AB50-ASA2-AA8,191,1817632.851 Reimbursement of emergency ambulance services. (1) In this 18section: AB50-ASA2-AA8,191,1919(a) “Ambulance service provider” has the meaning given in s. 256.01 (3). AB50-ASA2-AA8,191,2320(b) “Clean claim” means a claim that has no defect of impropriety, including a 21lack of required substantiating documentation or any particular circumstance that 22requires special treatment that prevents timely payment from being made on the 23claim. AB50-ASA2-AA8,192,1
1(c) “Emergency medical responder” has the meaning given in s. 256.01 (4p). AB50-ASA2-AA8,192,32(d) “Emergency medical services practitioner” has the meaning given in s. 3256.01 (5). AB50-ASA2-AA8,192,44(e) “Firefighter” has the meaning given in s. 36.27 (3m) (a) 1m. AB50-ASA2-AA8,192,55(f) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp). AB50-ASA2-AA8,192,66(g) “Law enforcement officer” has the meaning given in s. 165.85 (2) (c). AB50-ASA2-AA8,192,77(h) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c). AB50-ASA2-AA8,192,138(2) (a) A disability insurance policy or self-insured health plan shall, within 930 days after receipt of a clean claim for covered emergency ambulance services, 10promptly remit payment for the covered emergency ambulance services directly to 11the ambulance service provider. No disability insurance policy or self-insured 12health plan may send a payment for covered emergency ambulance services to an 13enrollee. AB50-ASA2-AA8,192,1814(b) A disability insurance policy or self-insured health plan shall respond to a 15claim for covered emergency ambulance services that is not a clean claim by sending 16a written notice, within 30 days after receipt of the claim, acknowledging the date of 17receipt of the claim and informing the ambulance service provider of one of the 18following: AB50-ASA2-AA8,192,20191. That the disability insurance policy or self-insured health plan is declining 20to pay all or part of the claim, including the specific reason or reasons for the denial. AB50-ASA2-AA8,192,22212. That additional information is necessary to determine if all or part of the 22claim is payable and the specific additional information that is required. AB50-ASA2-AA8,193,423(3) A disability insurance policy or self-insured health plan shall remit
1payment for the transportation of any patient by ambulance as a medically 2necessary emergency ambulance service if the transportation was requested by an 3emergency medical services practitioner, an emergency medical responder, a 4firefighter, a law enforcement officer, or a health care provider. AB50-ASA2-AA8,193,66(1) Coverage of emergency ambulance services. AB50-ASA2-AA8,193,107(a) For policies and plans containing provisions inconsistent with ss. 609.825 8and 632.851, the treatment of ss. 609.825 and 632.851 first applies to policy or plan 9years beginning on the effective date of this paragraph, except as provided in par. 10(b). AB50-ASA2-AA8,193,1611(b) For policies and plans that are affected by a collective bargaining 12agreement containing provisions inconsistent with ss. 609.825 and 632.851, the 13treatment of ss. 609.825 and 632.851 first applies to policy or plan years beginning 14on the effective date of this paragraph or on the day on which the collective 15bargaining agreement is entered into, extended, modified, or renewed, whichever is 16later. AB50-ASA2-AA8,193,2118(1) Coverage of emergency ambulance services. The treatment of ss. 1940.51 (8) and (8m), 66.0137 (4), 120.13 (2) (g), 185.983 (1) (intro.), 609.825, and 20632.851 and Section 9323 (1) of this act take effect on the first day of the 4th month 21beginning after publication.”. AB50-ASA2-AA8,194,824601.45 (1) Costs to be paid by examinees. The reasonable costs of
1examinations and audits under ss. 601.43, 601.44, 601.455, and 601.83 (5) (f) shall 2be paid by examinees except as provided in sub. (4), either on the basis of a system 3of billing for actual salaries and expenses of examiners and other apportionable 4expenses, including office overhead, or by a system of regular annual billings to 5cover the costs relating to a group of companies, or a combination of such systems, 6as the commissioner may by rule prescribe. Additional funding, if any, shall be 7governed by s. 601.32. The commissioner shall schedule annual hearings under s. 8601.41 (5) to review current problems in the area of examinations. AB50-ASA2-AA8,194,1110601.455 Fair claims processing, health insurance transparency, and 11claim denial rate audits. (1) Definitions. In this section: AB50-ASA2-AA8,194,1712(a) “Claim denial” means the refusal by an insurer to provide payment under 13a disability insurance policy for a service, treatment, or medication recommended 14by a health care provider. “Claim denial” includes the prospective refusal to pay for 15a service, treatment, or medication when a disability insurance policy requires 16advance approval before a prescribed medical service, treatment, or medication is 17provided. AB50-ASA2-AA8,194,1818(b) “Disability insurance policy” has the meaning given in s. 632.895 (1) (a). AB50-ASA2-AA8,194,1919(c) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (p). AB50-ASA2-AA8,194,2220(2) Claims processing. (a) Insurers shall process each claim for a disability 21insurance policy within a time frame that is reasonable and prevents an undue 22delay in an insured’s care, taking into account the medical urgency of the claim. AB50-ASA2-AA8,195,223(b) If an insurer determines additional information is needed to process a 24claim for a disability insurance policy, the insurer shall request the information
1from the insured within 5 business days of making the determination and shall 2provide at least 15 days for the insured to respond. AB50-ASA2-AA8,195,33(c) All claim denials shall include all of the following: AB50-ASA2-AA8,195,541. A specific and detailed explanation of the reason for the denial that cites 5the exact medical or policy basis for the denial. AB50-ASA2-AA8,195,862. A copy of or a publicly accessible link to any policy, coverage rules, clinical 7guidelines, or medical evidence relied upon in making the denial decision, with 8specific citation to the provision justifying the denial. AB50-ASA2-AA8,195,1193. Additional documentation, medical rationale, or criteria that must be met 10or provided for approval of the claim, including alternative options available under 11the policy. AB50-ASA2-AA8,195,1412(d) If an insurer uses artificial intelligence or algorithmic decision-making in 13processing a claim for a disability insurance policy, the insurer must notify the 14insured in writing of that fact. The notice shall include all of the following: AB50-ASA2-AA8,195,17151. A disclosure that artificial intelligence or algorithmic decision-making was 16used at any stage in reviewing the claim, even if a human later reviewed the 17outcome. AB50-ASA2-AA8,195,20182. A detailed explanation of how the artificial intelligence or algorithmic 19decision-making reached its decision, including any factors the artificial 20intelligence or algorithmic decision-making weighed. AB50-ASA2-AA8,195,22213. A contact point for requesting a human review of the claim if the claim was 22denied. AB50-ASA2-AA8,196,223(3) Independent review of denials. In addition to an insured’s right to an
1independent review under s. 632.835, as applicable, insureds have the right to 2request a review by the office of the public intervenor of any claim denial. AB50-ASA2-AA8,196,43(4) Prohibited practices. An insurer may not do any of the following with 4respect to a disability insurance policy: AB50-ASA2-AA8,196,55(a) Use vague or misleading policy terms to justify a claim denial. AB50-ASA2-AA8,196,66(b) Fail to provide a specific and comprehensible reason for a claim denial. AB50-ASA2-AA8,196,87(c) Cancel coverage under the policy after a claim is submitted due to alleged 8misstatements on the policy application. AB50-ASA2-AA8,196,109(d) Deny a claim based on hidden or ambiguous exclusions in a disability 10insurance policy. AB50-ASA2-AA8,196,1111(e) Stall review of a claim to avoid timely payment. AB50-ASA2-AA8,196,1312(f) Reject a claim without reviewing all relevant medical records or consulting 13qualified experts. AB50-ASA2-AA8,196,1514(g) Fail to properly review or respond to an insured’s appeal in a timely 15manner. AB50-ASA2-AA8,196,1716(h) Allow non-physician personnel to determine whether care is medically 17necessary. AB50-ASA2-AA8,196,1918(i) Apply different medical necessity criteria based on financial interests 19rather than patient needs. AB50-ASA2-AA8,196,2120(j) Disregard a treating health care provider’s medical assessment without a 21valid clinical reason. AB50-ASA2-AA8,196,2322(k) Mandate prior approval for routine or urgent procedures in a manner that 23causes harmful delays. AB50-ASA2-AA8,197,224(L) For a disability insurance policy that provides coverage of emergency
1medical services, refuse to cover emergency medical services provided by out-of-2network providers. AB50-ASA2-AA8,197,43(m) List a health care provider as in-network on a provider directory and then 4deny a claim by stating the health care provider is out-of-network. AB50-ASA2-AA8,197,65(n) Deny coverage based on age, gender, disability, or a chronic condition 6rather than medical necessity. AB50-ASA2-AA8,197,87(o) Apply stricter standards in reviewing claims related to mental health 8conditions than claims related to physical health conditions. AB50-ASA2-AA8,197,109(p) Perform a blanket denial of claims for high-cost conditions without an 10individualized review of each claim. AB50-ASA2-AA8,197,1111(r) Reclassify a claim to a lower-cost treatment to reduce insurer payout. AB50-ASA2-AA8,197,1312(s) Require an insured to fail a cheaper treatment before approving coverage 13for necessary care. AB50-ASA2-AA8,197,1414(t) Manipulate cost-sharing rules to shift higher costs to insureds. AB50-ASA2-AA8,197,1915(5) Transparency and reporting. (a) Beginning on January 1, 2027, an 16insurer shall annually publish a report detailing the insurer’s claim denial rates, 17reasons for claim denials, and the outcome of any appeal of a claim denial for the 18previous year for all disability insurance policies under which the insurer provides 19coverage. AB50-ASA2-AA8,197,2120(b) The commissioner shall maintain a public database of insurers’ claim 21denial rates and the outcomes of independent reviews under s. 632.835. AB50-ASA2-AA8,198,222(c) Beginning on January 1, 2027, an insurer that uses artificial intelligence 23or algorithmic decision-making in claims processing shall annually publish a report
1detailing all of the following for the previous year for all disability insurance policies 2under which the insurer provides coverage: AB50-ASA2-AA8,198,431. The percentage of claims submitted to the insurer that were reviewed by 4artificial intelligence or algorithmic decision-making. AB50-ASA2-AA8,198,752. The claim denial rate of claims reviewed by artificial intelligence or 6algorithmic decision-making compared to the claim denial rate of claims reviewed 7by humans. AB50-ASA2-AA8,198,983. The steps the insurer takes to ensure fairness and accuracy in decisions 9made by artificial intelligence or algorithmic decision-making. AB50-ASA2-AA8,198,1310(6) Claim denial rate audits. (a) The commissioner may conduct an audit 11of an insurer if the insurer’s claim denials are of such frequency as to indicate a 12general business practice. This paragraph is supplemental to and does not limit 13any other powers or duties of the commissioner. AB50-ASA2-AA8,198,1514(b) The commissioner may collect any relevant information from an insurer 15that is necessary to conduct an audit under par. (a). AB50-ASA2-AA8,198,1716(c) The commissioner may contract with a 3rd party to conduct an audit under 17par. (a). AB50-ASA2-AA8,198,2218(d) The commissioner may, based on the findings of an audit under par. (a), 19order the insurer who is the subject of the audit to comply with a corrective action 20plan approved by the commissioner. The commissioner shall specify in any 21corrective action plan under this paragraph the deadline by which an insurer must 22be in compliance with the corrective action plan. AB50-ASA2-AA8,198,2423(e) An insurer who is the subject of an audit under par. (a) shall provide a 24written response to any adverse findings of the audit. AB50-ASA2-AA8,199,3
1(f) If an insurer fails to comply with a corrective action plan under par. (d) by 2the deadline specified by the commissioner, the commissioner may order the 3insurer to pay a forfeiture pursuant to s. 601.64 (3). AB50-ASA2-AA8,199,74(7) Forfeitures. A violation of this section that results in a harmful delay in 5an insured’s care or an adverse health outcome for an insured shall be subject to a 6civil forfeiture of $10,000 per occurrence, in addition to any other penalties provided 7in s. 601.64 (3) or other law.”. AB50-ASA2-AA8,199,1010(1) Funding for health insurance navigators. AB50-ASA2-AA8,199,1111(a) In this subsection: AB50-ASA2-AA8,199,12121. “Commissioner” means the commissioner of insurance. AB50-ASA2-AA8,199,14132. “Navigator” means an individual navigator licensed under s. 628.92 (1) or a 14navigator entity licensed under s. 628.92 (2). AB50-ASA2-AA8,199,1715(b) From the appropriation under s. 20.145 (1) (g), the commissioner shall 16award $500,000 in fiscal year 2025-26 and shall award $500,000 in fiscal year 2026-1727 to a navigator to prioritize services for the direct care workforce population.”. AB50-ASA2-AA8,200,102015.01 (6) “Division,” “bureau,” “section,” and “unit” means the subunits of a 21department or an independent agency, whether specifically created by law or 22created by the head of the department or the independent agency for the more 23economic and efficient administration and operation of the programs assigned to
1the department or independent agency. The office of credit unions in the 2department of financial institutions, the office of the inspector general in the 3department of children and families, the office of the public intervenor in the office 4of the commissioner of insurance, the office of the inspector general in the 5department of health services, and the office of children’s mental health in the 6department of health services have the meaning of “division” under this 7subsection. The office of the long-term care ombudsman under the board on aging 8and long-term care and the office of educational accountability and the office of 9literacy in the department of public instruction have the meaning of “bureau” 10under this subsection. AB50-ASA2-AA8,200,141215.732 Same; attached office. (1) Office of the public intervenor. 13There is created an office of the public intervenor which is attached to the office of 14the commissioner of insurance. AB50-ASA2-AA8,34915Section 349. 20.145 (1) (g) 1. of the statutes is amended to read: AB50-ASA2-AA8,200,181620.145 (1) (g) 1. All moneys received under ss. 601.25 (2), 601.31, 601.32, 17601.42 (7), 601.45, and 601.47 and by the commissioner for expenses related to 18insurance company restructurings, except for restructurings specified in par. (h). AB50-ASA2-AA8,200,2320601.25 Office of the public intervenor. (1) The office of the public 21intervenor shall assist individuals with insurance claims, policies, appeals, and 22other legal actions to pursue insurance coverage for medical procedures, 23prescription medications, and other health care services. AB50-ASA2-AA8,201,424(2) The office of the public intervenor may levy an assessment on each insurer
1that is authorized to engage in the business of insurance in this state. The 2assessment levied under this subsection shall be based on the insurer’s premium 3volume for disability insurance policies, as defined in s. 632.895 (1) (a), written in 4this state.
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