
Subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care.
Subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition occurs such that the prior authorized procedurePage would9of at14 thatCODING: time have required disapproval pursuant to the terms and conditions for coverage under the patient's plan in effect at the time the prior authorization was issued.
Page 8of 13 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 5.procedure would at that time have required disapproval pursuant to the terms and conditions for coverage under the patient's plan in effect at the time the prior authorization was issued.
5.
The person receiving the procedure was not eligible to receive the procedure on the date of service.service, and the prepaid limited health service organization did not know, and with the exercise of reasonable care could not have known, of his or her ineligibility.
e.(b) This subsection may not be waived, voided, or nullified by contract, and any contractual clause in conflict with this subsection or which purports to waive any requirements of this subsection is null and void.
(c) The servicesoffice werehas providedall duringrights theand gracepowers periodto establishedenforce underthis subsection as provided by s.
636.016624.307. or applicable federal regulations, and the prepaid limited health service organization notified the dentist that the patient was in the grace period when the dentist requested eligibility or enrollment verification from the prepaid limited health service organization, if such request was made.
(b)(d) ThisThe subsectioncommission appliesmay toadopt contractsrules delivered,to issued,implement orthis renewedPage on10 orof14 afterCODING: January 1, 2025.
Section 4.
Subsections (13) and (14) are added to section 641.315, Florida Statutes, to read:
641.315 Provider contracts.— (13)(a) A contract between a health maintenance Page 9of 13 CODING:
hb1219-02-c2hb1219-01-c1 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 CS/CS/HB1219CS/HB1219 2024 organizationsubsection. and a dentist licensed under chapter 466 for the provision of services to a subscriber of the health maintenance organization may not require credit card payment as the only acceptable method for payments from the health maintenance organization to the dentist.
(b)Section If5. initiating or changing payments to a dentist using electronic funds transfer payments, including, but not limited to, virtual credit card payments, a health maintenance organization shall notify the dentist in writing of all of the following:
Subsection (11) of section 641.315, Florida Statutes, is amended, and subsections (13) and (14) are added to that section, to read:
641.315 Provider contracts.— (11) A contract between a health maintenance organization and a dentist licensed under chapter 466 for the provision of services to a subscriber of the health maintenance organization may not contain a provision that requires the dentist to provide services to the subscriber of the health maintenance organization at a fee set by the health maintenance organization unless such services are covered services under the applicable contract.
As used in this subsection, the term "covered services" means dental care services for which a reimbursement is available under the subscriber's contract, notwithstanding or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
(13)(a) A contract between a health maintenance organization and a dentist licensed under chapter 466 for the provision of services to a subscriber of the health maintenance organization may not specify credit card payment as the only acceptable method for payments from the health maintenance Page 11 of14 CODING:
Words strickenare deletions;
words underlined are additions.
hb1219-01-c1 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 CS/HB1219 2024 organization to the dentist.
(b) At least 10 days before a health maintenance organization pays a claim to a dentist through electronic funds transfer, including, but not limited to, virtual credit card payments, the health maintenance organization shall notify the dentist in writing of all of the following:
The available methods of payment of claims by the health maintenance organization, with clear instructions to the dentist on how to select an alternative payment method,method. if any.
(c) A health maintenance organization that pays a claim to a dentist through anAutomated automatedClearing clearinghouseHouse (ACH) transfer may not charge a fee solely to transmit the payment to the dentist unless the dentist has consented to the fee.
A(d) healthThis maintenancesubsection organization may chargenot reasonablebe feeswaived, forvoided, value-or addednullified servicesby relatedcontract, toand theany transfer,contractual including,clause butin notconflict limitedwith to,this transactionsubsection management,or datawhich management,purports andto portalwaive services.any requirements of this subsection is null and void.
(d)(e) ThisThe subsectionoffice applieshas toall contractsrights delivered,and issued,powers orto renewedenforce onthis orsubsection afteras Januaryprovided 1,by 2025.s.
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words underlined are additions.
hb1219-02-c2 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 CS/CS/HB1219 2024 (e) The office has all rights and powers to enforce this subsection as provided by s.
(14)(a) A health maintenance organization may not deny any claim subsequently submitted by a dentist licensed under chapter 466Page for12 proceduresof14 specificallyCODING: included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:
Words strickenare deletions;
words underlined are additions.
hb1219-01-c1 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 CS/HB1219 2024 466 for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:
Subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition of the patient occurs such that the prior authorized procedure would no longer be considered medically necessary, based on the prevailing standard of care.
Subsequent to the issuance of the prior authorization, new procedures are provided to the patient or a change in the patient's condition occurs such that the prior authorized procedure would at that time have required disapproval pursuant to the terms and conditions for coverage under the patient's Pageplan 11in of13effect CODING:at the time the prior authorization was issued.
Words strickenare deletions;
words underlined are additions.
hb1219-02-c2 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 CS/CS/HB1219 2024 plan in effect at the time the prior authorization was issued.
c.Page 13 of14 CODING:
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words underlined are additions.
hb1219-01-c1 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 CS/HB1219 2024 c.
The person receiving the procedure was not eligible to receive the procedure on the date of service.service, and the health maintenance organization did not know, and with the exercise of reasonable care could not have known, of his or her ineligibility.
e.(b) The subsection may not be waived, voided, or nullified by contract, and any contractual clause in conflict with this subsection or which purports to waive any requirements of this subsection is null and void.
The services were provided during the grace period established under s.
641.31 or applicable federal regulations, and the health maintenance organization notified the dentist that the patient was in the grace period when the dentist requested eligibility or enrollment verification from the health maintenance organization, if such request was made.
(b) This subsection applies to contracts delivered, issued, or renewed on or after January 1, 2025.
PageSection 126. of13 CODING:
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words underlined are additions.
hb1219-02-c2 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 CS/CS/HB1219 2024 Section 5.
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hb1219-02-c2hb1219-01-c1