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
HB 1605 2023
1 A bill to be entitled
2 An act relating to dental payments under health
3 insurance plans; amending s. 627.6131, F.S.;
4 prohibiting certain restrictions on payment methods by
5 individual health insurers to dentists; providing
6 requirements if certain payment methods are initiated
7 or changed; prohibiting fees for payment transmittals;
8 providing exceptions; prohibiting waivers; requiring
9 enforcement; prohibiting denials of certain claims
10 under specified circumstances; providing exceptions;
11 amending s. 627.6474, F.S.; revising the definition of
12 the term "covered services"; creating s. 627.65772,
13 F.S.; prohibiting certain restrictions on payment
14 methods by group health insurers to dentists;
15 providing requirements if certain payment methods are
16 initiated or changed; prohibiting fees for payment
17 transmittals; providing exceptions; requiring
18 enforcement of violations; prohibiting denials of
19 certain claims under specified circumstances;
20 providing exceptions; prohibiting waivers; amending s.
21 636.035, F.S.; revising the definition of the term
22 "covered services"; prohibiting certain restrictions
23 on payment methods by prepaid limited health service
24 organizations to dentists; providing requirements if
25 certain payment methods are initiated or changed;
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HB 1605 2023
26 prohibiting fees for payment transmittals; providin g
27 exceptions; prohibiting waivers; requiring
28 enforcement; prohibiting denials of certain claims
29 under specified circumstances; providing exceptions;
30 amending s. 641.315, F.S.; prohibiting certain
31 restrictions on payment methods by health maintenance
32 organizations to dentists; providing requirements if
33 certain payment methods are initiated or changed;
34 prohibiting fees for payment transmittals; providing
35 exceptions; prohibiting waivers; requiring
36 enforcement; prohibiting denials of certain claims
37 under specified circumstances; providing exceptions;
38 providing an effective date.
39
40 Be It Enacted by the Legislature of the State of Florida:
41
42 Section 1. Subsections (20) and (21) are added to section
43 627.6131, Florida Statutes, to read:
44 627.6131 Payment of claims.—
45 (20)(a) A contract between a health insurer and a dentist
46 licensed under chapter 466 for the provision of dental services
47 to an insured may not contain restrictions by the health insurer
48 or its contracted vendor on methods of payment by the health
49 insurer or its contracted vendor to the dentist in which the
50 only acceptable payment method is by credit card.
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51 (b)1. If initiating or changing payment methods to a
52 dentist to payments by electronic funds transfers, including
53 virtual credit card payments, a health insurer under its dental
54 benefit plan or a health insurer's contracted vendor must:
55 a. Notify the dentist if any fees are associated with a
56 particular payment method.
57 b. Advise the dentist of the available payment methods and
58 provide clear instructions to the dentist as to how to select an
59 alternative payment method.
60 2. If initiating or changing payments to a dentist to
61 payments through the Automated Clearing House network, as
62 provided under 45 C.F.R. ss. 162.1601 and 162.1602, a health
63 insurer under its dental benefit plan or a health insurer's
64 contracted vendor may not charge a fee solely to transmit the
65 payment to the dentist, unless the dentist has consented to the
66 fee. However, a dentist's agent may charge the dentist
67 reasonable fees when transmitting an Automated Clearing House
68 network payment related to transaction management, data
69 management, portal services, and other value-added services in
70 addition to the bank transmittal.
71 (c) The provisions of this subsection may not be waived by
72 contract. A contractual clause that is in conflict with this
73 subsection or that purports to waive any requirement of this
74 subsection is void.
75 (d) The commission shall enforce this subsection.
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HB 1605 2023
76 (21)(a) A health insurer providing coverage for dental
77 services may not deny a claim submitted by a dentist licensed
78 under chapter 466 for a procedure specifically included in a
79 prior authorization unless at least one of the following
80 circumstances applies:
81 1. Benefit limitations such as annual maximums and
82 frequency limitations not applicable at the time of the prior
83 authorization are reached due to use after issuance of the prior
84 authorization.
85 2. If, after issuance of the prior authorization, a new
86 procedure is provided to the patient or a change in the
87 condition of the patient occurs such that the prior authorized
88 procedure would:
89 a. No longer be considered medically necessary, based on
90 the prevailing standard of care; or
91 b. At the time of the use of the procedure, require denial
92 of authorization under the terms and conditions for coverage
93 under the patient's plan in effect at the time the prior
94 authorization was used.
95 3. The patient receiving the procedure was not eligible to
96 receive the procedure on the date of service, and the dentist
97 did not know, and with the exercise of reasonable care could not
98 have known, of the patient's eligibility status.
99 4. Another payer is responsible for the payment.
100 5. The dentist has already been paid for the procedure
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101 identified on the claim.
102 6. The documentation for the claim provided by the person
103 submitting the claim clearly fails to support the claim as
104 originally authorized.
105 7. The claim was submitted fraudulently, or the prior
106 authorization was based in whole or material part on erroneous
107 information provided by the dentist, the patient, or any other
108 person not related to the health insurer.
109 (b) The provisions of this subsection may not be waived by
110 contract. A contractual clause that is in conflict with this
111 subsection or that purports to waive any requirement of this
112 subsection is void.
113 Section 2. Subsection (2) of section 627.6474, Florida
114 Statutes, is amended to read:
115 627.6474 Provider contracts.—
116 (2) A contract between a health insurer and a dentist
117 licensed under chapter 466 for the provision of services to an
118 insured may not contain a provision that requires the dentist to
119 provide services to the insured under such contract at a fee set
120 by the health insurer unless such services are covered services
121 under the applicable contract. As used in this subsection, the
122 term "covered services" means dental care services for which a
123 reimbursement is available under the insured's contract,
124 excluding or for which a reimbursement would be available but
125 for the application of contractual limitations such as
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126 deductibles, coinsurance, waiting periods, annual or lifetime
127 maximums, frequency limitations, alternative benefit payments,
128 or any other limitation.
129 Section 3. Section 627.65772, Florida Statutes, is created
130 to read:
131 627.65772 Payment methods for dental services; claim
132 payment denials.—
133 (1)(a) A contract between a health insurer and a dentist
134 licensed under chapter 466 for the provision of dental services
135 to an insured may not contain restrictions by the health insurer
136 or its contracted vendor on methods of payment by the health
137 insurer or its contracted vendor to the dentist in which the
138 only acceptable payment method is by credit card.
139 (b)1. If initiating or changing payment methods to a
140 dentist to payments by electronic funds transfers, inclu ding
141 virtual credit card payments, a health insurer under its dental
142 benefit plan or a health insurer's contracted vendor must:
143 a. Notify the dentist if any fees are associated with a
144 particular payment method.
145 b. Advise the dentist of the available payment methods and
146 provide clear instructions to the dentist as to how to select an
147 alternative payment method.
148 2. If initiating or changing payments to a dentist to
149 payments through the Automated Clearing House network, as
150 provided under 45 C.F.R. ss. 162.1601 and 162.1602, a health
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151 insurer under its dental benefit plan or a health insurer's
152 contracted vendor may not charge a fee solely to transmit the
153 payment to the dentist, unless the dentist has consented to the
154 fee. However, a dentist's agent may charge the dentist
155 reasonable fees when transmitting an Automated Clearing House
156 network payment related to transaction management, data
157 management, portal services, and other value-added services in
158 addition to the bank transmittal.
159 (c) The commission shall enforce this subsection.
160 (2) A health insurer providing coverage for dental
161 services may not deny a claim submitted by a dentist licensed
162 under chapter 466 for a procedure specifically included in a
163 prior authorization unless at least one of the following
164 circumstances applies:
165 (a) Benefit limitations such as annual maximums and
166 frequency limitations not applicable at the time of the prior
167 authorization are reached due to use after issuance of the prior
168 authorization.
169 (b) If, after issuance of the prior authorization, a new
170 procedure is provided to the patient or a change in the
171 condition of the patient occurs such that the prior authorized
172 procedure would:
173 1. No longer be considered medically necessary, based on
174 the prevailing standard of care; or
175 2. At the time of the use of the procedure, require denial
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176 of authorization pursuant to the terms and conditions for
177 coverage under the patient's plan in effect at the time the
178 prior authorization was used.
179 (c) The patient receiving the procedure was not eligible
180 to receive the procedure on the date of service, and the dentist
181 did not know, and with the exercise of reasonable care could not
182 have known, of the patient's eligibility status.
183 (d) Another payer is responsible for the payment.
184 (e) The dentist has already been paid for the procedure
185 identified on the claim.
186 (f) The documentation for the claim provided by the person
187 submitting the claim clearly fails to support the claim as
188 originally authorized.
189 (g) The claim was submitted fraudulently, or the prior
190 authorization was based in whole or material part on erroneous
191 information provided by the dentist, the patient, or any other
192 person not related to the health insurer.
193 (3) The provisions of this section may not be waived by
194 contract. A contractual clause that is in conflict with this
195 section or that purports to waive any requirement of this
196 section is void.
197 Section 4. Subsection (13) of section 636.035, Florida
198 Statutes, is amended, and subsections (15) and (16) are added to
199 that section, to read:
200 636.035 Provider arrangements.—
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201 (13) A contract between a prepaid limited health service
202 organization and a dentist licensed under chapter 466 for the
203 provision of services to a subscriber of the prepaid limited
204 health service organization may not contain a provision that
205 requires the dentist to provide services to the subscriber of
206 the prepaid limited health service organization at a fee set by
207 the prepaid limited health service organization unless such
208 services are covered services under the applicable contract. As
209 used in this subsection, the term "covered services" means
210 dental care services for which a reimbursement is available
211 under the subscriber's contract, excluding or for which a
212 reimbursement would be available but for the application of
213 contractual limitations such as deductibles, coinsurance,
214 waiting periods, annual or lifetime maximums, frequency
215 limitations, alternative benefit payments, or any other
216 limitation.
217 (15)(a) A