SB45,1396,65(c) Cancel coverage under the policy after a claim is submitted due to alleged 6misstatements on the policy application. SB45,1396,87(d) Deny a claim based on hidden or ambiguous exclusions in a disability 8insurance policy. SB45,1396,99(e) Stall review of a claim to avoid timely payment. SB45,1396,1110(f) Reject a claim without reviewing all relevant medical records or consulting 11qualified experts. SB45,1396,1312(g) Fail to properly review or respond to an insured’s appeal in a timely 13manner. SB45,1396,1514(h) Allow non-physician personnel to determine whether care is medically 15necessary. SB45,1396,1716(i) Apply different medical necessity criteria based on financial interests 17rather than patient needs. SB45,1396,1918(j) Disregard a treating health care provider’s medical assessment without a 19valid clinical reason. SB45,1396,2120(k) Mandate prior approval for routine or urgent procedures in a manner that 21causes harmful delays. SB45,1396,2422(L) For a disability insurance policy that provides coverage of emergency 23medical services, refuse to cover emergency medical services provided by out-of-24network providers. SB45,1397,2
1(m) List a health care provider as in-network on a provider directory and then 2deny a claim by stating the health care provider is out-of-network. SB45,1397,43(n) Deny coverage based on age, gender, disability, or a chronic condition 4rather than medical necessity. SB45,1397,65(o) Apply stricter standards in reviewing claims related to mental health 6conditions than claims related to physical health conditions. SB45,1397,87(p) Perform a blanket denial of claims for high-cost conditions without an 8individualized review of each claim. SB45,1397,99(r) Reclassify a claim to a lower-cost treatment to reduce insurer payout. SB45,1397,1110(s) Require an insured to fail a cheaper treatment before approving coverage 11for necessary care. SB45,1397,1212(t) Manipulate cost-sharing rules to shift higher costs to insureds. SB45,1397,1713(5) Transparency and reporting. (a) Beginning on January 1, 2027, an 14insurer shall annually publish a report detailing the insurer’s claim denial rates, 15reasons for claim denials, and the outcome of any appeal of a claim denial for the 16previous year for all disability insurance policies under which the insurer provides 17coverage. SB45,1397,1918(b) The commissioner shall maintain a public database of insurers’ claim 19denial rates and the outcomes of independent reviews under s. 632.835. SB45,1397,2320(c) Beginning on January 1, 2027, an insurer that uses artificial intelligence 21or algorithmic decision-making in claims processing shall annually publish a report 22detailing all of the following for the previous year for all disability insurance policies 23under which the insurer provides coverage: SB45,1398,2
11. The percentage of claims submitted to the insurer that were reviewed by 2artificial intelligence or algorithmic decision-making. SB45,1398,532. The claim denial rate of claims reviewed by artificial intelligence or 4algorithmic decision-making compared to the claim denial rate of claims reviewed 5by humans. SB45,1398,763. The steps the insurer takes to ensure fairness and accuracy in decisions 7made by artificial intelligence or algorithmic decision-making. SB45,1398,118(6) Claim denial rate audits. (a) The commissioner may conduct an audit 9of an insurer if the insurer’s claim denials are of such frequency as to indicate a 10general business practice. This paragraph is supplemental to and does not limit 11any other powers or duties of the commissioner. SB45,1398,1312(b) The commissioner may collect any relevant information from an insurer 13that is necessary to conduct an audit under par. (a). SB45,1398,1514(c) The commissioner may contract with a 3rd party to conduct an audit under 15par. (a). SB45,1398,2016(d) The commissioner may, based on the findings of an audit under par. (a), 17order the insurer who is the subject of the audit to comply with a corrective action 18plan approved by the commissioner. The commissioner shall specify in any 19corrective action plan under this paragraph the deadline by which an insurer must 20be in compliance with the corrective action plan. SB45,1398,2221(e) An insurer who is the subject of an audit under par. (a) shall provide a 22written response to any adverse findings of the audit. SB45,1399,223(f) If an insurer fails to comply with a corrective action plan under par. (d) by
1the deadline specified by the commissioner, the commissioner may order the 2insurer to pay a forfeiture pursuant to s. 601.64 (3).