Senate Bill 2154c2
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Florida Senate - 2000 CS for CS for SB 2154, CS for SB 1900
& SB 282
By the Committees on Health, Aging and Long-Term Care; Banking
and Insurance; and Senators Latvala, Brown-Waite, Silver,
Geller, Campbell, Kurth, Mitchell, Dawson and Klein
317-2158B-00
1 A bill to be entitled
2 An act relating to health care; providing a
3 short title; amending s. 395.701, F.S.;
4 reducing an assessment against hospitals for
5 outpatient services; amending s. 395.7015,
6 F.S.; reducing an assessment against certain
7 health care entities; amending s. 408.904,
8 F.S.; increasing benefits for certain persons
9 who receive hospital outpatient services;
10 amending s. 408.905, F.S.; increasing benefits
11 furnished by Medicaid providers to recipients
12 of hospital outpatient services; amending s.
13 905.908, F.S.; increasing reimbursement to
14 hospitals for outpatient care; amending s.
15 409.912, F.S.; providing for a contract with
16 and reimbursement of an entity in Pasco or
17 Pinellas County that provides in-home physician
18 services to Medicaid recipients with
19 degenerative neurological diseases; providing
20 for future repeal; providing appropriations;
21 amending s. 400.471, F.S.; deleting the
22 certificate-of-need requirement for licensure
23 of Medicare-certified home health agencies;
24 amending s. 408.032, F.S.; adding definitions
25 of "exemption" and "mental health services";
26 revising the term "health service"; deleting
27 the definitions of "home health agency,"
28 "institutional health service," "intermediate
29 care facility," "multifacility project," and
30 "respite care"; amending s. 408.033, F.S.;
31 deleting references to the state health plan;
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1 amending s. 408.034, F.S.; deleting a reference
2 to licensing of home health agencies by the
3 Agency for Health Care Administration; amending
4 s. 408.035, F.S.; deleting obsolete
5 certificate-of-need review criteria and
6 revising other criteria; amending s. 408.036,
7 F.S.; revising provisions relating to projects
8 subject to review; deleting references to
9 Medicare-certified home health agencies;
10 deleting the review of certain acquisitions;
11 specifying the types of bed increases subject
12 to review; deleting cost overruns from review;
13 deleting review of combinations or division of
14 nursing home certificates of need; providing
15 for expedited review of certain conversions of
16 licensed hospital beds; deleting the
17 requirement for an exemption for initiation or
18 expansion of obstetric services, provision of
19 respite care services, establishment of a
20 Medicare-certified home health agency, or
21 provision of a health service exclusively on an
22 outpatient basis; providing exemptions for
23 combinations or divisions of nursing home
24 certificates of need and additions of certain
25 hospital beds and nursing home beds within
26 specified limitations; requiring a fee for each
27 request for exemption; amending s. 408.037,
28 F.S.; deleting reference to the state health
29 plan; amending ss. 408.038, 408.039, 408.044,
30 and 408.045, F.S.; replacing "department" with
31 "agency"; clarifying the opportunity to
2
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1 challenge an intended award of a certificate of
2 need; amending s. 408.040, F.S.; deleting an
3 obsolete reference; revising the format of
4 conditions related to Medicaid; creating a
5 certificate-of-need workgroup within the Agency
6 for Health Care Administration; providing for
7 expenses; providing membership, duties, and
8 meetings; providing for termination; amending
9 s. 651.118, F.S.; excluding a specified number
10 of beds from a time limit imposed on extension
11 of authorization for continuing care
12 residential community providers to use
13 sheltered beds for nonresidents; requiring a
14 facility to report such use after the
15 expiration of the extension; repealing s.
16 400.464(3), F.S., relating to home health
17 agency licenses provided to certificate-of-need
18 exempt entities; providing applicability;
19 reducing the allocation of funds and positions
20 from the Health Care Trust Fund in the Agency
21 for Health Care Administration; amending s.
22 216.136, F.S.; creating the Mandated Health
23 Insurance Benefits and Providers Estimating
24 Conference; providing for membership and duties
25 of the conference; providing duties of
26 legislative committees that have jurisdiction
27 over health insurance matters; amending s.
28 624.215, F.S.; providing that certain
29 legislative proposals must be submitted to and
30 assessed by the conference, rather than the
31 Agency for Health Care Administration; amending
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1 guidelines for assessing the impact of a
2 proposal to legislatively mandate certain
3 health coverage; providing prerequisites to
4 legislative consideration of such proposals;
5 requiring physicians and hospitals to post a
6 sign and provide a statement informing patients
7 about the toll-free health care hotline;
8 amending s. 408.7056, F.S.; providing
9 additional definitions for the Statewide
10 Provider and Subscriber Assistance Program;
11 amending s. 627.654, F.S.; providing for
12 insuring small employers under policies issued
13 to small employer health alliances; providing
14 requirements for participation; providing
15 limitations; providing for insuring spouses and
16 dependent children; allowing a single master
17 policy to include alternative health plans;
18 amending s. 627.6571, F.S.; including small
19 employer health alliances within policy
20 nonrenewal or discontinuance, coverage
21 modification, and application provisions;
22 amending s. 627.6699, F.S.; revising
23 restrictions relating to premium rates to
24 authorize small employer carriers to modify
25 rates under certain circumstances and to
26 authorize carriers to issue group health
27 insurance policies to small employer health
28 alliances under certain circumstances;
29 requiring carriers issuing a policy to an
30 alliance to allow appointed agents to sell such
31 a policy; amending ss. 240.2995, 240.2996,
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1 240.512, 381.0406, 395.3035, and 627.4301,
2 F.S.; conforming cross-references; defining the
3 term "managed care"; repealing ss. 408.70(3),
4 408.701, 408.702, 408.703, 408.704, 408.7041,
5 408.7042, 408.7045, 408.7055, and 408.706,
6 F.S., relating to community health purchasing
7 alliances; amending s. 627.6699, F.S.;
8 modifying definitions; requiring small employer
9 carriers to begin to offer and issue all small
10 employer benefit plans on a specified date;
11 deleting the requirement that basic and
12 standard small employer health benefit plans be
13 issued; providing additional requirements for
14 determining premium rates for benefit plans;
15 providing for applicability of the act to plans
16 provided by small employer carriers that are
17 insurers or health maintenance organizations
18 notwithstanding the provisions of certain other
19 specified statutes under specified conditions;
20 amending s. 641.27, F.S.; providing for payment
21 by a health maintenance organization of fees to
22 outside examiners appointed by the Department
23 of Insurance; providing for application of
24 federal solvency requirements to
25 provider-sponsored organizations; providing
26 that part IV of ch. 628, F.S., applies to
27 health maintenance organizations; creating s.
28 641.275, F.S.; providing legislative intent
29 that the rights of subscribers who are covered
30 under health maintenance organization contracts
31 be recognized and summarized; requiring health
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1 maintenance organizations to operate in
2 conformity with such rights; requiring
3 organizations to provide subscribers with a
4 copy of their rights; listing specified
5 requirements for organizations that are
6 currently required by other statutes;
7 authorizing administrative penalties for
8 enforcing the rights specified in s. 641.275,
9 F.S.; amending s. 641.28, F.S.; revising award
10 of attorney's fees in civil actions under
11 certain circumstances; amending s. 641.3917,
12 F.S.; authorizing civil actions against health
13 maintenance organizations by certain persons
14 under certain circumstances; providing
15 requirements and procedures; providing for
16 liability for damages and attorney's fees;
17 prohibiting punitive damages under certain
18 circumstances; requiring the advance posting of
19 discovery costs; amending s. 440.11, F.S.;
20 establishing exclusive liability of health
21 maintenance organizations; providing
22 application; providing a legislative
23 declaration; providing an appropriation;
24 amending ss. 641.31, 641.315, 641.3155, F.S.;
25 prohibiting a health maintenance organization
26 from restricting a provider's ability to
27 provide in-patient hospital services to a
28 subscriber; requiring payment for medically
29 necessary in-patient hospital services;
30 amending s. 641.51, F.S., relating to quality
31 assurance program requirements for certain
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1 managed-care organizations; allowing the
2 rendering of adverse determinations by
3 physicians licensed in Florida or states with
4 similar requirements; requiring the submission
5 of facts and documentation pertaining to
6 rendered adverse determinations; providing
7 timeframe for organizations to submit facts and
8 documentation to providers and subscribers in
9 writing; requiring an authorized representative
10 to sign the notification; providing effective
11 dates.
12
13 Be It Enacted by the Legislature of the State of Florida:
14
15 Section 1. This act may be cited as the "Health Care
16 Protection Act of 2000."
17 Section 2. Subsection (2) of section 395.701, Florida
18 Statutes, is amended to read:
19 395.701 Annual assessments on net operating revenues
20 to fund public medical assistance; administrative fines for
21 failure to pay assessments when due; exemption.--
22 (2) There is imposed upon each hospital an assessment
23 in an amount equal to 1.5 percent of the annual net operating
24 revenue for inpatient services and an assessment in an amount
25 equal to 1 percent of the annual net operating revenue for
26 outpatient services for each hospital, such revenue to be
27 determined by the agency, based on the actual experience of
28 the hospital as reported to the agency. Within 6 months after
29 the end of each hospital fiscal year, the agency shall certify
30 the amount of the assessment for each hospital. The
31 assessment shall be payable to and collected by the agency in
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1 equal quarterly amounts, on or before the first day of each
2 calendar quarter, beginning with the first full calendar
3 quarter that occurs after the agency certifies the amount of
4 the assessment for each hospital. All moneys collected
5 pursuant to this subsection shall be deposited into the Public
6 Medical Assistance Trust Fund.
7 Section 3. Subsection (2) of section 395.7015, Florida
8 Statutes, is amended to read:
9 395.7015 Annual assessment on health care entities.--
10 (2) There is imposed an annual assessment against
11 certain health care entities as described in this section:
12 (a) The assessment shall be equal to 1 1.5 percent of
13 the annual net operating revenues of health care entities. The
14 assessment shall be payable to and collected by the agency.
15 Assessments shall be based on annual net operating revenues
16 for the entity's most recently completed fiscal year as
17 provided in subsection (3).
18 (b) For the purpose of this section, "health care
19 entities" include the following:
20 1. Ambulatory surgical centers and mobile surgical
21 facilities licensed under s. 395.003. This subsection shall
22 only apply to mobile surgical facilities operating under
23 contracts entered into on or after July 1, 1998.
24 2. Clinical laboratories licensed under s. 483.091,
25 excluding any hospital laboratory defined under s. 483.041(5),
26 any clinical laboratory operated by the state or a political
27 subdivision of the state, any clinical laboratory which
28 qualifies as an exempt organization under s. 501(c)(3) of the
29 Internal Revenue Code of 1986, as amended, and which receives
30 70 percent or more of its gross revenues from services to
31 charity patients or Medicaid patients, and any blood, plasma,
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1 or tissue bank procuring, storing, or distributing blood,
2 plasma, or tissue either for future manufacture or research or
3 distributed on a nonprofit basis, and further excluding any
4 clinical laboratory which is wholly owned and operated by 6 or
5 fewer physicians who are licensed pursuant to chapter 458 or
6 chapter 459 and who practice in the same group practice, and
7 at which no clinical laboratory work is performed for patients
8 referred by any health care provider who is not a member of
9 the same group.
10 3. Diagnostic-imaging centers that are freestanding
11 outpatient facilities that provide specialized services for
12 the identification or determination of a disease through
13 examination and also provide sophisticated radiological
14 services, and in which services are rendered by a physician
15 licensed by the Board of Medicine under s. 458.311, s.
16 458.313, or s. 458.317, or by an osteopathic physician
17 licensed by the Board of Osteopathic Medicine under s.
18 459.006, s. 459.007, or s. 459.0075. For purposes of this
19 paragraph, "sophisticated radiological services" means the
20 following: magnetic resonance imaging; nuclear medicine;
21 angiography; arteriography; computed tomography; positron
22 emission tomography; digital vascular imaging; bronchography;
23 lymphangiography; splenography; ultrasound, excluding
24 ultrasound providers that are part of a private physician's
25 office practice or when ultrasound is provided by two or more
26 physicians licensed under chapter 458 or chapter 459 who are
27 members of the same professional association and who practice
28 in the same medical specialties; and such other sophisticated
29 radiological services, excluding mammography, as adopted in
30 rule by the board.
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1 Section 4. Paragraph (c) of subsection (2) of section
2 408.904, Florida Statutes, is amended to read:
3 408.904 Benefits.--
4 (2) Covered health services include:
5 (c) Hospital outpatient services. Those services
6 provided to a member in the outpatient portion of a hospital
7 licensed under part I of chapter 395, up to a limit of $1,500
8 $1,000 per calendar year per member, that are preventive,
9 diagnostic, therapeutic, or palliative.
10 Section 5. Subsection (6) of section 409.905, Florida
11 Statutes, is amended to read:
12 409.905 Mandatory Medicaid services.--The agency may
13 make payments for the following services, which are required
14 of the state by Title XIX of the Social Security Act,
15 furnished by Medicaid providers to recipients who are
16 determined to be eligible on the dates on which the services
17 were provided. Any service under this section shall be
18 provided only when medically necessary and in accordance with
19 state and federal law. Nothing in this section shall be
20 construed to prevent or limit the agency from adjusting fees,
21 reimbursement rates, lengths of stay, number of visits, number
22 of services, or any other adjustments necessary to comply with
23 the availability of moneys and any limitations or directions
24 provided for in the General Appropriations Act or chapter 216.
25 (6) HOSPITAL OUTPATIENT SERVICES.--The agency shall
26 pay for preventive, diagnostic, therapeutic, or palliative
27 care and other services provided to a recipient in the
28 outpatient portion of a hospital licensed under part I of
29 chapter 395, and provided under the direction of a licensed
30 physician or licensed dentist, except that payment for such
31 care and services is limited to $1,500 $1,000 per state fiscal
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1 year per recipient, unless an exception has been made by the
2 agency, and with the exception of a Medicaid recipient under
3 age 21, in which case the only limitation is medical
4 necessity.
5 Section 6. Paragraph (a) of subsection (1) of section
6 409.908, Florida Statutes, is amended to read:
7 409.908 Reimbursement of Medicaid providers.--Subject
8 to specific appropriations, the agency shall reimburse
9 Medicaid providers, in accordance with state and federal law,
10 according to methodologies set forth in the rules of the
11 agency and in policy manuals and handbooks incorporated by
12 reference therein. These methodologies may include fee
13 schedules, reimbursement methods based on cost reporting,
14 negotiated fees, competitive bidding pursuant to s. 287.057,
15 and other mechanisms the agency considers efficient and
16 effective for purchasing services or goods on behalf of
17 recipients. Payment for Medicaid compensable services made on
18 behalf of Medicaid eligible persons is subject to the
19 availability of moneys and any limitations or directions
20 provided for in the General Appropriations Act or chapter 216.
21 Further, nothing in this section shall be construed to prevent
22 or limit the agency from adjusting fees, reimbursement rates,
23 lengths of stay, number of visits, or number of services, or
24 making any other adjustments necessary to comply with the
25 availability of moneys and any limitations or directions
26 provided for in the General Appropriations Act, provided the
27 adjustment is consistent with legislative intent.
28 (1) Reimbursement to hospitals licensed under part I
29 of chapter 395 must be made prospectively or on the basis of
30 negotiation.
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1 (a) Reimbursement for inpatient care is limited as
2 provided for in s. 409.905(5). Reimbursement for hospital
3 outpatient care is limited to $1,500 $1,000 per state fiscal
4 year per recipient, except for:
5 1. Such care provided to a Medicaid recipient under
6 age 21, in which case the only limitation is medical
7 necessity;
8 2. Renal dialysis services; and
9 3. Other exceptions made by the agency.
10 Section 7. Paragraph (e) is added to subsection (3) of
11 section 409.912, Florida Statutes, to read:
12 409.912 Cost-effective purchasing of health care.--The
13 agency shall purchase goods and services for Medicaid
14 recipients in the most cost-effective manner consistent with
15 the delivery of quality medical care. The agency shall
16 maximize the use of prepaid per capita and prepaid aggregate
17 fixed-sum basis services when appropriate and other
18 alternative service delivery and reimbursement methodologies,
19 including competitive bidding pursuant to s. 287.057, designed
20 to facilitate the cost-effective purchase of a case-managed
21 continuum of care. The agency shall also require providers to
22 minimize the exposure of recipients to the need for acute
23 inpatient, custodial, and other institutional care and the
24 inappropriate or unnecessary use of high-cost services.
25 (3) The agency may contract with:
26 (e) An entity in Pasco County or Pinellas County that
27 provides in-home physician services to Medicaid recipients
28 having degenerative neurological diseases in order to test the
29 cost-effectiveness of enhanced home-based medical care. The
30 entity providing the services shall be reimbursed on a
31 fee-for-service basis at a rate not less than comparable
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1 Medicare reimbursement rates. The agency may apply for waivers
2 of federal regulations necessary to implement such program.
3 This paragraph expires July 1, 2002.
4 Section 8. The Legislature shall appropriate each
5 fiscal year from the General Revenue Fund to the Public
6 Medical Assistance Trust Fund an amount sufficient to replace
7 the funds lost due to the reduction by this act of the
8 assessment on other health care entities under section
9 395.7015, Florida Statutes, and the reduction by this act in
10 the assessment on hospitals under section 395.701, Florida
11 Statutes, and to maintain federal approval of the reduced
12 amount of funds deposited into the Public Medical Assistance
13 Trust Fund under section 395.701, Florida Statutes, as state
14 matching funds for the state's Medicaid program.
15 Section 9. The sum of $28.3 million is appropriated
16 from the General Revenue Fund to the Agency for Health Care
17 Administration for the purpose of implementing this act.
18 However, such appropriation shall be reduced by an amount
19 equal to any similar appropriation for the same purpose which
20 is contained in other legislation adopted during the 2000
21 legislative session and which becomes a law.
22 Section 10. Subsections (2) and (11) of section
23 400.471, Florida Statutes, are amended to read:
24 400.471 Application for license; fee; provisional
25 license; temporary permit.--
26 (2) The applicant must file with the application
27 satisfactory proof that the home health agency is in
28 compliance with this part and applicable rules, including:
29 (a) A listing of services to be provided, either
30 directly by the applicant or through contractual arrangements
31 with existing providers;
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1 (b) The number and discipline of professional staff to
2 be employed; and
3 (c) Proof of financial ability to operate.
4
5 If the applicant has applied for a certificate of need under
6 ss. 408.0331-408.045 within the preceding 12 months, the
7 applicant may submit the proof required during the
8 certificate-of-need process along with an attestation that
9 there has been no substantial change in the facts and
10 circumstances underlying the original submission.
11 (11) The agency may not issue a license designated as
12 certified to a home health agency that fails to receive a
13 certificate of need under ss. 408.031-408.045 or that fails to
14 satisfy the requirements of a Medicare certification survey
15 from the agency.
16 Section 11. Section 408.032, Florida Statutes, is
17 amended to read:
18 408.032 Definitions.--As used in ss. 408.031-408.045,
19 the term:
20 (1) "Agency" means the Agency for Health Care
21 Administration.
22 (2) "Capital expenditure" means an expenditure,
23 including an expenditure for a construction project undertaken
24 by a health care facility as its own contractor, which, under
25 generally accepted accounting principles, is not properly
26 chargeable as an expense of operation and maintenance, which
27 is made to change the bed capacity of the facility, or
28 substantially change the services or service area of the
29 health care facility, health service provider, or hospice, and
30 which includes the cost of the studies, surveys, designs,
31 plans, working drawings, specifications, initial financing
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1 costs, and other activities essential to acquisition,
2 improvement, expansion, or replacement of the plant and
3 equipment.
4 (3) "Certificate of need" means a written statement
5 issued by the agency evidencing community need for a new,
6 converted, expanded, or otherwise significantly modified
7 health care facility, health service, or hospice.
8 (4) "Commenced construction" means initiation of and
9 continuous activities beyond site preparation associated with
10 erecting or modifying a health care facility, including
11 procurement of a building permit applying the use of
12 agency-approved construction documents, proof of an executed
13 owner/contractor agreement or an irrevocable or binding forced
14 account, and actual undertaking of foundation forming with
15 steel installation and concrete placing.
16 (5) "District" means a health service planning
17 district composed of the following counties:
18 District 1.--Escambia, Santa Rosa, Okaloosa, and Walton
19 Counties.
20 District 2.--Holmes, Washington, Bay, Jackson,
21 Franklin, Gulf, Gadsden, Liberty, Calhoun, Leon, Wakulla,
22 Jefferson, Madison, and Taylor Counties.
23 District 3.--Hamilton, Suwannee, Lafayette, Dixie,
24 Columbia, Gilchrist, Levy, Union, Bradford, Putnam, Alachua,
25 Marion, Citrus, Hernando, Sumter, and Lake Counties.
26 District 4.--Baker, Nassau, Duval, Clay, St. Johns,
27 Flagler, and Volusia Counties.
28 District 5.--Pasco and Pinellas Counties.
29 District 6.--Hillsborough, Manatee, Polk, Hardee, and
30 Highlands Counties.
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1 District 7.--Seminole, Orange, Osceola, and Brevard
2 Counties.
3 District 8.--Sarasota, DeSoto, Charlotte, Lee, Glades,
4 Hendry, and Collier Counties.
5 District 9.--Indian River, Okeechobee, St. Lucie,
6 Martin, and Palm Beach Counties.
7 District 10.--Broward County.
8 District 11.--Dade and Monroe Counties.
9 (6) "Exemption" means the process by which a proposal
10 that would otherwise require a certificate of need may proceed
11 without a certificate of need.
12 (7)(6) "Expedited review" means the process by which
13 certain types of applications are not subject to the review
14 cycle requirements contained in s. 408.039(1), and the letter
15 of intent requirements contained in s. 408.039(2).
16 (8)(7) "Health care facility" means a hospital,
17 long-term care hospital, skilled nursing facility, hospice,
18 intermediate care facility, or intermediate care facility for
19 the developmentally disabled. A facility relying solely on
20 spiritual means through prayer for healing is not included as
21 a health care facility.
22 (9)(8) "Health services" means diagnostic, curative,
23 or rehabilitative services and includes alcohol treatment,
24 drug abuse treatment, and mental health services. Obstetric
25 services are not health services for purposes of ss.
26 408.031-408.045.
27 (9) "Home health agency" means an organization, as
28 defined in s. 400.462(4), that is certified or seeks
29 certification as a Medicare home health service provider.
30 (10) "Hospice" or "hospice program" means a hospice as
31 defined in part VI of chapter 400.
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1 (11) "Hospital" means a health care facility licensed
2 under chapter 395.
3 (12) "Institutional health service" means a health
4 service which is provided by or through a health care facility
5 and which entails an annual operating cost of $500,000 or
6 more. The agency shall, by rule, adjust the annual operating
7 cost threshold annually using an appropriate inflation index.
8 (13) "Intermediate care facility" means an institution
9 which provides, on a regular basis, health-related care and
10 services to individuals who do not require the degree of care
11 and treatment which a hospital or skilled nursing facility is
12 designed to provide, but who, because of their mental or
13 physical condition, require health-related care and services
14 above the level of room and board.
15 (12)(14) "Intermediate care facility for the
16 developmentally disabled" means a residential facility
17 licensed under chapter 393 and certified by the Federal
18 Government pursuant to the Social Security Act as a provider
19 of Medicaid services to persons who are mentally retarded or
20 who have a related condition.
21 (13)(15) "Long-term care hospital" means a hospital
22 licensed under chapter 395 which meets the requirements of 42
23 C.F.R. s. 412.23(e) and seeks exclusion from the Medicare
24 prospective payment system for inpatient hospital services.
25 (14) "Mental health services" means inpatient services
26 provided in a hospital licensed under chapter 395 and listed
27 on the hospital license as psychiatric beds for adults;
28 psychiatric beds for children and adolescents; intensive
29 residential treatment beds for children and adolescents;
30 substance abuse beds for adults; or substance abuse beds for
31 children and adolescents.
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1 (16) "Multifacility project" means an integrated
2 residential and health care facility consisting of independent
3 living units, assisted living facility units, and nursing home
4 beds certificated on or after January 1, 1987, where:
5 (a) The aggregate total number of independent living
6 units and assisted living facility units exceeds the number of
7 nursing home beds.
8 (b) The developer of the project has expended the sum
9 of $500,000 or more on the certificated and noncertificated
10 elements of the project combined, exclusive of land costs, by
11 the conclusion of the 18th month of the life of the
12 certificate of need.
13 (c) The total aggregate cost of construction of the
14 certificated element of the project, when combined with other,
15 noncertificated elements, is $10 million or more.
16 (d) All elements of the project are contiguous or
17 immediately adjacent to each other and construction of all
18 elements will be continuous.
19 (15)(17) "Nursing home geographically underserved
20 area" means:
21 (a) A county in which there is no existing or approved
22 nursing home;
23 (b) An area with a radius of at least 20 miles in
24 which there is no existing or approved nursing home; or
25 (c) An area with a radius of at least 20 miles in
26 which all existing nursing homes have maintained at least a 95
27 percent occupancy rate for the most recent 6 months or a 90
28 percent occupancy rate for the most recent 12 months.
29 (18) "Respite care" means short-term care in a
30 licensed health care facility which is personal or custodial
31 and is provided for chronic illness, physical infirmity, or
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1 advanced age for the purpose of temporarily relieving family
2 members of the burden of providing care and attendance.
3 (16)(19) "Skilled nursing facility" means an
4 institution, or a distinct part of an institution, which is
5 primarily engaged in providing, to inpatients, skilled nursing
6 care and related services for patients who require medical or
7 nursing care, or rehabilitation services for the
8 rehabilitation of injured, disabled, or sick persons.
9 (17)(20) "Tertiary health service" means a health
10 service which, due to its high level of intensity, complexity,
11 specialized or limited applicability, and cost, should be
12 limited to, and concentrated in, a limited number of hospitals
13 to ensure the quality, availability, and cost-effectiveness of
14 such service. Examples of such service include, but are not
15 limited to, organ transplantation, specialty burn units,
16 neonatal intensive care units, comprehensive rehabilitation,
17 and medical or surgical services which are experimental or
18 developmental in nature to the extent that the provision of
19 such services is not yet contemplated within the commonly
20 accepted course of diagnosis or treatment for the condition
21 addressed by a given service. The agency shall establish by
22 rule a list of all tertiary health services.
23 (18)(21) "Regional area" means any of those regional
24 health planning areas established by the agency to which local
25 and district health planning funds are directed to local
26 health councils through the General Appropriations Act.
27 Section 12. Paragraph (b) of subsection (1) and
28 paragraph (a) of subsection (3) of section 408.033, Florida
29 Statutes, are amended to read:
30 408.033 Local and state health planning.--
31 (1) LOCAL HEALTH COUNCILS.--
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1 (b) Each local health council may:
2 1. Develop a district or regional area health plan
3 that permits is consistent with the objectives and strategies
4 in the state health plan, but that shall permit each local
5 health council to develop strategies and set priorities for
6 implementation based on its unique local health needs. The
7 district or regional area health plan must contain preferences
8 for the development of health services and facilities, which
9 may be considered by the agency in its review of
10 certificate-of-need applications. The district health plan
11 shall be submitted to the agency and updated periodically. The
12 district health plans shall use a uniform format and be
13 submitted to the agency according to a schedule developed by
14 the agency in conjunction with the local health councils. The
15 schedule must provide for coordination between the development
16 of the state health plan and the district health plans and for
17 the development of district health plans by major sections
18 over a multiyear period. The elements of a district plan
19 which are necessary to the review of certificate-of-need
20 applications for proposed projects within the district may be
21 adopted by the agency as a part of its rules.
22 2. Advise the agency on health care issues and
23 resource allocations.
24 3. Promote public awareness of community health needs,
25 emphasizing health promotion and cost-effective health service
26 selection.
27 4. Collect data and conduct analyses and studies
28 related to health care needs of the district, including the
29 needs of medically indigent persons, and assist the agency and
30 other state agencies in carrying out data collection
31 activities that relate to the functions in this subsection.
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1 5. Monitor the onsite construction progress, if any,
2 of certificate-of-need approved projects and report council
3 findings to the agency on forms provided by the agency.
4 6. Advise and assist any regional planning councils
5 within each district that have elected to address health
6 issues in their strategic regional policy plans with the
7 development of the health element of the plans to address the
8 health goals and policies in the State Comprehensive Plan.
9 7. Advise and assist local governments within each
10 district on the development of an optional health plan element
11 of the comprehensive plan provided in chapter 163, to assure
12 compatibility with the health goals and policies in the State
13 Comprehensive Plan and district health plan. To facilitate
14 the implementation of this section, the local health council
15 shall annually provide the local governments in its service
16 area, upon request, with:
17 a. A copy and appropriate updates of the district
18 health plan;
19 b. A report of hospital and nursing home utilization
20 statistics for facilities within the local government
21 jurisdiction; and
22 c. Applicable agency rules and calculated need
23 methodologies for health facilities and services regulated
24 under s. 408.034 for the district served by the local health
25 council.
26 8. Monitor and evaluate the adequacy, appropriateness,
27 and effectiveness, within the district, of local, state,
28 federal, and private funds distributed to meet the needs of
29 the medically indigent and other underserved population
30 groups.
31
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1 9. In conjunction with the Agency for Health Care
2 Administration, plan for services at the local level for
3 persons infected with the human immunodeficiency virus.
4 10. Provide technical assistance to encourage and
5 support activities by providers, purchasers, consumers, and
6 local, regional, and state agencies in meeting the health care
7 goals, objectives, and policies adopted by the local health
8 council.
9 11. Provide the agency with data required by rule for
10 the review of certificate-of-need applications and the
11 projection of need for health services and facilities in the
12 district.
13 (3) DUTIES AND RESPONSIBILITIES OF THE AGENCY.--
14 (a) The agency, in conjunction with the local health
15 councils, is responsible for the coordinated planning of all
16 health care services in the state and for the preparation of
17 the state health plan.
18 Section 13. Subsection (2) of section 408.034, Florida
19 Statutes, is amended to read:
20 408.034 Duties and responsibilities of agency;
21 rules.--
22 (2) In the exercise of its authority to issue licenses
23 to health care facilities and health service providers, as
24 provided under chapters 393, 395, and parts II, IV, and VI of
25 chapter 400, the agency may not issue a license to any health
26 care facility, health service provider, hospice, or part of a
27 health care facility which fails to receive a certificate of
28 need or an exemption for the licensed facility or service.
29 Section 14. Section 408.035, Florida Statutes, is
30 amended to read:
31 408.035 Review criteria.--
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1 (1) The agency shall determine the reviewability of
2 applications and shall review applications for
3 certificate-of-need determinations for health care facilities
4 and health services in context with the following criteria:
5 (1)(a) The need for the health care facilities and
6 health services being proposed in relation to the applicable
7 district health plan, except in emergency circumstances that
8 pose a threat to the public health.
9 (2)(b) The availability, quality of care, efficiency,
10 appropriateness, accessibility, and extent of utilization of,
11 and adequacy of like and existing health care facilities and
12 health services in the service district of the applicant.
13 (3)(c) The ability of the applicant to provide quality
14 of care and the applicant's record of providing quality of
15 care.
16 (d) The availability and adequacy of other health care
17 facilities and health services in the service district of the
18 applicant, such as outpatient care and ambulatory or home care
19 services, which may serve as alternatives for the health care
20 facilities and health services to be provided by the
21 applicant.
22 (e) Probable economies and improvements in service
23 which may be derived from operation of joint, cooperative, or
24 shared health care resources.
25 (4)(f) The need in the service district of the
26 applicant for special health care equipment and services that
27 are not reasonably and economically accessible in adjoining
28 areas.
29 (5)(g) The needs of need for research and educational
30 facilities, including, but not limited to, facilities with
31 institutional training programs and community training
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1 programs for health care practitioners and for doctors of
2 osteopathic medicine and medicine at the student, internship,
3 and residency training levels.
4 (6)(h) The availability of resources, including health
5 personnel, management personnel, and funds for capital and
6 operating expenditures, for project accomplishment and
7 operation.; the effects the project will have on clinical
8 needs of health professional training programs in the service
9 district; the extent to which the services will be accessible
10 to schools for health professions in the service district for
11 training purposes if such services are available in a limited
12 number of facilities; the availability of alternative uses of
13 such resources for the provision of other health services; and
14 (7) The extent to which the proposed services will
15 enhance access to health care for be accessible to all
16 residents of the service district.
17 (8)(i) The immediate and long-term financial
18 feasibility of the proposal.
19 (j) The special needs and circumstances of health
20 maintenance organizations.
21 (k) The needs and circumstances of those entities that
22 provide a substantial portion of their services or resources,
23 or both, to individuals not residing in the service district
24 in which the entities are located or in adjacent service
25 districts. Such entities may include medical and other health
26 professions, schools, multidisciplinary clinics, and specialty
27 services such as open-heart surgery, radiation therapy, and
28 renal transplantation.
29 (9)(l) The extent to which the proposal will foster
30 competition that promotes quality and cost-effectiveness. The
31 probable impact of the proposed project on the costs of
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1 providing health services proposed by the applicant, upon
2 consideration of factors including, but not limited to, the
3 effects of competition on the supply of health services being
4 proposed and the improvements or innovations in the financing
5 and delivery of health services which foster competition and
6 service to promote quality assurance and cost-effectiveness.
7 (10)(m) The costs and methods of the proposed
8 construction, including the costs and methods of energy
9 provision and the availability of alternative, less costly, or
10 more effective methods of construction.
11 (11)(n) The applicant's past and proposed provision of
12 health care services to Medicaid patients and the medically
13 indigent.
14 (o) The applicant's past and proposed provision of
15 services that promote a continuum of care in a multilevel
16 health care system, which may include, but are not limited to,
17 acute care, skilled nursing care, home health care, and
18 assisted living facilities.
19 (12)(p) The applicant's designation as a Gold Seal
20 Program nursing facility pursuant to s. 400.235, when the
21 applicant is requesting additional nursing home beds at that
22 facility.
23 (2) In cases of capital expenditure proposals for the
24 provision of new health services to inpatients, the agency
25 shall also reference each of the following in its findings of
26 fact:
27 (a) That less costly, more efficient, or more
28 appropriate alternatives to such inpatient services are not
29 available and the development of such alternatives has been
30 studied and found not practicable.
31
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1 (b) That existing inpatient facilities providing
2 inpatient services similar to those proposed are being used in
3 an appropriate and efficient manner.
4 (c) In the case of new construction or replacement
5 construction, that alternatives to the construction, for
6 example, modernization or sharing arrangements, have been
7 considered and have been implemented to the maximum extent
8 practicable.
9 (d) That patients will experience serious problems in
10 obtaining inpatient care of the type proposed, in the absence
11 of the proposed new service.
12 (e) In the case of a proposal for the addition of beds
13 for the provision of skilled nursing or intermediate care
14 services, that the addition will be consistent with the plans
15 of other agencies of the state responsible for the provision
16 and financing of long-term care, including home health
17 services.
18 Section 15. Section 408.036, Florida Statutes, is
19 amended to read:
20 408.036 Projects subject to review.--
21 (1) APPLICABILITY.--Unless exempt under subsection
22 (3), all health-care-related projects, as described in
23 paragraphs (a)-(h)(k), are subject to review and must file an
24 application for a certificate of need with the agency. The
25 agency is exclusively responsible for determining whether a
26 health-care-related project is subject to review under ss.
27 408.031-408.045.
28 (a) The addition of beds by new construction or
29 alteration.
30 (b) The new construction or establishment of
31 additional health care facilities, including a replacement
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1 health care facility when the proposed project site is not
2 located on the same site as the existing health care facility.
3 (c) The conversion from one type of health care
4 facility to another, including the conversion from one level
5 of care to another, in a skilled or intermediate nursing
6 facility, if the conversion effects a change in the level of
7 care of 10 beds or 10 percent of total bed capacity of the
8 skilled or intermediate nursing facility within a 2-year
9 period. If the nursing facility is certified for both skilled
10 and intermediate nursing care, the provisions of this
11 paragraph do not apply.
12 (d) An Any increase in the total licensed bed capacity
13 of a health care facility.
14 (e) Subject to the provisions of paragraph (3)(i), The
15 establishment of a Medicare-certified home health agency, the
16 establishment of a hospice or hospice inpatient facility,
17 except as provided in s. 408.043 or the direct provision of
18 such services by a health care facility or health maintenance
19 organization for those other than the subscribers of the
20 health maintenance organization; except that this paragraph
21 does not apply to the establishment of a Medicare-certified
22 home health agency by a facility described in paragraph
23 (3)(h).
24 (f) An acquisition by or on behalf of a health care
25 facility or health maintenance organization, by any means,
26 which acquisition would have required review if the
27 acquisition had been by purchase.
28 (f)(g) The establishment of inpatient institutional
29 health services by a health care facility, or a substantial
30 change in such services.
31
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1 (h) The acquisition by any means of an existing health
2 care facility by any person, unless the person provides the
3 agency with at least 30 days' written notice of the proposed
4 acquisition, which notice is to include the services to be
5 offered and the bed capacity of the facility, and unless the
6 agency does not determine, within 30 days after receipt of
7 such notice, that the services to be provided and the bed
8 capacity of the facility will be changed.
9 (i) An increase in the cost of a project for which a
10 certificate of need has been issued when the increase in cost
11 exceeds 20 percent of the originally approved cost of the
12 project, except that a cost overrun review is not necessary
13 when the cost overrun is less than $20,000.
14 (g)(j) An increase in the number of beds for acute
15 care, nursing home care beds, specialty burn units, neonatal
16 intensive care units, comprehensive rehabilitation, mental
17 health services, or hospital-based distinct part skilled
18 nursing units, or at a long-term care hospital psychiatric or
19 rehabilitation beds.
20 (h)(k) The establishment of tertiary health services.
21 (2) PROJECTS SUBJECT TO EXPEDITED REVIEW.--Unless
22 exempt pursuant to subsection (3), projects subject to an
23 expedited review shall include, but not be limited to:
24 (a) Cost overruns, as defined in paragraph (1)(i).
25 (a)(b) Research, education, and training programs.
26 (b)(c) Shared services contracts or projects.
27 (c)(d) A transfer of a certificate of need.
28 (d)(e) A 50-percent increase in nursing home beds for
29 a facility incorporated and operating in this state for at
30 least 60 years on or before July 1, 1988, which has a licensed
31 nursing home facility located on a campus providing a variety
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1 of residential settings and supportive services. The
2 increased nursing home beds shall be for the exclusive use of
3 the campus residents. Any application on behalf of an
4 applicant meeting this requirement shall be subject to the
5 base fee of $5,000 provided in s. 408.038.
6 (f) Combination within one nursing home facility of
7 the beds or services authorized by two or more certificates of
8 need issued in the same planning subdistrict.
9 (g) Division into two or more nursing home facilities
10 of beds or services authorized by one certificate of need
11 issued in the same planning subdistrict. Such division shall
12 not be approved if it would adversely affect the original
13 certificate's approved cost.
14 (e)(h) Replacement of a health care facility when the
15 proposed project site is located in the same district and
16 within a 1-mile radius of the replaced health care facility.
17 (f) The conversion of mental health services beds
18 licensed under chapter 395 or hospital-based distinct part
19 skilled nursing unit beds to general acute care beds; the
20 conversion of mental health services beds between or among the
21 licensed bed categories defined as beds for mental health
22 services; or the conversion of general acute care beds to beds
23 for mental health services.
24 1. Conversion under this paragraph shall not establish
25 a new licensed bed category at the hospital but shall apply
26 only to categories of beds licensed at that hospital.
27 2. Beds converted under this paragraph must be
28 licensed and operational for at least 12 months before the
29 hospital may apply for additional conversion affecting beds of
30 the same type.
31
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1 The agency shall develop rules to implement the provisions for
2 expedited review, including time schedule, application content
3 which may be reduced from the full requirements of s.
4 408.037(1), and application processing.
5 (3) EXEMPTIONS.--Upon request, the following projects
6 are subject to supported by such documentation as the agency
7 requires, the agency shall grant an exemption from the
8 provisions of subsection (1):
9 (a) For the initiation or expansion of obstetric
10 services.
11 (a)(b) For replacement of any expenditure to replace
12 or renovate any part of a licensed health care facility on the
13 same site, provided that the number of licensed beds in each
14 licensed bed category will not increase and, in the case of a
15 replacement facility, the project site is the same as the
16 facility being replaced.
17 (c) For providing respite care services. An individual
18 may be admitted to a respite care program in a hospital
19 without regard to inpatient requirements relating to admitting
20 order and attendance of a member of a medical staff.
21 (b)(d) For hospice services or home health services
22 provided by a rural hospital, as defined in s. 395.602, or for
23 swing beds in a such rural hospital, as defined in s. 395.602,
24 in a number that does not exceed one-half of its licensed
25 beds.
26 (c)(e) For the conversion of licensed acute care
27 hospital beds to Medicare and Medicaid certified skilled
28 nursing beds in a rural hospital, as defined in s. 395.602, so
29 long as the conversion of the beds does not involve the
30 construction of new facilities. The total number of skilled
31 nursing beds, including swing beds, may not exceed one-half of
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1 the total number of licensed beds in the rural hospital as of
2 July 1, 1993. Certified skilled nursing beds designated under
3 this paragraph, excluding swing beds, shall be included in the
4 community nursing home bed inventory. A rural hospital which
5 subsequently decertifies any acute care beds exempted under
6 this paragraph shall notify the agency of the decertification,
7 and the agency shall adjust the community nursing home bed
8 inventory accordingly.
9 (d)(f) For the addition of nursing home beds at a
10 skilled nursing facility that is part of a retirement
11 community that provides a variety of residential settings and
12 supportive services and that has been incorporated and
13 operated in this state for at least 65 years on or before July
14 1, 1994. All nursing home beds must not be available to the
15 public but must be for the exclusive use of the community
16 residents.
17 (e)(g) For an increase in the bed capacity of a
18 nursing facility licensed for at least 50 beds as of January
19 1, 1994, under part II of chapter 400 which is not part of a
20 continuing care facility if, after the increase, the total
21 licensed bed capacity of that facility is not more than 60
22 beds and if the facility has been continuously licensed since
23 1950 and has received a superior rating on each of its two
24 most recent licensure surveys.
25 (h) For the establishment of a Medicare-certified home
26 health agency by a facility certified under chapter 651; a
27 retirement community, as defined in s. 400.404(2)(g); or a
28 residential facility that serves only retired military
29 personnel, their dependents, and the surviving dependents of
30 deceased military personnel. Medicare-reimbursed home health
31 services provided through such agency shall be offered
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1 exclusively to residents of the facility or retirement
2 community or to residents of facilities or retirement
3 communities owned, operated, or managed by the same corporate
4 entity. Each visit made to deliver Medicare-reimbursable home
5 health services to a home health patient who, at the time of
6 service, is not a resident of the facility or retirement
7 community shall be a deceptive and unfair trade practice and
8 constitutes a violation of ss. 501.201-501.213.
9 (i) For the establishment of a Medicare-certified home
10 health agency. This paragraph shall take effect 90 days after
11 the adjournment sine die of the next regular session of the
12 Legislature occurring after the legislative session in which
13 the Legislature receives a report from the Director of Health
14 Care Administration certifying that the federal Health Care
15 Financing Administration has implemented a per-episode
16 prospective pay system for Medicare-certified home health
17 agencies.
18 (f)(j) For an inmate health care facility built by or
19 for the exclusive use of the Department of Corrections as
20 provided in chapter 945. This exemption expires when such
21 facility is converted to other uses.
22 (k) For an expenditure by or on behalf of a health
23 care facility to provide a health service exclusively on an
24 outpatient basis.
25 (g)(l) For the termination of an inpatient a health
26 care service.
27 (h)(m) For the delicensure of beds. A request for
28 exemption An application submitted under this paragraph must
29 identify the number, the category of beds classification, and
30 the name of the facility in which the beds to be delicensed
31 are located.
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1 (i)(n) For the provision of adult inpatient diagnostic
2 cardiac catheterization services in a hospital.
3 1. In addition to any other documentation otherwise
4 required by the agency, a request for an exemption submitted
5 under this paragraph must comply with the following criteria:
6 a. The applicant must certify it will not provide
7 therapeutic cardiac catheterization pursuant to the grant of
8 the exemption.
9 b. The applicant must certify it will meet and
10 continuously maintain the minimum licensure requirements
11 adopted by the agency governing such programs pursuant to
12 subparagraph 2.
13 c. The applicant must certify it will provide a
14 minimum of 2 percent of its services to charity and Medicaid
15 patients.
16 2. The agency shall adopt licensure requirements by
17 rule which govern the operation of adult inpatient diagnostic
18 cardiac catheterization programs established pursuant to the
19 exemption provided in this paragraph. The rules shall ensure
20 that such programs:
21 a. Perform only adult inpatient diagnostic cardiac
22 catheterization services authorized by the exemption and will
23 not provide therapeutic cardiac catheterization or any other
24 services not authorized by the exemption.
25 b. Maintain sufficient appropriate equipment and
26 health personnel to ensure quality and safety.
27 c. Maintain appropriate times of operation and
28 protocols to ensure availability and appropriate referrals in
29 the event of emergencies.
30 d. Maintain appropriate program volumes to ensure
31 quality and safety.
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1 e. Provide a minimum of 2 percent of its services to
2 charity and Medicaid patients each year.
3 3.a. The exemption provided by this paragraph shall
4 not apply unless the agency determines that the program is in
5 compliance with the requirements of subparagraph 1. and that
6 the program will, after beginning operation, continuously
7 comply with the rules adopted pursuant to subparagraph 2. The
8 agency shall monitor such programs to ensure compliance with
9 the requirements of subparagraph 2.
10 b.(I) The exemption for a program shall expire
11 immediately when the program fails to comply with the rules
12 adopted pursuant to sub-subparagraphs 2.a., b., and c.
13 (II) Beginning 18 months after a program first begins
14 treating patients, the exemption for a program shall expire
15 when the program fails to comply with the rules adopted
16 pursuant to sub-subparagraphs 2.d. and e.
17 (III) If the exemption for a program expires pursuant
18 to sub-sub-subparagraph (I) or sub-sub-subparagraph (II), the
19 agency shall not grant an exemption pursuant to this paragraph
20 for an adult inpatient diagnostic cardiac catheterization
21 program located at the same hospital until 2 years following
22 the date of the determination by the agency that the program
23 failed to comply with the rules adopted pursuant to
24 subparagraph 2.
25 4. The agency shall not grant any exemption under this
26 paragraph until the adoption of the rules required under this
27 paragraph, or until March 1, 1998, whichever comes first.
28 However, if final rules have not been adopted by March 1,
29 1998, the proposed rules governing the exemptions shall be
30 used by the agency to grant exemptions under the provisions of
31 this paragraph until final rules become effective.
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1 (j)(o) For any expenditure to provide mobile surgical
2 facilities and related health care services provided under
3 contract with the Department of Corrections or a private
4 correctional facility operating pursuant to chapter 957.
5 (k)(p) For state veterans' nursing homes operated by
6 or on behalf of the Florida Department of Veterans' Affairs in
7 accordance with part II of chapter 296 for which at least 50
8 percent of the construction cost is federally funded and for
9 which the Federal Government pays a per diem rate not to
10 exceed one-half of the cost of the veterans' care in such
11 state nursing homes. These beds shall not be included in the
12 nursing home bed inventory.
13 (l) For combination within one nursing home facility
14 of the beds or services authorized by two or more certificates
15 of need issued in the same planning subdistrict. An exemption
16 granted under this paragraph shall extend the validity period
17 of the certificates of need to be consolidated by the length
18 of the period beginning upon submission of the exemption
19 request and ending with issuance of the exemption. The
20 longest validity period among the certificates shall be
21 applicable to each of the combined certificates.
22 (m) For division into two or more nursing home
23 facilities of beds or services authorized by one certificate
24 of need issued in the same planning subdistrict. An exemption
25 granted under this paragraph shall extend the validity period
26 of the certificate of need to be divided by the length of the
27 period beginning upon submission of the exemption request and
28 ending with issuance of the exemption.
29 (n) For the addition of hospital beds licensed under
30 chapter 395 for acute care, mental health services, or a
31 hospital-based distinct part skilled nursing unit in a number
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1 that may not exceed 10 total beds or 10 percent of the
2 licensed capacity of the bed category being expanded,
3 whichever is greater. Beds for specialty burn units, neonatal
4 intensive care units, or comprehensive rehabilitation, or at a
5 long-term care hospital, may not be increased under this
6 paragraph.
7 1. In addition to any other documentation otherwise
8 required by the agency, a request for exemption submitted
9 under this paragraph must:
10 a. Certify that the prior 12-month average occupancy
11 rate for the category of licensed beds being expanded at the
12 facility meets or exceeds 80 percent or, for a hospital-based
13 distinct part skilled nursing unit, the prior 12-month average
14 occupancy rate meets or exceeds 96 percent.
15 b. Certify that any beds of the same type authorized
16 for the facility under this paragraph before the date of the
17 current request for an exemption have been licensed and
18 operational for at least 12 months.
19 2. The timeframes and monitoring process specified in
20 s. 408.040(2)(a)-(c) apply to any exemption issued under this
21 paragraph.
22 3. The agency shall count beds authorized under this
23 paragraph as approved beds in the published inventory of
24 hospital beds until the beds are licensed.
25 (o) For the addition of acute care beds, as authorized
26 by rule consistent with s. 395.003(4), in a number that may
27 not exceed 10 total beds or 10 percent of licensed bed
28 capacity, whichever is greater, for temporary beds in a
29 hospital that has experienced high seasonal occupancy within
30 the prior 12-month period or in a hospital that must respond
31 to emergency circumstances.
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1 (p) For the addition of nursing home beds licensed
2 under chapter 400 in a number not exceeding 10 total beds or
3 10 percent of the number of beds licensed in the facility
4 being expanded, whichever is greater.
5 1. In addition to any other documentation required by
6 the agency, a request for exemption submitted under this
7 paragraph must:
8 a. Effective until June 30, 2001, certify that the
9 facility has not had any class I or class II deficiencies
10 within the 30 months preceding the request for addition.
11 b. Effective on July 1, 2001, certify that the
12 facility has been designated as a Gold Seal nursing home under
13 s. 400.235.
14 c. Certify that the prior 12-month average occupancy
15 rate for the nursing home beds at the facility meets or
16 exceeds 96 percent.
17 d. Certify that any beds authorized for the facility
18 under this paragraph before the date of the current request
19 for an exemption have been licensed and operational for at
20 least 12 months.
21 2. The timeframes and monitoring process specified in
22 s. 408.040(2)(a)-(c) apply to any exemption issued under this
23 paragraph.
24 3. The agency shall count beds authorized under this
25 paragraph as approved beds in the published inventory of
26 nursing home beds until the beds are licensed.
27 (4) A request for exemption under this subsection (3)
28 may be made at any time and is not subject to the batching
29 requirements of this section. The request shall be supported
30 by such documentation as the agency requires by rule. The
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1 agency shall assess a fee of $250 for each request for
2 exemption submitted under subsection (3).
3 Section 16. Paragraph (a) of subsection (1) of section
4 408.037, Florida Statutes, is amended to read:
5 408.037 Application content.--
6 (1) An application for a certificate of need must
7 contain:
8 (a) A detailed description of the proposed project and
9 statement of its purpose and need in relation to the local
10 health plan and the state health plan.
11 Section 17. Section 408.038, Florida Statutes, is
12 amended to read:
13 408.038 Fees.--The agency department shall assess fees
14 on certificate-of-need applications. Such fees shall be for
15 the purpose of funding the functions of the local health
16 councils and the activities of the agency department and shall
17 be allocated as provided in s. 408.033. The fee shall be
18 determined as follows:
19 (1) A minimum base fee of $5,000.
20 (2) In addition to the base fee of $5,000, 0.015 of
21 each dollar of proposed expenditure, except that a fee may not
22 exceed $22,000.
23 Section 18. Subsections (3) and (4) and paragraphs (a)
24 and (b) of subsection (6) of section 408.039, Florida
25 Statutes, are amended to read:
26 408.039 Review process.--The review process for
27 certificates of need shall be as follows:
28 (3) APPLICATION PROCESSING.--
29 (a) An applicant shall file an application with the
30 agency department, and shall furnish a copy of the application
31 to the local health council and the agency department. Within
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1 15 days after the applicable application filing deadline
2 established by agency department rule, the staff of the agency
3 department shall determine if the application is complete. If
4 the application is incomplete, the staff shall request
5 specific information from the applicant necessary for the
6 application to be complete; however, the staff may make only
7 one such request. If the requested information is not filed
8 with the agency department within 21 days of the receipt of
9 the staff's request, the application shall be deemed
10 incomplete and deemed withdrawn from consideration.
11 (b) Upon the request of any applicant or substantially
12 affected person within 14 days after notice that an
13 application has been filed, a public hearing may be held at
14 the agency's department's discretion if the agency department
15 determines that a proposed project involves issues of great
16 local public interest. The public hearing shall allow
17 applicants and other interested parties reasonable time to
18 present their positions and to present rebuttal information. A
19 recorded verbatim record of the hearing shall be maintained.
20 The public hearing shall be held at the local level within 21
21 days after the application is deemed complete.
22 (4) STAFF RECOMMENDATIONS.--
23 (a) The agency's department's review of and final
24 agency action on applications shall be in accordance with the
25 district health plan, and statutory criteria, and the
26 implementing administrative rules. In the application review
27 process, the agency department shall give a preference, as
28 defined by rule of the agency department, to an applicant
29 which proposes to develop a nursing home in a nursing home
30 geographically underserved area.
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1 (b) Within 60 days after all the applications in a
2 review cycle are determined to be complete, the agency
3 department shall issue its State Agency Action Report and
4 Notice of Intent to grant a certificate of need for the
5 project in its entirety, to grant a certificate of need for
6 identifiable portions of the project, or to deny a certificate
7 of need. The State Agency Action Report shall set forth in
8 writing its findings of fact and determinations upon which its
9 decision is based. If a finding of fact or determination by
10 the agency department is counter to the district health plan
11 of the local health council, the agency department shall
12 provide in writing its reason for its findings, item by item,
13 to the local health council. If the agency department intends
14 to grant a certificate of need, the State Agency Action Report
15 or the Notice of Intent shall also include any conditions
16 which the agency department intends to attach to the
17 certificate of need. The agency department shall designate by
18 rule a senior staff person, other than the person who issues
19 the final order, to issue State Agency Action Reports and
20 Notices of Intent.
21 (c) The agency department shall publish its proposed
22 decision set forth in the Notice of Intent in the Florida
23 Administrative Weekly within 14 days after the Notice of
24 Intent is issued.
25 (d) If no administrative hearing is requested pursuant
26 to subsection (5), the State Agency Action Report and the
27 Notice of Intent shall become the final order of the agency
28 department. The agency department shall provide a copy of the
29 final order to the appropriate local health council.
30 (6) JUDICIAL REVIEW.--
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1 (a) A party to an administrative hearing for an
2 application for a certificate of need has the right, within
3 not more than 30 days after the date of the final order, to
4 seek judicial review in the District Court of Appeal pursuant
5 to s. 120.68. The agency department shall be a party in any
6 such proceeding.
7 (b) In such judicial review, the court shall affirm
8 the final order of the agency department, unless the decision
9 is arbitrary, capricious, or not in compliance with ss.
10 408.031-408.045.
11 Section 19. Subsections (1) and (2) of section
12 408.040, Florida Statutes, are amended to read:
13 408.040 Conditions and monitoring.--
14 (1)(a) The agency may issue a certificate of need
15 predicated upon statements of intent expressed by an applicant
16 in the application for a certificate of need. Any conditions
17 imposed on a certificate of need based on such statements of
18 intent shall be stated on the face of the certificate of need.
19 1. Any certificate of need issued for construction of
20 a new hospital or for the addition of beds to an existing
21 hospital shall include a statement of the number of beds
22 approved by category of service, including rehabilitation or
23 psychiatric service, for which the agency has adopted by rule
24 a specialty-bed-need methodology. All beds that are approved,
25 but are not covered by any specialty-bed-need methodology,
26 shall be designated as general.
27 (b)2. The agency may consider, in addition to the
28 other criteria specified in s. 408.035, a statement of intent
29 by the applicant that a specified to designate a percentage of
30 the annual patient days at beds of the facility will be
31 utilized for use by patients eligible for care under Title XIX
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1 of the Social Security Act. Any certificate of need issued to
2 a nursing home in reliance upon an applicant's statements that
3 to provide a specified percentage number of annual patient
4 days will be utilized beds for use by residents eligible for
5 care under Title XIX of the Social Security Act must include a
6 statement that such certification is a condition of issuance
7 of the certificate of need. The certificate-of-need program
8 shall notify the Medicaid program office and the Department of
9 Elderly Affairs when it imposes conditions as authorized in
10 this paragraph subparagraph in an area in which a community
11 diversion pilot project is implemented.
12 (c)(b) A certificateholder may apply to the agency for
13 a modification of conditions imposed under paragraph (a) or
14 paragraph (b). If the holder of a certificate of need
15 demonstrates good cause why the certificate should be
16 modified, the agency shall reissue the certificate of need
17 with such modifications as may be appropriate. The agency
18 shall by rule define the factors constituting good cause for
19 modification.
20 (d)(c) If the holder of a certificate of need fails to
21 comply with a condition upon which the issuance of the
22 certificate was predicated, the agency may assess an
23 administrative fine against the certificateholder in an amount
24 not to exceed $1,000 per failure per day. In assessing the
25 penalty, the agency shall take into account as mitigation the
26 relative lack of severity of a particular failure. Proceeds
27 of such penalties shall be deposited in the Public Medical
28 Assistance Trust Fund.
29 (2)(a) Unless the applicant has commenced
30 construction, if the project provides for construction, unless
31 the applicant has incurred an enforceable capital expenditure
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1 commitment for a project, if the project does not provide for
2 construction, or unless subject to paragraph (b), a
3 certificate of need shall terminate 18 months after the date
4 of issuance, except in the case of a multifacility project, as
5 defined in s. 408.032, where the certificate of need shall
6 terminate 2 years after the date of issuance. The agency shall
7 monitor the progress of the holder of the certificate of need
8 in meeting the timetable for project development specified in
9 the application with the assistance of the local health
10 council as specified in s. 408.033(1)(b)5., and may revoke the
11 certificate of need, if the holder of the certificate is not
12 meeting such timetable and is not making a good-faith good
13 faith effort, as defined by rule, to meet it.
14 (b) A certificate of need issued to an applicant
15 holding a provisional certificate of authority under chapter
16 651 shall terminate 1 year after the applicant receives a
17 valid certificate of authority from the Department of
18 Insurance.
19 (c) The certificate-of-need validity period for a
20 project shall be extended by the agency, to the extent that
21 the applicant demonstrates to the satisfaction of the agency
22 that good-faith good faith commencement of the project is
23 being delayed by litigation or by governmental action or
24 inaction with respect to regulations or permitting precluding
25 commencement of the project.
26 (d) If an application is filed to consolidate two or
27 more certificates as authorized by s. 408.036(2)(f) or to
28 divide a certificate of need into two or more facilities as
29 authorized by s. 408.036(2)(g), the validity period of the
30 certificate or certificates of need to be consolidated or
31 divided shall be extended for the period beginning upon
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1 submission of the application and ending when final agency
2 action and any appeal from such action has been concluded.
3 However, no such suspension shall be effected if the
4 application is withdrawn by the applicant.
5 Section 20. Section 408.044, Florida Statutes, is
6 amended to read:
7 408.044 Injunction.--Notwithstanding the existence or
8 pursuit of any other remedy, the agency department may
9 maintain an action in the name of the state for injunction or
10 other process against any person to restrain or prevent the
11 pursuit of a project subject to review under ss.
12 408.031-408.045, in the absence of a valid certificate of
13 need.
14 Section 21. Section 408.045, Florida Statutes, is
15 amended to read:
16 408.045 Certificate of need; competitive sealed
17 proposals.--
18 (1) The application, review, and issuance procedures
19 for a certificate of need for an intermediate care facility
20 for the developmentally disabled may be made by the agency
21 department by competitive sealed proposals.
22 (2) The agency department shall make a decision
23 regarding the issuance of the certificate of need in
24 accordance with the provisions of s. 287.057(15), rules
25 adopted by the agency department relating to intermediate care
26 facilities for the developmentally disabled, and the criteria
27 in s. 408.035, as further defined by rule.
28 (3) Notification of the decision shall be issued to
29 all applicants not later than 28 calendar days after the date
30 responses to a request for proposal are due.
31
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1 (4) The procedures provided for under this section are
2 exempt from the batching cycle requirements and the public
3 hearing requirement of s. 408.039.
4 (5) The agency department may use the competitive
5 sealed proposal procedure for determining a certificate of
6 need for other types of health care facilities and services if
7 the agency department identifies an unmet health care need and
8 when funding in whole or in part for such health care
9 facilities or services is authorized by the Legislature.
10 Section 22. (1)(a) There is created a
11 certificate-of-need workgroup staffed by the Agency for Health
12 Care Administration.
13 (b) Workgroup participants shall be responsible for
14 only the expenses that they generate individually through
15 workgroup participation. The agency shall be responsible for
16 expenses incidental to the production of any required data or
17 reports.
18 (2) The workgroup shall consist of 30 members, 10
19 appointed by the Governor, 10 appointed by the President of
20 the Senate, and 10 appointed by the Speaker of the House of
21 Representatives. The workgroup chairperson shall be selected
22 by majority vote of a quorum present. Sixteen members shall
23 constitute a quorum. The membership shall include, but not be
24 limited to, representatives from health care provider
25 organizations, health care facilities, individual health care
26 practitioners, local health councils, and consumer
27 organizations, and persons with health care market expertise
28 as a private-sector consultant.
29 (3) Appointment to the workgroup shall be as follows:
30 (a) The Governor shall appoint one representative each
31 from the hospital industry; nursing home industry; hospice
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1 industry; local health councils; a consumer organization; and
2 three health care market consultants, one of whom is a
3 recognized expert on hospital markets, one of whom is a
4 recognized expert on nursing home or long-term-care markets,
5 and one of whom is a recognized expert on hospice markets; one
6 representative from the Medicaid program; and one
7 representative from a health care facility that provides a
8 tertiary service.
9 (b) The President of the Senate shall appoint a
10 representative of a for-profit hospital, a representative of a
11 not-for-profit hospital, a representative of a public
12 hospital, two representatives of the nursing home industry,
13 two representatives of the hospice industry, a representative
14 of a consumer organization, a representative from the
15 Department of Elderly Affairs involved with the implementation
16 of a long-term-care community diversion program, and a health
17 care market consultant with expertise in health care
18 economics.
19 (c) The Speaker of the House of Representatives shall
20 appoint a representative from the Florida Hospital
21 Association, a representative of the Association of Community
22 Hospitals and Health Systems of Florida, a representative of
23 the Florida League of Health Systems, a representative of the
24 Florida Health Care Association, a representative of the
25 Florida Association of Homes for the Aging, three
26 representatives of Florida Hospices and Palliative Care, one
27 representative of local health councils, and one
28 representative of a consumer organization.
29 (4) The workgroup shall study issues pertaining to the
30 certificate-of-need program, including the impact of trends in
31 health care delivery and financing. The workgroup shall study
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1 issues relating to implementation of the certificate-of-need
2 program.
3 (5) The workgroup shall meet at least annually, at the
4 request of the chairperson. The workgroup shall submit an
5 interim report by December 31, 2001, and a final report by
6 December 31, 2002. The workgroup is abolished effective July
7 1, 2003.
8 Section 23. Subsection (7) of section 651.118, Florida
9 Statutes, is amended to read:
10 651.118 Agency for Health Care Administration;
11 certificates of need; sheltered beds; community beds.--
12 (7) Notwithstanding the provisions of subsection (2),
13 at the discretion of the continuing care provider, sheltered
14 nursing home beds may be used for persons who are not
15 residents of the facility and who are not parties to a
16 continuing care contract for a period of up to 5 years after
17 the date of issuance of the initial nursing home license. A
18 provider whose 5-year period has expired or is expiring may
19 request the Agency for Health Care Administration for an
20 extension, not to exceed 30 percent of the total sheltered
21 nursing home beds, if the utilization by residents of the
22 facility in the sheltered beds will not generate sufficient
23 income to cover facility expenses, as evidenced by one of the
24 following:
25 (a) The facility has a net loss for the most recent
26 fiscal year as determined under generally accepted accounting
27 principles, excluding the effects of extraordinary or unusual
28 items, as demonstrated in the most recently audited financial
29 statement; or
30 (b) The facility would have had a pro forma loss for
31 the most recent fiscal year, excluding the effects of
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1 extraordinary or unusual items, if revenues were reduced by
2 the amount of revenues from persons in sheltered beds who were
3 not residents, as reported on by a certified public
4 accountant.
5
6 The agency shall be authorized to grant an extension to the
7 provider based on the evidence required in this subsection.
8 The agency may request a facility to use up to 25 percent of
9 the patient days generated by new admissions of nonresidents
10 during the extension period to serve Medicaid recipients for
11 those beds authorized for extended use if there is a
12 demonstrated need in the respective service area and if funds
13 are available. A provider who obtains an extension is
14 prohibited from applying for additional sheltered beds under
15 the provision of subsection (2), unless additional residential
16 units are built or the provider can demonstrate need by
17 facility residents to the Agency for Health Care
18 Administration. The 5-year limit does not apply to up to five
19 sheltered beds designated for inpatient hospice care as part
20 of a contractual arrangement with a hospice licensed under
21 part VI of chapter 400. A facility that uses such beds after
22 the 5-year period shall report such use to the Agency for
23 Health Care Administration. For purposes of this subsection,
24 "resident" means a person who, upon admission to the facility,
25 initially resides in a part of the facility not licensed under
26 part II of chapter 400.
27 Section 24. Subsection (3) of section 400.464, Florida
28 Statutes, is repealed.
29 Section 25. Applications for certificates of need
30 submitted under section 408.031-408.045, Florida Statutes,
31
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1 before the effective date of this act shall be governed by the
2 law in effect at the time the application was submitted.
3 Section 26. The General Appropriations Act for Fiscal
4 Year 2000-2001 shall be reduced by 4 FTE and $260,719 from the
5 Health Care Trust Fund in the Agency for Health Care
6 Administration for purposes of implementing the provisions of
7 sections 10 through 25 of this act.
8 Section 27. Subsection (12) is added to section
9 216.136, Florida Statutes, to read:
10 216.136 Consensus estimating conferences; duties and
11 principals.--
12 (12) MANDATED HEALTH INSURANCE BENEFITS AND PROVIDERS
13 ESTIMATING CONFERENCE.--
14 (a) Duties.--The Mandated Health Insurance Benefits
15 and Providers Estimating Conference shall:
16 1. Develop and maintain, with the Department of
17 Insurance, a system and program of data collection to assess
18 the impact of mandated benefits and providers, including costs
19 to employers and insurers, impact of treatment, cost savings
20 in the health care system, number of providers, and other
21 appropriate data.
22 2. Prescribe the format, content, and timing of
23 information that is to be submitted to the conference and used
24 by the conference in its assessment of proposed and existing
25 mandated benefits and providers. Such format, content, and
26 timing requirements are binding upon all parties submitting
27 information for the conference to use in its assessment of
28 proposed and existing mandated benefits and providers.
29 3. Provide assessments of proposed and existing
30 mandated benefits and providers and other studies of mandated
31 benefits and provider issues as requested by the Legislature
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1 or the Governor. When a legislative measure containing a
2 mandated health insurance benefit or provider is proposed, the
3 standing committee of the Legislature which has jurisdiction
4 over the proposal shall request that the conference prepare
5 and forward to the Governor and the Legislature a study that
6 provides, for each measure, a cost-benefit analysis that
7 assesses the social and financial impact and the medical
8 efficacy according to prevailing medical standards of the
9 proposed mandate. The conference has 12 months after the
10 committee makes its request in which to complete and submit
11 the conference's report. The standing committee may not
12 consider such a proposed legislative measure until 12 months
13 after it has requested the report and has received the
14 conference's report on the measure.
15 4. The standing committees of the Legislature which
16 have jurisdiction over health insurance matters shall request
17 that the conference assess the social and financial impact and
18 the medical efficacy of existing mandated benefits and
19 providers. The committees shall submit to the conference by
20 January 1, 2001, a schedule of evaluations that sets forth the
21 respective dates by which the conference must have completed
22 its evaluations of particular existing mandates.
23 (b) Principals.--The Executive Office of the Governor,
24 the Insurance Commissioner, the Agency for Health Care
25 Administration, the Director of the Division of Economic and
26 Demographic Research of the Joint Legislative Management
27 Committee, and professional staff of the Senate and the House
28 of Representatives who have health insurance expertise, or
29 their designees, are the principals of the Mandated Health
30 Insurance Benefits and Providers Estimating Conference. The
31
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1 responsibility of presiding over sessions of the conference
2 shall be rotated among the principals.
3 Section 28. Section 624.215, Florida Statutes, is
4 amended to read:
5 624.215 Proposals for legislation which mandates
6 health benefit coverage; review by Legislature.--
7 (1) LEGISLATIVE INTENT.--The Legislature finds that
8 there is an increasing number of proposals which mandate that
9 certain health benefits be provided by insurers and health
10 maintenance organizations as components of individual and
11 group policies. The Legislature further finds that many of
12 these benefits provide beneficial social and health
13 consequences which may be in the public interest. However,
14 the Legislature also recognizes that most mandated benefits
15 contribute to the increasing cost of health insurance
16 premiums. Therefore, it is the intent of the Legislature to
17 conduct a systematic review of current and proposed mandated
18 or mandatorily offered health coverages and to establish
19 guidelines for such a review. This review will assist the
20 Legislature in determining whether mandating a particular
21 coverage is in the public interest.
22 (2) MANDATED HEALTH COVERAGE; REPORT TO THE MANDATED
23 HEALTH INSURANCE BENEFITS AND PROVIDERS ESTIMATING CONFERENCE
24 AGENCY FOR HEALTH CARE ADMINISTRATION AND LEGISLATIVE
25 COMMITTEES; GUIDELINES FOR ASSESSING IMPACT.--Every person or
26 organization seeking consideration of a legislative proposal
27 which would mandate a health coverage or the offering of a
28 health coverage by an insurance carrier, health care service
29 contractor, or health maintenance organization as a component
30 of individual or group policies, shall submit to the Mandated
31 Health Insurance Benefits and Providers Estimating Conference
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1 Agency for Health Care Administration and the legislative
2 committees having jurisdiction a report which assesses the
3 social and financial impacts of the proposed coverage.
4 Guidelines for assessing the impact of a proposed mandated or
5 mandatorily offered health coverage must, to the extent that
6 information is available, shall include:
7 (a) To what extent is the treatment or service
8 generally used by a significant portion of the population.
9 (b) To what extent is the insurance coverage generally
10 available.
11 (c) If the insurance coverage is not generally
12 available, to what extent does the lack of coverage result in
13 persons avoiding necessary health care treatment.
14 (d) If the coverage is not generally available, to
15 what extent does the lack of coverage result in unreasonable
16 financial hardship.
17 (e) The level of public demand for the treatment or
18 service.
19 (f) The level of public demand for insurance coverage
20 of the treatment or service.
21 (g) The level of interest of collective bargaining
22 agents in negotiating for the inclusion of this coverage in
23 group contracts.
24 (h) A report, prepared by a certified actuary, of the
25 extent to which To what extent will the coverage will increase
26 or decrease the cost of the treatment or service.
27 (i) A report, prepared by a certified actuary, of the
28 extent to which To what extent will the coverage will increase
29 the appropriate uses of the treatment or service.
30 (j) A report, prepared by a certified actuary, of the
31 extent to which To what extent will the mandated treatment or
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1 service will be a substitute for a more expensive treatment or
2 service.
3 (k) A report, prepared by a certified actuary, of the
4 extent to which To what extent will the coverage will increase
5 or decrease the administrative expenses of insurance companies
6 and the premium and administrative expenses of policyholders.
7 (l) A report, prepared by a certified actuary, as to
8 the impact of this coverage on the total cost of health care.
9
10 The standing committee of the Legislature which has
11 jurisdiction over the legislative proposal must request and
12 receive a report from the Mandated Health Insurance Benefits
13 and Providers Estimating Conference before the committee
14 considers the proposal. The committee may not consider a
15 legislative proposal that would mandate a health coverage or
16 the offering of a health coverage by an insurance carrier,
17 health care service contractor, or health maintenance
18 organization until after the committee's request to the
19 Mandated Health Insurance Benefits and Providers Estimating
20 Conference has been answered. As used in this section, the
21 term "health coverage mandate" includes mandating the use of a
22 type of provider.
23 Section 29. Effective January 1, 2001, a physician
24 licensed under chapter 458, Florida Statutes, or chapter 459,
25 Florida Statutes, or a hospital licensed under chapter 395,
26 Florida Statutes, shall provide a consumer-assistance notice
27 in the form of a sign that is prominently displayed in the
28 reception area and clearly noticeable by all patients and in
29 the form of a written statement that is given to each person
30 to whom medical services are being provided. Such a sign or
31 statement must state that consumer information regarding a
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1 doctor, hospital, or health plan is available through a
2 toll-free number and website maintained by the Agency for
3 Health Care Administration. In addition, the sign and
4 statement must state that any complaint regarding medical
5 services received or the patient's health plan may be
6 submitted through the toll-free number. The agency, in
7 cooperation with other appropriate agencies, shall establish
8 the consumer-assistance program and provide physicians and
9 hospitals with information regarding the toll-free number and
10 website and with signs for posting in facilities at no cost to
11 the provider.
12 Section 30. Subsection (1) of section 408.7056,
13 Florida Statutes, is amended to read:
14 408.7056 Statewide Provider and Subscriber Assistance
15 Program.--
16 (1) As used in this section, the term:
17 (a) "Agency" means the Agency for Health Care
18 Administration.
19 (b) "Department" means the Department of Insurance.
20 (c) "Grievance procedure" means an established set of
21 rules that specify a process for appeal of an organizational
22 decision.
23 (d) "Health care provider" or "provider" means a
24 state-licensed or state-authorized facility, a facility
25 principally supported by a local government or by funds from a
26 charitable organization that holds a current exemption from
27 federal income tax under s. 501(c)(3) of the Internal Revenue
28 Code, a licensed practitioner, a county health department
29 established under part I of chapter 154, a prescribed
30 pediatric extended care center defined in s. 400.902, a
31 federally supported primary care program such as a migrant
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1 health center or a community health center authorized under s.
2 329 or s. 330 of the United States Public Health Services Act
3 that delivers health care services to individuals, or a
4 community facility that receives funds from the state under
5 the Community Alcohol, Drug Abuse, and Mental Health Services
6 Act and provides mental health services to individuals.
7 (e)(a) "Managed care entity" means a health
8 maintenance organization or a prepaid health clinic certified
9 under chapter 641, a prepaid health plan authorized under s.
10 409.912, or an exclusive provider organization certified under
11 s. 627.6472.
12 (f)(b) "Panel" means a statewide provider and
13 subscriber assistance panel selected as provided in subsection
14 (11).
15 Section 31. Section 627.654, Florida Statutes, is
16 amended to read:
17 627.654 Labor union, and association, and small
18 employer health alliance groups.--
19 (1)(a) A group of individuals may be insured under a
20 policy issued to an association, including a labor union,
21 which association has a constitution and bylaws and not less
22 than 25 individual members and which has been organized and
23 has been maintained in good faith for a period of 1 year for
24 purposes other than that of obtaining insurance, or to the
25 trustees of a fund established by such an association, which
26 association or trustees shall be deemed the policyholder,
27 insuring at least 15 individual members of the association for
28 the benefit of persons other than the officers of the
29 association, the association or trustees.
30 (b) A small employer, as defined in s. 627.6699 and
31 including the employer's eligible employees and the spouses
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1 and dependents of such employees, may be insured under a
2 policy issued to a small employer health alliance by a carrier
3 as defined in s. 627.6699. A small employer health alliance
4 must be organized as a not-for-profit corporation under
5 chapter 617. Notwithstanding any other law, if a
6 small-employer member of an alliance loses eligibility to
7 purchase health care through the alliance solely because the
8 business of the small-employer member expands to more than 50
9 and fewer than 75 eligible employees, the small-employer
10 member may, at its next renewal date, purchase coverage
11 through the alliance for not more than 1 additional year. A
12 small employer health alliance shall establish conditions of
13 participation in the alliance by a small employer, including,
14 but not limited to:
15 1. Assurance that the small employer is not formed for
16 the purpose of securing health benefit coverage.
17 2. Assurance that the employees of a small employer
18 have not been added for the purpose of securing health benefit
19 coverage.
20 (2) No such policy of insurance as defined in
21 subsection (1) may be issued to any such association or
22 alliance, unless all individual members of such association,
23 or all small-employer members of an alliance, or all of any
24 class or classes thereof, are declared eligible and acceptable
25 to the insurer at the time of issuance of the policy.
26 (3) Any such policy issued under paragraph (1)(a) may
27 insure the spouse or dependent children with or without the
28 member being insured.
29 (4) A single master policy issued to an association,
30 labor union, or small-employer health alliance may include
31 more than one health plan from the same insurer or affiliated
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1 insurer group as alternatives for an employer, employee, or
2 member to select.
3 Section 32. Paragraph (f) of subsection (2), paragraph
4 (b) of subsection (4), and subsection (6) of section 627.6571,
5 Florida Statutes, are amended to read:
6 627.6571 Guaranteed renewability of coverage.--
7 (2) An insurer may nonrenew or discontinue a group
8 health insurance policy based only on one or more of the
9 following conditions:
10 (f) In the case of health insurance coverage that is
11 made available only through one or more bona fide associations
12 as defined in subsection (5) or through one or more small
13 employer health alliances as described in s. 627.654(1)(b),
14 the membership of an employer in the association or in the
15 small employer health alliance, on the basis of which the
16 coverage is provided, ceases, but only if such coverage is
17 terminated under this paragraph uniformly without regard to
18 any health-status-related factor that relates to any covered
19 individuals.
20 (4) At the time of coverage renewal, an insurer may
21 modify the health insurance coverage for a product offered:
22 (b) In the small-group market if, for coverage that is
23 available in such market other than only through one or more
24 bona fide associations as defined in subsection (5) or through
25 one or more small employer health alliances as described in s.
26 627.654(1)(b), such modification is consistent with s.
27 627.6699 and effective on a uniform basis among group health
28 plans with that product.
29 (6) In applying this section in the case of health
30 insurance coverage that is made available by an insurer in the
31 small-group market or large-group market to employers only
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1 through one or more associations or through one or more small
2 employer health alliances as described in s. 627.654(1)(b), a
3 reference to "policyholder" is deemed, with respect to
4 coverage provided to an employer member of the association, to
5 include a reference to such employer.
6 Section 33. Paragraph (h) of subsection (5), and
7 paragraph (a) of subsection (12) of section 627.6699, Florida
8 Statutes, are amended to read:
9 627.6699 Employee Health Care Access Act.--
10 (5) AVAILABILITY OF COVERAGE.--
11 (h) All health benefit plans issued under this section
12 must comply with the following conditions:
13 1. For employers who have fewer than two employees, a
14 late enrollee may be excluded from coverage for no longer than
15 24 months if he or she was not covered by creditable coverage
16 continually to a date not more than 63 days before the
17 effective date of his or her new coverage.
18 2. Any requirement used by a small employer carrier in
19 determining whether to provide coverage to a small employer
20 group, including requirements for minimum participation of
21 eligible employees and minimum employer contributions, must be
22 applied uniformly among all small employer groups having the
23 same number of eligible employees applying for coverage or
24 receiving coverage from the small employer carrier, except
25 that a small employer carrier that participates in,
26 administers, or issues health benefits pursuant to s. 381.0406
27 which do not include a preexisting condition exclusion may
28 require as a condition of offering such benefits that the
29 employer has had no health insurance coverage for its
30 employees for a period of at least 6 months. A small employer
31 carrier may vary application of minimum participation
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1 requirements and minimum employer contribution requirements
2 only by the size of the small employer group.
3 3. In applying minimum participation requirements with
4 respect to a small employer, a small employer carrier shall
5 not consider as an eligible employee employees or dependents
6 who have qualifying existing coverage in an employer-based
7 group insurance plan or an ERISA qualified self-insurance plan
8 in determining whether the applicable percentage of
9 participation is met. However, a small employer carrier may
10 count eligible employees and dependents who have coverage
11 under another health plan that is sponsored by that employer
12 except if such plan is offered pursuant to s. 408.706.
13 4. A small employer carrier shall not increase any
14 requirement for minimum employee participation or any
15 requirement for minimum employer contribution applicable to a
16 small employer at any time after the small employer has been
17 accepted for coverage, unless the employer size has changed,
18 in which case the small employer carrier may apply the
19 requirements that are applicable to the new group size.
20 5. If a small employer carrier offers coverage to a
21 small employer, it must offer coverage to all the small
22 employer's eligible employees and their dependents. A small
23 employer carrier may not offer coverage limited to certain
24 persons in a group or to part of a group, except with respect
25 to late enrollees.
26 6. A small employer carrier may not modify any health
27 benefit plan issued to a small employer with respect to a
28 small employer or any eligible employee or dependent through
29 riders, endorsements, or otherwise to restrict or exclude
30 coverage for certain diseases or medical conditions otherwise
31 covered by the health benefit plan.
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1 7. An initial enrollment period of at least 30 days
2 must be provided. An annual 30-day open enrollment period
3 must be offered to each small employer's eligible employees
4 and their dependents. A small employer carrier must provide
5 special enrollment periods as required by s. 627.65615.
6 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
7 PLANS.--
8 (a)1. By May 15, 1993, the commissioner shall appoint
9 a health benefit plan committee composed of four
10 representatives of carriers which shall include at least two
11 representatives of HMOs, at least one of which is a staff
12 model HMO, two representatives of agents, four representatives
13 of small employers, and one employee of a small employer. The
14 carrier members shall be selected from a list of individuals
15 recommended by the board. The commissioner may require the
16 board to submit additional recommendations of individuals for
17 appointment. As alliances are established under s. 408.702,
18 each alliance shall also appoint an additional member to the
19 committee.
20 2. The committee shall develop changes to the form and
21 level of coverages for the standard health benefit plan and
22 the basic health benefit plan, and shall submit the forms, and
23 levels of coverages to the department by September 30, 1993.
24 The department must approve such forms and levels of coverages
25 by November 30, 1993, and may return the submissions to the
26 committee for modification on a schedule that allows the
27 department to grant final approval by November 30, 1993.
28 3. The plans shall comply with all of the requirements
29 of this subsection.
30
31
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1 4. The plans must be filed with and approved by the
2 department prior to issuance or delivery by any small employer
3 carrier.
4 5. After approval of the revised health benefit plans,
5 if the department determines that modifications to a plan
6 might be appropriate, the commissioner shall appoint a new
7 health benefit plan committee in the manner provided in
8 subparagraph 1. to submit recommended modifications to the
9 department for approval.
10 Section 34. Subsection (1) of section 240.2995,
11 Florida Statutes, is amended to read:
12 240.2995 University health services support
13 organizations.--
14 (1) Each state university is authorized to establish
15 university health services support organizations which shall
16 have the ability to enter into, for the benefit of the
17 university academic health sciences center, and arrangements
18 with other entities as providers for accountable health
19 partnerships, as defined in s. 408.701, and providers in other
20 integrated health care systems or similar entities. To the
21 extent required by law or rule, university health services
22 support organizations shall become licensed as insurance
23 companies, pursuant to chapter 624, or be certified as health
24 maintenance organizations, pursuant to chapter 641.
25 University health services support organizations shall have
26 sole responsibility for the acts, debts, liabilities, and
27 obligations of the organization. In no case shall the state
28 or university have any responsibility for such acts, debts,
29 liabilities, and obligations incurred or assumed by university
30 health services support organizations.
31
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1 Section 35. Paragraph (a) of subsection (2) of section
2 240.2996, Florida Statutes, is amended to read:
3 240.2996 University health services support
4 organization; confidentiality of information.--
5 (2) The following university health services support
6 organization's records and information are confidential and
7 exempt from the provisions of s. 119.07(1) and s. 24(a), Art.
8 I of the State Constitution:
9 (a) Contracts for managed care arrangements, as
10 managed care is defined in s. 408.701, under which the
11 university health services support organization provides
12 health care services, including preferred provider
13 organization contracts, health maintenance organization
14 contracts, alliance network arrangements, and exclusive
15 provider organization contracts, and any documents directly
16 relating to the negotiation, performance, and implementation
17 of any such contracts for managed care arrangements or
18 alliance network arrangements. As used in this paragraph, the
19 term "managed care" means systems or techniques generally used
20 by third-party payors or their agents to affect access to and
21 control payment for health care services. Managed-care
22 techniques most often include one or more of the following:
23 prior, concurrent, and retrospective review of the medical
24 necessity and appropriateness of services or site of services;
25 contracts with selected health care providers; financial
26 incentives or disincentives related to the use of specific
27 providers, services, or service sites; controlled access to
28 and coordination of services by a case manager; and payor
29 efforts to identify treatment alternatives and modify benefit
30 restrictions for high-cost patient care.
31
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1 The exemptions in this subsection are subject to the Open
2 Government Sunset Review Act of 1995 in accordance with s.
3 119.15 and shall stand repealed on October 2, 2001, unless
4 reviewed and saved from repeal through reenactment by the
5 Legislature.
6 Section 36. Paragraph (b) of subsection (8) of section
7 240.512, Florida Statutes, is amended to read:
8 240.512 H. Lee Moffitt Cancer Center and Research
9 Institute.--There is established the H. Lee Moffitt Cancer
10 Center and Research Institute at the University of South
11 Florida.
12 (8)
13 (b) Proprietary confidential business information is
14 confidential and exempt from the provisions of s. 119.07(1)
15 and s. 24(a), Art. I of the State Constitution. However, the
16 Auditor General and Board of Regents, pursuant to their
17 oversight and auditing functions, must be given access to all
18 proprietary confidential business information upon request and
19 without subpoena and must maintain the confidentiality of
20 information so received. As used in this paragraph, the term
21 "proprietary confidential business information" means
22 information, regardless of its form or characteristics, which
23 is owned or controlled by the not-for-profit corporation or
24 its subsidiaries; is intended to be and is treated by the
25 not-for-profit corporation or its subsidiaries as private and
26 the disclosure of which would harm the business operations of
27 the not-for-profit corporation or its subsidiaries; has not
28 been intentionally disclosed by the corporation or its
29 subsidiaries unless pursuant to law, an order of a court or
30 administrative body, a legislative proceeding pursuant to s.
31 5, Art. III of the State Constitution, or a private agreement
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1 that provides that the information may be released to the
2 public; and which is information concerning:
3 1. Internal auditing controls and reports of internal
4 auditors;
5 2. Matters reasonably encompassed in privileged
6 attorney-client communications;
7 3. Contracts for managed-care arrangements, as managed
8 care is defined in s. 408.701, including preferred provider
9 organization contracts, health maintenance organization
10 contracts, and exclusive provider organization contracts, and
11 any documents directly relating to the negotiation,
12 performance, and implementation of any such contracts for
13 managed-care arrangements;
14 4. Bids or other contractual data, banking records,
15 and credit agreements the disclosure of which would impair the
16 efforts of the not-for-profit corporation or its subsidiaries
17 to contract for goods or services on favorable terms;
18 5. Information relating to private contractual data,
19 the disclosure of which would impair the competitive interest
20 of the provider of the information;
21 6. Corporate officer and employee personnel
22 information;
23 7. Information relating to the proceedings and records
24 of credentialing panels and committees and of the governing
25 board of the not-for-profit corporation or its subsidiaries
26 relating to credentialing;
27 8. Minutes of meetings of the governing board of the
28 not-for-profit corporation and its subsidiaries, except
29 minutes of meetings open to the public pursuant to subsection
30 (9);
31
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1 9. Information that reveals plans for marketing
2 services that the corporation or its subsidiaries reasonably
3 expect to be provided by competitors;
4 10. Trade secrets as defined in s. 688.002, including
5 reimbursement methodologies or rates; or
6 11. The identity of donors or prospective donors of
7 property who wish to remain anonymous or any information
8 identifying such donors or prospective donors. The anonymity
9 of these donors or prospective donors must be maintained in
10 the auditor's report.
11
12 As used in this paragraph, the term "managed care" means
13 systems or techniques generally used by third-party payors or
14 their agents to affect access to and control payment for
15 health care services. Managed-care techniques most often
16 include one or more of the following: prior, concurrent, and
17 retrospective review of the medical necessity and
18 appropriateness of services or site of services; contracts
19 with selected health care providers; financial incentives or
20 disincentives related to the use of specific providers,
21 services, or service sites; controlled access to and
22 coordination of services by a case manager; and payor efforts
23 to identify treatment alternatives and modify benefit
24 restrictions for high-cost patient care.
25 Section 37. Subsection (14) of section 381.0406,
26 Florida Statutes, is amended to read:
27 381.0406 Rural health networks.--
28 (14) NETWORK FINANCING.--Networks may use all sources
29 of public and private funds to support network activities.
30 Nothing in this section prohibits networks from becoming
31 managed care providers, or accountable health partnerships,
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1 provided they meet the requirements for an accountable health
2 partnership as specified in s. 408.706.
3 Section 38. Paragraph (a) of subsection (2) of section
4 395.3035, Florida Statutes, is amended to read:
5 395.3035 Confidentiality of hospital records and
6 meetings.--
7 (2) The following records and information of any
8 hospital that is subject to chapter 119 and s. 24(a), Art. I
9 of the State Constitution are confidential and exempt from the
10 provisions of s. 119.07(1) and s. 24(a), Art. I of the State
11 Constitution:
12 (a) Contracts for managed care arrangements, as
13 managed care is defined in s. 408.701, under which the public
14 hospital provides health care services, including preferred
15 provider organization contracts, health maintenance
16 organization contracts, exclusive provider organization
17 contracts, and alliance network arrangements, and any
18 documents directly relating to the negotiation, performance,
19 and implementation of any such contracts for managed care or
20 alliance network arrangements. As used in this paragraph, the
21 term "managed care" means systems or techniques generally used
22 by third-party payors or their agents to affect access to and
23 control payment for health care services. Managed-care
24 techniques most often include one or more of the following:
25 prior, concurrent, and retrospective review of the medical
26 necessity and appropriateness of services or site of services;
27 contracts with selected health care providers; financial
28 incentives or disincentives related to the use of specific
29 providers, services, or service sites; controlled access to
30 and coordination of services by a case manager; and payor
31
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1 efforts to identify treatment alternatives and modify benefit
2 restrictions for high-cost patient care.
3 Section 39. Paragraph (b) of subsection (1) of section
4 627.4301, Florida Statutes, is amended to read:
5 627.4301 Genetic information for insurance purposes.--
6 (1) DEFINITIONS.--As used in this section, the term:
7 (b) "Health insurer" means an authorized insurer
8 offering health insurance as defined in s. 624.603, a
9 self-insured plan as defined in s. 624.031, a
10 multiple-employer welfare arrangement as defined in s.
11 624.437, a prepaid limited health service organization as
12 defined in s. 636.003, a health maintenance organization as
13 defined in s. 641.19, a prepaid health clinic as defined in s.
14 641.402, a fraternal benefit society as defined in s. 632.601,
15 an accountable health partnership as defined in s. 408.701, or
16 any health care arrangement whereby risk is assumed.
17 Section 40. Subsection (3) of section 408.70, and
18 sections 408.701, 408.702, 408.703, 408.704, 408.7041,
19 408.7042, 408.7045, 408.7055, and 408.706, Florida Statutes,
20 are repealed.
21 Section 41. Paragraph (n) of subsection (3), paragraph
22 (c) of subsection (5), and paragraphs (b) and (d) of
23 subsection (6) of section 627.6699, Florida Statutes, are
24 amended to read:
25 627.6699 Employee Health Care Access Act.--
26 (3) DEFINITIONS.--As used in this section, the term:
27 (n) "Modified community rating" means a method used to
28 develop carrier premiums which spreads financial risk across a
29 large population and allows adjustments for age, gender,
30 family composition, tobacco usage, and geographic area as
31 determined under paragraph (5)(j); claims experience, health
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1 status, or duration of coverage as permitted under
2 subparagraph (6)(b)5.; and administrative and acquisition
3 expenses as permitted under subparagraph (6)(b)6.
4 (5) AVAILABILITY OF COVERAGE.--
5 (c) Every small employer carrier must, as a condition
6 of transacting business in this state:
7 1. Beginning July 1, 2000, January 1, 1994, offer and
8 issue all small employer health benefit plans on a
9 guaranteed-issue basis to every eligible small employer, with
10 2 3 to 50 eligible employees, that elects to be covered under
11 such plan, agrees to make the required premium payments, and
12 satisfies the other provisions of the plan. A rider for
13 additional or increased benefits may be medically underwritten
14 and may only be added to the standard health benefit plan.
15 The increased rate charged for the additional or increased
16 benefit must be rated in accordance with this section.
17 2. Beginning August 1, 2000 April 15, 1994, offer and
18 issue basic and standard small employer health benefit plans
19 on a guaranteed-issue basis, during a 31-day open enrollment
20 period of August 1 through August 31 of each year, to every
21 eligible small employer, with less than one or two eligible
22 employees, which small employer is not formed primarily for
23 the purpose of buying health insurance and which elects to be
24 covered under such plan, agrees to make the required premium
25 payments, and satisfies the other provisions of the plan.
26 Coverage provided under this subparagraph shall begin on
27 October 1 of the same year as the date of enrollment, unless
28 the small employer carrier and the small employer agree to a
29 different date. A rider for additional or increased benefits
30 may be medically underwritten and may only be added to the
31 standard health benefit plan. The increased rate charged for
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1 the additional or increased benefit must be rated in
2 accordance with this section. For purposes of this
3 subparagraph, a person, his or her spouse, and his or her
4 dependent children constitute a single eligible employee if
5 that person and spouse are employed by the same small employer
6 and either that person or his or her spouse has a normal work
7 week of less than 25 hours.
8 3. Offer to eligible small employers the standard and
9 basic health benefit plans. This paragraph subparagraph does
10 not limit a carrier's ability to offer other health benefit
11 plans to small employers if the standard and basic health
12 benefit plans are offered and rejected.
13 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
14 (b) For all small employer health benefit plans that
15 are subject to this section and are issued by small employer
16 carriers on or after January 1, 1994, premium rates for health
17 benefit plans subject to this section are subject to the
18 following:
19 1. Small employer carriers must use a modified
20 community rating methodology in which the premium for each
21 small employer must be determined solely on the basis of the
22 eligible employee's and eligible dependent's gender, age,
23 family composition, tobacco use, or geographic area as
24 determined under paragraph (5)(j) and in which the premium may
25 be adjusted as permitted by subparagraphs 5. and 6.
26 2. Rating factors related to age, gender, family
27 composition, tobacco use, or geographic location may be
28 developed by each carrier to reflect the carrier's experience.
29 The factors used by carriers are subject to department review
30 and approval.
31
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1 3. Small employer carriers may not modify the rate for
2 a small employer for 12 months from the initial issue date or
3 renewal date, unless the composition of the group changes or
4 benefits are changed. However, a small employer carrier may
5 modify the rate one time prior to 12 months after the initial
6 issue date for a small employer who enrolls under a previously
7 issued group policy that has a common anniversary date for all
8 employers covered under the policy if:
9 a. The carrier discloses to the employer in a clear
10 and conspicuous manner the date of the first renewal and the
11 fact that the premium may increase on or after that date.
12 b. The insurer demonstrates to the department that
13 efficiencies in administration are achieved and reflected in
14 the rates charged to small employers covered under the policy.
15 4. A carrier may issue a group health insurance policy
16 to a small employer health alliance or other group association
17 with rates that reflect a premium credit for expense savings
18 attributable to administrative activities being performed by
19 the alliance or group association if such expense savings are
20 specifically documented in the insurer's rate filing and are
21 approved by the department. Any such credit may not be based
22 on different morbidity assumptions or on any other factor
23 related to the health status or claims experience of any
24 person covered under the policy. Nothing in this subparagraph
25 exempts an alliance or group association from licensure for
26 any activities that require licensure under the Insurance
27 Code. A carrier issuing a group health insurance policy to a
28 small-employer health alliance or other group association
29 shall allow any properly licensed and appointed agent of that
30 carrier to market and sell the small-employer health alliance
31 or other group association policy. Such agent shall be paid
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1 the usual and customary commission paid to any agent selling
2 the policy. Carriers participating in the alliance program, in
3 accordance with ss. 408.70-408.706, may apply a different
4 community rate to business written in that program.
5 5. Any adjustments in rates for claims experience,
6 health status, or duration of coverage may not be charged to
7 individual employees or dependents. For a small employer's
8 policy, such adjustments may not result in a rate for the
9 small employer which deviates more than 15 percent from the
10 carrier's approved rate. Any such adjustment must be applied
11 uniformly to the rates charged for all employees and
12 dependents of the small employer. A small employer carrier may
13 make an adjustment to a small employer's renewal premium, not
14 to exceed 10 percent annually, due to the claims experience,
15 health status, or duration of coverage of the employees or
16 dependents of the small employer. Semiannually small group
17 carriers shall report information on forms adopted by rule by
18 the department to enable the department to monitor the
19 relationship of aggregate adjusted premiums actually charged
20 policyholders by each carrier to the premiums that would have
21 been charged by application of the carrier's approved modified
22 community rates. If the aggregate resulting from the
23 application of such adjustment exceeds the premium that would
24 have been charged by application of the approved modified
25 community rate by 5 percent for the current reporting period,
26 the carrier shall limit the application of such adjustments
27 only to minus adjustments beginning not more than 60 days
28 after the report is sent to the department. For any subsequent
29 reporting period, if the total aggregate adjusted premium
30 actually charged does not exceed the premium that would have
31 been charged by application of the approved modified community
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1 rate by 5 percent, the carrier may apply both plus and minus
2 adjustments. A small employer carrier may provide a credit to
3 a small employer's premium based on administrative and
4 acquisition expense differences resulting from the size of the
5 group. Group size administrative and acquisition expense
6 factors may be developed by each carrier to reflect the
7 carrier's experience and are subject to department review and
8 approval.
9 6. A small employer carrier rating methodology may
10 include separate rating categories for one dependent child,
11 for two dependent children, and for three or more dependent
12 children for family coverage of employees having a spouse and
13 dependent children or employees having dependent children
14 only. A small employer carrier may have fewer, but not
15 greater, numbers of categories for dependent children than
16 those specified in this subparagraph.
17 7. Small employer carriers may not use a composite
18 rating methodology to rate a small employer with fewer than 10
19 employees. For the purposes of this subparagraph, a "composite
20 rating methodology" means a rating methodology that averages
21 the impact of the rating factors for age and gender in the
22 premiums charged to all of the employees of a small employer.
23 (d) Notwithstanding s. 627.401(2), this section and
24 ss. 627.410 and 627.411 apply to any health benefit plan
25 provided by a small employer carrier that is an insurer, and
26 this section and s. 641.31 apply to any health benefit
27 provided by a small employer carrier that is a health
28 maintenance organization that provides coverage to one or more
29 employees of a small employer regardless of where the policy,
30 certificate, or contract is issued or delivered, if the health
31
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1 benefit plan covers employees or their covered dependents who
2 are residents of this state.
3 Section 42. Subsection (2) of section 641.27, Florida
4 Statutes, is amended to read:
5 641.27 Examination by the department.--
6 (2) The department may contract, at reasonable fees
7 for work performed, with qualified, impartial outside sources
8 to perform audits or examinations or portions thereof
9 pertaining to the qualification of an entity for issuance of a
10 certificate of authority or to determine continued compliance
11 with the requirements of this part, in which case the payment
12 must be made, directly to the contracted examiner by the
13 health maintenance organization examined, in accordance with
14 the rates and terms agreed to by the department and the
15 examiner. Any contracted assistance shall be under the direct
16 supervision of the department. The results of any contracted
17 assistance shall be subject to the review of, and approval,
18 disapproval, or modification by, the department.
19 Section 43. Application of federal solvency
20 requirements to provider-sponsored organizations.--The
21 solvency requirements of sections 1855 and 1856 of the
22 Balanced Budget Act of 1997 and rules adopted by the Secretary
23 of the United States Department of Health and Human Services
24 apply to a health maintenance organization that is a
25 provider-sponsored organization rather than the solvency
26 requirements of part I of chapter 64, Florida Statutes.
27 However, if the provider-sponsored organization does not meet
28 the solvency requirements of this part, the organization is
29 limited to the issuance of Medicare+Choice plans to eligible
30 individuals. For the purposes of this section, the terms
31 "Medicare+Choice plans," "provider-sponsored organizations,"
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1 and "solvency requirements" have the same meaning as defined
2 in the federal act and federal rules and regulations.
3 Section 44. Insurance holding companies.--Part IV of
4 chapter 628, Florida Statutes, applies to health maintenance
5 organizations licensed under part I of chapter 641, Florida
6 Statutes.
7 Section 45. Section 641.275, Florida Statutes, is
8 created to read:
9 641.275 Subscriber's rights under health maintenance
10 contracts; required notice.--
11 (1) It is the intent of the Legislature that the
12 rights of subscribers who are covered under health maintenance
13 organization contracts be recognized and summarized in a
14 statement of subscriber rights. An organization may not
15 require a subscriber to waive his or her rights as a condition
16 of coverage or treatment and must operate in conformity with
17 such rights.
18 (2) Each organization must provide subscribers with a
19 copy of their rights as set forth in this section, in such
20 form as approved by the department.
21 (3) An organization shall:
22 (a) Ensure that health care services provided to
23 subscribers are rendered under reasonable standards of quality
24 of care consistent with the prevailing standards of medical
25 practice in the community, as required by s. 641.51;
26 (b) Have a quality assurance program for health care
27 services, as required by s. 641.51;
28 (c) Not modify the professional judgment of a
29 physician unless the course of treatment is inconsistent with
30 the prevailing standards of medical practice in the community,
31 as required by s. 641.51;
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1 (d) Not restrict a provider's ability to communicate
2 information to the subscriber/patient regarding medical care
3 options that are in the best interest of the
4 subscriber/patient, as required by s. 641.315(8);
5 (e) Provide for standing referrals to specialists for
6 subscribers with chronic and disabling conditions, as required
7 by s. 641.51;
8 (f) Allow a female subscriber to select an
9 obstetrician/gynecologist as her primary care physician, as
10 required by s. 641.19(13)(e);
11 (g) Provide direct access, without prior
12 authorization, for a female subscriber to visit a
13 obstetrician/gynecologist, as required by s. 641.51(10);
14 (h) Provide direct access, without prior
15 authorization, to a dermatologist, as required by s.
16 641.31(33);
17 (i) Not limit coverage for the length of stay in a
18 hospital for a mastectomy for any time period that is less
19 than that determined to be medically necessary by the treating
20 physician, as required by s. 641.31(33);
21 (j) Not limit coverage for the length of a maternity
22 or newborn stay in a hospital or for follow-up care outside
23 the hospital to any time period less than that determined to
24 be medically necessary by the treating provider, as required
25 by s. 641.31(18);
26 (k) Not exclude coverage for bone marrow transplant
27 procedures determined by the Agency for Health Care
28 Administration to not be experimental, as required by s.
29 627.4236;
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1 (l) Not exclude coverage for drugs on the ground that
2 the drug is not approved by the U.S. Food and Drug
3 Administration, as required by s. 627.4239;
4 (m) Give the subscriber the right to a second medical
5 opinion as required by s. 641.51(4);
6 (n) Allow subscribers to continue treatment from a
7 provider after the provider's contract with the organization
8 has been terminated, as required by s. 641.51(7);
9 (o) Establish a procedure for resolving subscriber
10 grievances, including review of adverse determinations by the
11 organization and expedited review of urgent subscriber
12 grievances, as required by s. 641.511;
13 (p) Notify subscribers of the right to an independent
14 external review of grievances not resolved by the
15 organization, as required by s. 408.7056;
16 (q) Provide, without prior authorization, coverage for
17 emergency services and care, as required by s. 641.513;
18 (r) Not require or solicit genetic information or use
19 genetic test results for any insurance purposes, as required
20 by s. 627.4310;
21 (s) Promptly pay or deny claims as required by s.
22 641.3155;
23 (t) Provide information to subscribers regarding
24 benefits, limitations, resolving grievances, emergency
25 services and care, treatment by non-contract providers, list
26 of contract providers, authorization and referral process, the
27 process used to determine whether services are medically
28 necessary, quality assurance program, prescription drug
29 benefits and use of a drug formulary, confidentiality and
30 disclosure of medical records, process of determining
31 experimental or investigational medical treatments, and
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1 process used to examine qualifications of contract providers,
2 as required by ss. 641.31, 641.495, and 641.54.
3 (4) The statement of rights in subsection (3) is a
4 summary of selected requirements for organizations contained
5 in other sections of the Florida Statutes. This section does
6 not alter the requirements of such other sections.
7 (5)(a) The department may impose a fine against a
8 health maintenance organization for a violation of this
9 section which refers to a section in this part or in chapter
10 627. Such fines shall be in the amounts specified in s.
11 641.25.
12 (b) The agency may impose a fine against a health
13 maintenance organization for a violation of this section which
14 refers to a section in part III of this chapter or in chapter
15 408. Such fines shall be in the amounts specified in s.
16 641.52.
17 Section 46. Section 641.28, Florida Statutes, is
18 amended to read:
19 641.28 Civil remedy.--
20 (1) In any civil action brought to enforce the terms
21 and conditions of a health maintenance organization contract:
22 (a) If the civil action is filed before or within 60
23 days after the subscriber or enrollee filed a notice of intent
24 to sue with the statewide provider and subscriber assistance
25 program established pursuant to s. 408.7056 or a notice
26 pursuant to s. 641.3917, the prevailing party is entitled to
27 recover reasonable attorney's fees and court costs.
28 (b) If the civil action is filed more than 60 days
29 after the subscriber or enrollee filed a notice of intent to
30 sue with the statewide provider and subscriber assistance
31 program established pursuant to s. 408.7056 or a notice
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1 pursuant to s. 641.3917, and the subscriber or enrollee
2 receives a final judgment or decree against the health
3 maintenance organization in favor of the subscriber or
4 enrollee, the court shall enter a judgment or decree against
5 the health maintenance organization in favor of the subscriber
6 or enrollee for reasonable attorney's fees and court costs.
7 (2) This section shall not be construed to authorize a
8 civil action against the department, its employees, or the
9 Insurance Commissioner or against the Agency for Health Care
10 Administration, its employees, or the director of the agency.
11 Section 47. Paragraphs (c), (d), and (e) are added to
12 subsection (10) of section 641.3903, Florida Statutes, and
13 subsection (15) is added to that section, to read:
14 641.3903 Unfair methods of competition and unfair or
15 deceptive acts or practices defined.--The following are
16 defined as unfair methods of competition and unfair or
17 deceptive acts or practices:
18 (10) ILLEGAL DEALINGS IN PREMIUMS; EXCESS OR REDUCED
19 CHARGES FOR HEALTH MAINTENANCE COVERAGE.--
20 (c) Cancelling or otherwise terminating any health
21 maintenance contract or coverage, or requiring execution of a
22 consent to rate endorsement, during the stated contract term
23 for the purpose of offering to issue, or issuing, a similar or
24 identical contract to the same subscriber or enrollee with the
25 same exposure at a higher premium rate or continuing an
26 existing contract with the same exposure at an increased
27 premium.
28 (d) Issuing a nonrenewal notice on any health
29 maintenance organization contract, or requiring execution of a
30 consent to rate endorsement, for the purpose of offering to
31 issue, or issuing, a similar or identical contract to the same
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1 subscriber or enrollee at a higher premium rate or continuing
2 an existing contract at an increased premium without meeting
3 any applicable notice requirements.
4 (e) Cancelling or issuing a nonrenewal notice on any
5 health maintenance organization contract without complying
6 with any applicable cancellation or nonrenewal provision
7 required under the Florida Insurance Code.
8 (15) REFUSAL TO COVER.--In addition to other
9 provisions of this code, the refusal to cover, or continue to
10 cover, any individual solely because of:
11 (a) Race, color, creed, marital status, sex, or
12 national origin;
13 (b) The residence, age, or lawful occupation of the
14 individual, unless there is a reasonable relationship between
15 the residence, age, or lawful occupation of the individual and
16 the coverage issued or to be issued; or
17 (c) The fact that the enrollee or applicant had been
18 previously refused insurance coverage or health maintenance
19 organization coverage by any insurer or health maintenance
20 organization when such refusal to cover or continue to cover
21 for this reason occurs with such frequency as to indicate a
22 general business practice.
23 Section 48. Section 641.3917, Florida Statutes, is
24 amended to read:
25 641.3917 Civil liability.--The provisions of this part
26 are cumulative to rights under the general civil and common
27 law, and no action of the department shall abrogate such
28 rights to damage or other relief in any court.
29 (1) Any person to whom a duty is owed may bring a
30 civil action against a health maintenance organization when
31 such person suffers damages as a result of:
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1 (a) A violation of s. 641.3903(5)(a), (b), (c)1.-7.,
2 (10), or (15) by the health maintenance organization; or
3 (b) The health maintenance organization's failure to
4 provide a covered service when in good faith the health
5 maintenance organization should have provided the service if
6 it had acted fairly and honestly toward its subscriber or
7 enrollee and with due regard for his or her interests and, in
8 the independent medical judgment of a contract treating
9 physician or other physician authorized by the health
10 maintenance organization, the service is medically necessary.
11
12 However, a person pursuing a remedy under this section need
13 not prove that such acts were committed or performed with such
14 frequency as to indicate a general business practice.
15 (2)(a) As a condition precedent to bringing an action
16 under this section, the department and the health maintenance
17 organization must have been given 60 days' written notice of
18 the violation. If the department returns a notice for lack of
19 specificity, the 60-day time period does not begin until a
20 proper notice is filed.
21 (b) The notice must be on a form provided by the
22 department and must state with specificity the following
23 information and such other information as the department
24 requires:
25 1. The provision of law, including the specific
26 language of the law, which the health maintenance organization
27 has allegedly violated.
28 2. The facts and circumstances giving rise to the
29 violation.
30 3. The name of any individual involved in the
31 violation.
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1 4. Any reference to specific contract language that is
2 relevant to the violation.
3 5. A statement that the notice is given in order to
4 perfect the right to pursue the civil remedy authorized by
5 this section.
6 (c) Within 20 days after receipt of the notice, the
7 department may return any notice that does not provide the
8 specific information required by this section, and the
9 department shall indicate the specific deficiencies contained
10 in the notice. A determination by the department to return a
11 notice for lack of specificity is exempt from the requirements
12 of chapter 120.
13 (d) No action shall lie under this section if, within
14 60 days after filing notice, the damages are paid or the
15 circumstances giving rise to the violation are corrected.
16 (e) The health maintenance organization that is the
17 recipient of a notice filed under this section shall report to
18 the department on the disposition of the alleged violation.
19 (f) The applicable statute of limitations for an
20 action under this section shall be tolled for a period of 65
21 days by the mailing of the notice required by this subsection
22 or the mailing of a subsequent notice required by this
23 subsection.
24 (3) Upon adverse adjudication at trial or upon appeal,
25 the health maintenance organization is liable for damages,
26 together with court costs and reasonable attorney's fees,
27 incurred by the plaintiff.
28 (4) Punitive damages shall not be awarded under this
29 section unless the acts giving rise to the violation occur
30 with such frequency as to indicate a general business practice
31 and are either willful, wanton, and malicious or are in
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1 reckless disregard for the rights of any subscriber or
2 enrollee. Any person who pursues a claim under this
3 subsection shall post, in advance, the costs of discovery.
4 Such costs shall be awarded to the health maintenance
5 organization if no punitive damages are awarded to the
6 plaintiff.
7 (5) This section shall not be construed to authorize a
8 class action suit against a health maintenance organization or
9 a civil action against the department, its employees, or the
10 Insurance Commissioner, or against the Agency for Health Care
11 Administration, its employees, or the director of the agency
12 or to create a cause of action when a health maintenance
13 organization refuses to pay a claim for reimbursement on the
14 grounds that the charge for a service was unreasonably high or
15 that the service provided was not medically necessary.
16 (6)(a) The civil remedy specified in this section does
17 not preempt any other remedy or cause of action provided for
18 pursuant to any other law or pursuant to the common law of
19 this state. Any person may obtain a judgment under either the
20 common law remedy of bad faith or the remedy provided in this
21 section, but is not entitled to a judgment under both
22 remedies. This section does not create a common law cause of
23 action. The damages recoverable under this section include
24 damages that are a reasonably foreseeable result of a
25 specified violation of this section by the health maintenance
26 organization and may include an award or judgment in an amount
27 that exceeds contract limits.
28 (b) This section does not create a cause of action for
29 medical malpractice. Such an action is subject to the
30 provisions of chapter 766.
31
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1 (c) This section does not apply to the provision of
2 medical care, treatment, or attendance pursuant to chapter
3 440.
4 Section 49. Subsection (4) of section 440.11, Florida
5 Statutes, is amended to read:
6 440.11 Exclusiveness of liability.--
7 (4) Notwithstanding the provisions of s. 624.155 or s.
8 641.3917, the liability of a carrier or a health maintenance
9 organization to an employee or to anyone entitled to bring
10 suit in the name of the employee shall be as provided in this
11 chapter, which shall be exclusive and in place of all other
12 liability.
13 Section 50. The Legislature finds that the provisions
14 of this act will fulfill an important state interest.
15 Section 51. The sum of $112,000 is appropriated from
16 the Insurance Commissioner's Regulatory Trust Fund to the
17 Department of Insurance and three positions are authorized for
18 the purposes of carrying out the provisions of sections 46
19 through 49 of this act.
20 Section 52. Subsection (39) is added to section
21 641.31, Florida Statutes, to read:
22 641.31 Health maintenance contracts.--
23 (39) A health maintenance organization contract may
24 not prohibit or restrict a subscriber from receiving
25 in-patient services in a contracted hospital from a contracted
26 primary care or admitting physician if such services are
27 determined by the organization to be medically necessary and
28 covered services under the organization's contract with the
29 contract holder.
30 Section 53. Subsection (11) is added to section
31 641.315, Florida Statutes, to read:
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1 641.315 Provider contracts.--
2 (11) A contract between a health maintenance
3 organization and a contracted primary-care or admitting
4 physician may not contain any provision that prohibits such
5 physician from providing in-patient services in a contracted
6 hospital to a subscriber if such services are determined by
7 the organization to be medically necessary and covered
8 services under the organization's contract with the contract
9 holder.
10 Section 54. Subsection (5) is added to section
11 641.3155, Florida Statutes, to read:
12 641.3155 Provider contracts; payment of claims.--
13 (5) A health maintenance organization shall pay a
14 contracted primary-care or admitting physician, pursuant to
15 such physician's contract, for providing in-patient services
16 in a contracted hospital to a subscriber, if such services are
17 determined by the organization to be medically necessary and
18 covered services under the organization's contract with the
19 contract holder.
20 Section 55. Present subsections (4), (5), (6), (7),
21 (8), (9), and (10) of section 641.51, Florida Statutes, are
22 redesignated as subsections (5), (6), (7), (8), (9), (10), and
23 (11), respectively, and a new subsection (4) is added to that
24 section to read:
25 641.51 Quality assurance program; second medical
26 opinion requirement.--
27 (4) The organization shall ensure that only a
28 physician licensed under chapter 458 or chapter 459; or an
29 M.D. or D.O. physician with an active, unencumbered license in
30 another state with similar licensing requirements may render
31 an adverse determination regarding a service provided by a
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1 physician licensed in this state. The organization shall
2 submit to the treating provider and the subscriber written
3 notification regarding the organization's adverse
4 determination within 2 working days after the subscriber or
5 provider is notified of the adverse determination. The written
6 notification must include the utilization review criteria or
7 benefits provisions used in the adverse determination,
8 identify the physician who rendered the adverse determination,
9 and be signed by an authorized representative of the
10 organization or the physician who renders the adverse
11 determination. The organization must include with the
12 notification of an adverse determination information
13 concerning the appeal process for adverse determinations.
14 Section 56. This act shall take effect July 1, 2000,
15 and apply to contracts issued or renewed on or after that
16 date, except as otherwise provided in this act and except that
17 the amendment to section 395.701, Florida Statutes, by this
18 act shall take effect only upon the receipt by the Agency for
19 Health Care Administration of written confirmation from the
20 federal Health Care Financing Administration that the changes
21 contained in such amendment will not adversely affect the use
22 of the remaining assessments as state match for the state's
23 Medicaid program.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS/SB 2154, CS/SB 1900 and SB 282
3
4 This bill combines provisions of CS/CS/SB 162, CS/SB 420,
CS/SB 866, CS/SB 954, CS/SB 1300, SB 1534, CS/SB 1900, CS/SB
5 2086, SB 2152, CS/SB 2154, and SB 2612. The bill includes
provisions relating to: assessments on certain health care
6 entities to fund the Public Medical Assistance Trust Fund;
Medicaid reimbursement limits on hospital outpatient services;
7 the certificate-of-need program; mandated health insurance
benefits; consumer-assistance notices by physicians and
8 hospitals and a consumer assistance program; small employer
health alliances; the Employee Health Care Access Act and
9 rating restrictions on small group insurance; regulation of
health maintenance organizations; health maintenance
10 organization subscribers' rights; civil liability of health
maintenance organizations; mandatory use of "hospitalists" by
11 health maintenance organizations; and adverse determinations
by health maintenance organizations.
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