HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/CS/HB 1219 Dental Insurance Claims
SPONSOR(S): Health & Human Services Committee, Insurance & Banking Subcommittee, Black
TIED BILLS: IDEN./SIM. BILLS: CS/CS/SB 892
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Insurance & Banking Subcommittee 17 Y, 0 N, As CS Herrera Lloyd
2) Health & Human Services Committee 19 Y, 0 N, As CS Lloyd Calamas
3) Commerce Committee 16 Y, 0 N Herrera Hamon
SUMMARY ANALYSIS
Health insurance serves a vital role in protecting individuals from financial hardships caused by accidents,
illnesses, or disabilities. Health insurers and health care providers often interact with one another prior to the
delivery of care. An initial interaction often involves a provider seeking verification from an insurer that a patient
has active insurance coverage.
Dental insurance is subject to regulation by the Office of Insurance Regulation (OIR) and the Department of
Financial Services (DFS) for adherence to insurance laws and fair practices and by the Agency for Health Care
Administration (AHCA) for quality of care issues.
The federal Patient Protection and Affordable Care Act (Act) also provides consumer protections to those
individuals who purchase qualified health plans, and receive a federal premium tax credit towards that
coverage. These individuals also are eligible for extended grace periods for non-payment of premiums. Federal
regulations require coverage of services during a portion of that grace period.
If patients seek services for which they are not currently covered, the claim may be denied. For example, a
patient may seek services prior to that patient’s coverage effective date, after coverage terminates, or during
grace period when a patient has not yet paid the premium. A provider may have also verified that the patient
had coverage, provided services based on that verification, and in some cases, already received payment from
the insurer. Retroactive denials can result in the provider or the patient covering the financial costs, despite a
verification of eligibility.
The bill regulates dental services claims payment contract terms for insurers, including prepaid limited health
service organizations (PLHSOs), preferred provider organizations (PPOs), exclusive provider organizations
(EPOs), and health maintenance organizations (HMOs). The bill will:
Prohibit mandating credit card payments as the sole means of reimbursement for dental services.
Require written notice by insurers to dental providers of the initiation or change in payment methods or
fees for electronic fund transfers.
Allow the insurer to deny claims if the services were provided during the premium non-payment grace
period and the insurer informed the provider of such in response to an eligibility inquiry.
Establishes criteria for other claims denial under prior authorizations under specific circumstances.
Mandates OIR enforcement of claims payment provisions.
Establishes an application date for all contractual changes required by the bill as the date of the next
issuance, delivery, or renewal date of the impacted contract.
The bill may have a positive impact on state government revenue and local governments. It has an
indeterminate economic impact on the private sector and state government expenditures.
The bill provides an effective date of July 1, 2024.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
STORAGE NAME: h1219e.COM
DATE: 2/23/2024
FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
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 and protecting themselves from unexpected medical bills or large health care costs. Many
individuals access health care coverage as a benefit of employment where the employer may
contribute towards the cost of the employee’s coverage while others may purchase coverage directly
from an insurance company or from places like the Act’s marketplace. 2 Health insurance may be
purchased on an individual basis or for an entire family.
Managed Care
Managed care is the most common delivery system for medical care today by health insurers. 3
Managed care systems combine the delivery and financing of health care services by limiting the
choice of doctors and hospitals.4 In return for this limited choice, however, medical care is usually less
costly to the patient due to lower out of pocket costs and the managed care network’s ability to control
the cost and utilization of health care services. Some common forms of managed care are preferred
provider organizations 5 (PPOs), exclusive provider organizations (EPOs),6 and health maintenance
organizations 7 (HMOs). For services to be covered at the lowest out of pocket cost to the insured, the
insured must utilize the managed care plan’s network of providers, except in cases of an emergency.
Different managed care companies have a variety of network and out of pocket cost arrangements
based on an individual’s or family’s needs.
Office of Insurance Regulation
The Office of Insurance Regulation (OIR) regulates specified insurance products, insurers and other
risk bearing entities in Florida, as well as licensing, rates, policy forms, market conduct, claims,
issuances of certificates of authority, solvency, viatical statements, premium financing, and
administrative supervision, as provided under the Florida Insurance Code.8 .The OIR is also authorized
to conduct market conduct examinations to determine compliance with applicable provisions of the
Insurance Code.9 For managed care entities to receive a license from OIR, the entity must meet
financial guidelines, benefits, and policy standards as established under ch. 690.154, F.A.C.
The Agency for Health Care Administration
1 S. 624.603, F.S.
2 See Healthcare.gov, How to apply and enroll, Apply for Health Insurance | HealthCare.gov (last visited Feb. 12, 2024).
3 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).
4 Id.
5 S. 627.6471, F.S.
6 S. 627.6472, F.S.
7 Part I of ch. 641, F.S.
8 S. 20.121(3)(a), F.S.
9 The Code is comprised of chs. 624-632, 634-636, 641, 642, 648, and 651, F.S. See S. 624.3161, F.S.
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The Agency for Health Care Administration (AHCA) is the chief health policy and planning entity for the
state,10 and regulates the quality of care provided by managed care organizations under ch. 408, F.S.
Health Maintenance Organizations
Health Maintenance Organizations (HMOs) operate within a regulatory framework dually overseen by
the OIR and AHCA. To offer a commercial health insurance plan in Florida, an HMO must obtain a
license from the OIR11 and a Certificate of Authority from AHCA. An HMO is also required to become
accredited by one of the state’s approved organizations: National Committee for Quality Assurance,
National Association for Ambulatory Health Care, and American Accreditation HealthCare
Commission.12 Certificates of authority are granted by AHCA, if found to be compliant with the
certification process, on a county by county basis or for a portion of a county. 13
Most managed care enrollment in Florida is through an HMO. For the last quarterly submission to
AHCA in September 2023, Florida HMOs reported over 8.2 million enrollees as shown in the table
below.14
HMO Enrollment
Group Type Third Qtr 2023
Small Group 203,821
Large Group 476,358
Individual 1,909,616
Other 8,559
Healthy Kids 109,385
Medicaid 3,763,314
Medicare 1,763,708
Federal Employees 6,207
GRAND TOTAL: 8,240,968
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, for services to be covered.18
10 AHCA, Ab out the Agency for Health Care Administration, https://ahca.myflorida.com/about-the-agency-for-health-care-administration
(last visited Jan. 26, 2024).
11 S. 641.21(1), F.S.
12 Agency for Health Care Administration, Health Care Provider Certificate Process, Health Care Provider Certificate Process
(myflorida.com) (last visited Feb. 13, 2024).
13 Id.
14 Florida Office of Insurance Regulation, Managed Care Report: Quarterly Data Summary as of Septemb er 30, 2023, managed-care-
report-2023-q3-15dec2023.pdf (floir.com) (last visited Feb. 13, 2024).
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).
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Florida law, under ch. 641, F.S., provides various consumer protections, including guaranteed access
to emergency services, coverage for essential health benefits 19 mandated by the Act,20 and the right to
appeal coverage decisions made by the HMO.21
Prepaid Limited Health Service Organizations
Prepaid limited health service organizations (PLHSOs) 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 PLHSOs are authorized in s. 636.035, F.S., and must comply with the
requirements in that section.
Preferred Provider Organizations
Authorized under ch. 627, F.S., a preferred provider organization (PPO) includes those licensed health
insurers who have contracted with providers or a group of providers, directly or indirectly for an
alternative or reduced rate of payment to provide a list of covered services to policyholders under the
insurer’s plan.22 A PPO provider must distribute to its policyholders a list of preferred providers and
make the list available on its website. Insureds have a choice of who may provide their services, but
usually pay a lower deductible and less other out of pockets costs if they choose a preferred provider. 23
Exclusive Provider Organizations
Exclusive provider organizations (EPOs) are another form of managed care that is also dually regulated
by the OIR and the AHCA. Regulated under chapter 627, F.S., an EPO is a group of providers who
have signed written contracts with an insurer to provide services to the insured’s subscribers. Before
the EPO can issue a policy; however, the AHCA must issue a Certificate of Authority which specifically
includes approval of the EPO’s plan of operation. In addition to a plan of operation, an EPO must
maintain a quality assurance program and the ability to resolve complaints and grievances from its
subscribers.24
Dental Insurance Plans
19 Under the Patient Protection and Affordable Care Act, all non -grandfathered plans in the non-group and small group private health
insurance markets must offer a core package of health insurance services known as the essential health benefits (EHBs). While not
specifying the details of these benefits and services, there are ten general categ ories including coverage for pediatric dental services.
Adult dental benefits are not an essential health benefit. See Essential Health Benefits, Healthcare.gov, Find out what Marketplace
health insurance plans cover | HealthCare.gov (last visited Feb. 13, 2024).
20 Patient Protection and Affordable Care Act, (March 23, 2010), P.L. 111 -141, as amended.
21 Consumer Services, Health Insurance & HMO Overview, https://www.myfloridacfo.com/division/consumers/understanding-
insurance/health-insurance-and-hmo-overview (last visited Feb. 12, 2024).
22 S. 627.6471, F.S.
23 Supra, note 30.
24 Agency for Health Care Administration, Exclusive Provider Organizations (EPOs), Exclusive Provider Organizations (EPOs)
(myflorida.com) (last visited Feb. 12, 2024).
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Dental insurance is a contract with an insurance company which provides benefits that can help lower
the costs of dental treatment.25 In exchange for a premium paid, dental insurance typically covers the
cost of preventive care, such as routine cleanings and check-ups, but other care such as restorative
treatments like fillings and extractions is usually covered at lower percentage rates, such as 80 percent,
requiring higher out of pocket costs by the patient.26 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.27 Many dental plans may also impose an
annual benefit maximum (dollar amount).
Consumers in Florida have the option to purchase dental insurance plans on the individual market or
through group plans offered by employers, other organizations, or on the Act’s marketplace.28 An Act’s
dental plan cannot be purchased separately; it can only be purchased if a health plan is bought at the
same time.29 Some of the marketplace plans offer health plans which include dental benefits under a
single premium amount. For children aged 18 or younger, dental coverage is an essential health benefit
and therefore, dental coverage must be available either as part of the health plan or offered as a
separate plan. While dental coverage must be available to children, it is not required that it be
purchased.30
The availability and cost of dental insurance coverage can vary depending on factors such as age,
location, and the extent of coverage desired.31 In addition to traditional dental insurance plans, some
employees may also have access to dental discount plans, health reimbursement accounts, flexible
spending accounts, or health savings accounts (HSAs) that can help employees save for major and
minor dental expenses and offset the cost of dental care.32 Some of these options allow employees to
deposit funds pre-tax through pay-roll deductions to potentially receive a tax break on predictable out of
pocket costs.
Insurer Contracts with Dentists
A contract between an insurer and dentist licensed under ch. 466, F.S., for the provision of services to
a subscriber of the HMO, PPO, PLHSO, or other insurer may not require the dentist to provide services
to the subscriber of the HMO at a fee set by the HMO unless such services are covered services under
the applicable contract.33 The term “covered services” means dental care services for which a
reimbursement is available under the subscriber’s contract, 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.34 Currently, if an insured patient exhausts his benefits or reaches a limitation, but the contract
is still active, the dental patient is entitled to pay the price negotiated between the plan and the dental
provider for that covered service, not a fee unilaterally set by the dental provider.
Health Insurance Contracts
All health insurance policies issued in the state of Florida, with the exception of certain self-insured
policies,35 must meet certain requirements that are detailed throughout the Florida Insurance Code. A