Florida Senate - 2012 SB 1634
By Senator Montford
6-01237-12 20121634__
1 A bill to be entitled
2 An act relating to health care grievances; amending s.
3 641.511, F.S.; retaining the requirement that any
4 health maintenance organization and any prepaid health
5 clinic must have a grievance procedure available to
6 subscribers to address complaints and grievances;
7 deleting provisions that require, specify, or provide
8 for certain reports, procedures, processes,
9 notifications, reviews, deadlines, or administrative
10 penalties relating to such required grievance
11 procedure; repealing s. 408.7056, F.S., relating to
12 the Subscriber Assistance Program; deleting authority
13 for the Subscriber Assistance Program, adopted and
14 implemented by the Agency for Health Care
15 Administration, to provide assistance to subscribers
16 whose grievances are not resolved by a managed care
17 entity to the satisfaction of the subscriber and
18 deleting procedures, processes, and requirements with
19 respect thereto; amending ss. 220.1845, 376.30781,
20 376.86, 409.818, 409.91211, 641.185, 641.3154, 641.51,
21 641.515, and 641.58, F.S.; conforming cross
22 references; providing an effective date.
23
24 Be It Enacted by the Legislature of the State of Florida:
25
26 Section 1. Section 641.511, Florida Statutes, is amended to
27 read:
28 641.511 Subscriber grievance procedure reporting and
29 resolution requirements.—
30 (1) Every organization must have a grievance procedure
31 available to its subscribers for the purpose of addressing
32 complaints and grievances. Every organization must notify its
33 subscribers that a subscriber must submit a grievance within 1
34 year after the date of occurrence of the action that initiated
35 the grievance, and may submit the grievance for review to the
36 Subscriber Assistance Program panel as provided in s. 408.7056
37 after receiving a final disposition of the grievance through the
38 organization’s grievance process. An organization shall maintain
39 records of all grievances and shall report annually to the
40 agency the total number of grievances handled, a categorization
41 of the cases underlying the grievances, and the final
42 disposition of the grievances.
43 (2) When an organization receives an initial complaint from
44 a subscriber, the organization must respond to the complaint
45 within a reasonable time after its submission. At the time of
46 receipt of the initial complaint, the organization shall inform
47 the subscriber that the subscriber has a right to file a written
48 grievance at any time and that assistance in preparing the
49 written grievance shall be provided by the organization.
50 (3) Each organization’s grievance procedure, as required
51 under subsection (1), must include, at a minimum:
52 (a) An explanation of how to pursue redress of a grievance.
53 (b) The names of the appropriate employees or a list of
54 grievance departments that are responsible for implementing the
55 organization’s grievance procedure. The list must include the
56 address and the toll-free telephone number of each grievance
57 department, the address of the agency and its toll-free
58 telephone hotline number, and the address of the Subscriber
59 Assistance Program and its toll-free telephone number.
60 (c) The description of the process through which a
61 subscriber may, at any time, contact the toll-free telephone
62 hotline of the agency to inform it of the unresolved grievance.
63 (d) A procedure for establishing methods for classifying
64 grievances as urgent and for establishing time limits for an
65 expedited review within which such grievances must be resolved.
66 (e) A notice that a subscriber may voluntarily pursue
67 binding arbitration in accordance with the terms of the contract
68 if offered by the organization, after completing the
69 organization’s grievance procedure and as an alternative to the
70 Subscriber Assistance Program. Such notice shall include an
71 explanation that the subscriber may incur some costs if the
72 subscriber pursues binding arbitration, depending upon the terms
73 of the subscriber’s contract.
74 (f) A process whereby the grievance manager acknowledges
75 the grievance and investigates the grievance in order to notify
76 the subscriber of a final decision in writing.
77 (g) A procedure for providing individuals who are unable to
78 submit a written grievance with access to the grievance process,
79 which shall include assistance by the organization in preparing
80 the grievance and communicating back to the subscriber.
81 (4)(a) With respect to a grievance concerning an adverse
82 determination, an organization shall make available to the
83 subscriber a review of the grievance by an internal review
84 panel; such review must be requested within 30 days after the
85 organization’s transmittal of the final determination notice of
86 an adverse determination. A majority of the panel shall be
87 persons who previously were not involved in the initial adverse
88 determination. A person who previously was involved in the
89 adverse determination may appear before the panel to present
90 information or answer questions. The panel shall have the
91 authority to bind the organization to the panel’s decision.
92 (b) An organization shall ensure that a majority of the
93 persons reviewing a grievance involving an adverse determination
94 are providers who have appropriate expertise. An organization
95 shall issue a copy of the written decision of the review panel
96 to the subscriber and to the provider, if any, who submits a
97 grievance on behalf of a subscriber. In cases where there has
98 been a denial of coverage of service, the reviewing provider
99 shall not be a provider previously involved with the adverse
100 determination.
101 (c) An organization shall establish written procedures for
102 a review of an adverse determination. Review procedures shall be
103 available to the subscriber and to a provider acting on behalf
104 of a subscriber.
105 (d) In any case when the review process does not resolve a
106 difference of opinion between the organization and the
107 subscriber or the provider acting on behalf of the subscriber,
108 the subscriber or the provider acting on behalf of the
109 subscriber may submit a written grievance to the Subscriber
110 Assistance Program.
111 (5) Except as provided in subsection (6), the organization
112 shall resolve a grievance within 60 days after receipt of the
113 grievance, or within a maximum of 90 days if the grievance
114 involves the collection of information outside the service area.
115 These time limitations are tolled if the organization has
116 notified the subscriber, in writing, that additional information
117 is required for proper review of the grievance and that such
118 time limitations are tolled until such information is provided.
119 After the organization receives the requested information, the
120 time allowed for completion of the grievance process resumes.
121 The Employee Retirement Income Security Act of 1974, as
122 implemented by 29 C.F.R. s. 2560.503-1, is adopted and
123 incorporated by reference as applicable to all organizations
124 that administer small and large group health plans that are
125 subject to 29 C.F.R. s. 2560.503-1. The claims procedures of the
126 regulations of the Employee Retirement Income Security Act of
127 1974, as implemented by 29 C.F.R. s. 2560.503-1, shall be the
128 minimum standards for grievance processes for claims for
129 benefits for small and large group health plans that are subject
130 to 29 C.F.R. s. 2560.503-1.
131 (6)(a) An organization shall establish written procedures
132 for the expedited review of an urgent grievance. A request for
133 an expedited review may be submitted orally or in writing and
134 shall be subject to the review procedures of this section, if it
135 meets the criteria of this section. Unless it is submitted in
136 writing, for purposes of the grievance reporting requirements in
137 subsection (1), the request shall be considered an appeal of a
138 utilization review decision and not a grievance. Expedited
139 review procedures shall be available to a subscriber and to the
140 provider acting on behalf of a subscriber. For purposes of this
141 subsection, “subscriber” includes the legal representative of a
142 subscriber.
143 (b) Expedited reviews shall be evaluated by an appropriate
144 clinical peer or peers. The clinical peer or peers shall not
145 have been involved in the initial adverse determination.
146 (c) In an expedited review, all necessary information,
147 including the organization’s decision, shall be transmitted
148 between the organization and the subscriber, or the provider
149 acting on behalf of the subscriber, by telephone, facsimile, or
150 the most expeditious method available.
151 (d) In an expedited review, an organization shall make a
152 decision and notify the subscriber, or the provider acting on
153 behalf of the subscriber, as expeditiously as the subscriber’s
154 medical condition requires, but in no event more than 72 hours
155 after receipt of the request for review. If the expedited review
156 is a concurrent review determination, the service shall be
157 continued without liability to the subscriber until the
158 subscriber has been notified of the determination.
159 (e) An organization shall provide written confirmation of
160 its decision concerning an expedited review within 2 working
161 days after providing notification of that decision, if the
162 initial notification was not in writing.
163 (f) An organization shall provide reasonable access, not to
164 exceed 24 hours after receiving a request for an expedited
165 review, to a clinical peer who can perform the expedited review.
166 (g) In any case when the expedited review process does not
167 resolve a difference of opinion between the organization and the
168 subscriber or the provider acting on behalf of the subscriber,
169 the subscriber or the provider acting on behalf of the
170 subscriber may submit a written grievance to the Subscriber
171 Assistance Program.
172 (h) An organization shall not provide an expedited
173 retrospective review of an adverse determination.
174 (7) Each organization shall send to the agency a copy of
175 its quarterly grievance reports submitted to the office pursuant
176 to s. 408.7056(12).
177 (8) The agency shall investigate all reports of unresolved
178 quality of care grievances received from:
179 (a) Annual and quarterly grievance reports submitted by the
180 organization to the office.
181 (b) Review requests of subscribers whose grievances remain
182 unresolved after the subscriber has followed the full grievance
183 procedure of the organization.
184 (9)(a) The agency shall advise subscribers with grievances
185 to follow their organization’s formal grievance process for
186 resolution prior to review by the Subscriber Assistance Program.
187 The subscriber may, however, submit a copy of the grievance to
188 the agency at any time during the process.
189 (b) Requiring completion of the organization’s grievance
190 process before the Subscriber Assistance Program panel’s review
191 does not preclude the agency from investigating any complaint or
192 grievance before the organization makes its final determination.
193 (10) Each organization must notify the subscriber in a
194 final decision letter that the subscriber may request review of
195 the organization’s decision concerning the grievance by the
196 Subscriber Assistance Program, as provided in s. 408.7056, if
197 the grievance is not resolved to the satisfaction of the
198 subscriber. The final decision letter must inform the subscriber
199 that the request for review must be made within 365 days after
200 receipt of the final decision letter, must explain how to
201 initiate such a review, and must include the addresses and toll
202 free telephone numbers of the agency and the Subscriber
203 Assistance Program.
204 (11) Each organization, as part of its contract with any
205 provider, must require the provider to post a consumer
206 assistance notice prominently displayed in the reception area of
207 the provider and clearly noticeable by all patients. The
208 consumer assistance notice must state the addresses and toll
209 free telephone numbers of the Agency for Health Care
210 Administration, the Subscriber Assistance Program, and the
211 Department of Financial Services. The consumer assistance notice
212 must also clearly state that the address and toll-free telephone
213 number of the organization’s grievance department shall be
214 provided upon request. The agency may adopt rules to implement
215 this section.
216 (12) The agency may impose administrative sanction, in
217 accordance with s. 641.52, against an organization for
218 noncompliance with this section.
219 Section 2. Section 408.7056, Florida Statutes, is repealed.
220 Section 3. Paragraph (k) of subsection (2) of section
221 220.1845, Florida Statutes, is amended to read:
222 220.1845 Contaminated site rehabilitation tax credit.—
223 (2) AUTHORIZATION FOR TAX CREDIT; LIMITATIONS.—
224 (k) In order to encourage the construction and operation of
225 a new health care facility as defined in s. 408.032 or s.
226 408.07, or a health care provider as defined in s. 408.07 or
227 former s. 408.7056, on a brownfield site, an applicant for a tax
228 credit may claim an additional 25 percent of the total site
229 rehabilitation costs, not to exceed $500,000, if the applicant
230 meets the requirements of this paragraph. In order to receive
231 this additional tax credit, the applicant must provide
232 documentation indicating that the construction of the health
233 care facility or health care provider by the applicant on the
234 brownfield site has received a certificate of occupancy or a
235 license or certificate has been issued for the operation of the
236 health care facility or health care provider.
237 Section 4. Paragraph (f) of subsection (3) of section
238 376.30781, Florida Statutes, is amended to read:
239 376.30781 Tax credits for rehabilitation of drycleaning
240 solvent-contaminated sites and brownfield sites in designated
241 brownfield areas; application process; rulemaking authority;
242 revocation authority.—
243 (3)
244 (f) In order to encourage the construction and operation of
245 a new health care facility or a health care provider, as defined
246 in s. 408.032, s. 408.07, or former s. 408.7056, on a brownfield
247 site, an applicant for a tax credit may claim an additional 25
248 percent of the total site rehabilitation costs, not to exceed
249 $500,000, if the applicant meets the requirements of this
250 paragraph. In order to receive this additional tax credit, the
251 applicant must provide documentation indicating that the
252 construction of the health care facility or health care provider
253 by the applicant on the brownfield site has received a
254 certificate of occupancy or a license or certificate has been
255 issued for the operation of the health care facility or health
256 care provider.
257 Section 5. Subsection (1) of section 376.86, Florida
258 Statutes, is amended to read:
259 376.86 Brownfield Areas Loan Guarantee Program.—
260 (1) The Brownfield Areas Loan Guarantee Council is created
261 to review and approve or deny, by a majority vote of its
262 membership, the situations and circumstances for participation
263 in partnerships by agreements with local governments, financial
264 institutions, and others associated with the redevelopment of
265 brownfield areas pursuant to the Brownfields Redevelopment Act
266 for a limited state guaranty of up to 5 years of loan guarantees
267 or loan loss reserves issued pursuant to law. The limited state
268 loan guaranty applies only to 50 percent of the primary lenders
269 loans for redevelopment projects in brownfield areas. If the
270 redevelopment project is for affordable housing, as defined in
271 s. 420.0004, in a brownfield area, the limited state loan
272 guaranty applies to 75 percent of the primary lender’s loan. If
273 the redevelopment project includes the construction and
274 operation of a new health care facility or a health care
275 provider, as defined in s. 408.032, s. 408.07, or former s.
276 408.7056, on a brownfield site and the applicant has obtained
277 documentation in accordance with s. 376.30781 indicating that
278 the construction of the health care facility or health care
279 provider by the applicant on the brownfield site has received a
280 certificate of occupancy or a license or certificate has been
281 issued for the operation of the health care facility or health
282 care provider, the limited state loan guaranty applies to 75
283 percent of the primary lender’s loan. A limited state guaranty
284 of private loans or a loan loss reserve is authorized for
285 lenders licensed to operate in the state upon a determination by
286 the council that such an arrangement would be in the public
287 interest and the likelihood of the success of the loan is great.
288 Section 6. Paragraph (d) of subsection (3) of section
289 409.818, Florida Statutes, is amended to read:
290 409.818 Administration.—In order to implement ss. 409.810
291 409.821, the following agencies shall have the following duties:
292 (3) The Agency for Health Care Administration, under the
293 authority granted in s. 409.914(1), shall:
294 (d) Establish a mechanism for investigating and resolving
295 complaints and grievances from program applicants, enrollees,
296 and health benefits coverage providers, and maintain a record of
297 complaints and confirmed problems. In the case of a child who is
298 enrolled in a health maintenance organization, the agency must
299 use the provisions of s. 641.511 to address grievance reporting
300 and resolution requirements.
301
302 The agency is designated the lead state agency for Title XXI of
303 the Social Security Act for purposes of receipt of federal
304 funds, for reporting purposes, and for ensuring compliance with
305 federal and state regulations and rules.
306 Section 7. Paragraph (q) of subsection (3) of section
307 409.91211, Florida Statutes, is amended to read:
308 409.91211 Medicaid managed care pilot program.—
309 (3) The agency shall have the following powers, duties, and
310 responsibilities with respect to the pilot program:
311 (q) To implement a grievance resolution process for
312 Medicaid recipients enrolled in a capitated managed care network
313 under the pilot program modeled after the subscriber assistance
314 panel, as created in former s. 408.7056. This process shall
315 include a mechanism for an expedited review of no greater than
316 24 hours after notification of a grievance if the life of a
317 Medicaid recipient is in imminent and emergent jeopardy.
318 Section 8. Paragraph (j) of subsection (1) of section
319 641.185, Florida Statutes, is amended to read:
320 641.185 Health maintenance organization subscriber
321 protections.—
322 (1) With respect to the provisions of this part and part
323 III, the principles expressed in the following statements shall
324 serve as standards to be followed by the commission, the office,
325 the department, and the Agency for Health Care Administration in
326 exercising their powers and duties, in exercising administrative
327 discretion, in administrative interpretations of the law, in
328 enforcing its provisions, and in adopting rules:
329 (j) A health maintenance organization should receive timely
330 and, if necessary, urgent review by an independent state
331 external review organization for unresolved grievances and
332 appeals pursuant to s. 408.7056.
333 Section 9. Subsection (4) of section 641.3154, Florida
334 Statutes, is amended to read:
335 641.3154 Organization liability; provider billing
336 prohibited.—
337 (4) A provider or any representative of a provider,
338 regardless of whether the provider is under contract with the
339 health maintenance organization, may not collect or attempt to
340 collect money from, maintain any action at law against, or
341 report to a credit agency a subscriber of an organization for
342 payment of services for which the organization is liable, if the
343 provider in good faith knows or should know that the
344 organization is liable. This prohibition applies during the
345 pendency of any claim for payment made by the provider to the
346 organization for payment of the services and any legal
347 proceedings or dispute resolution process to determine whether
348 the organization is liable for the services if the provider is
349 informed that such proceedings are taking place. It is presumed
350 that a provider does not know and should not know that an
351 organization is liable unless:
352 (a) The provider is informed by the organization that it
353 accepts liability;
354 (b) A court of competent jurisdiction determines that the
355 organization is liable;
356 (c) The office or agency makes a final determination that
357 the organization is required to pay for such services subsequent
358 to a recommendation made by the Subscriber Assistance Panel
359 pursuant to s. 408.7056; or
360 (d) The agency issues a final order that the organization
361 is required to pay for such services subsequent to a
362 recommendation made by a resolution organization pursuant to s.
363 408.7057.
364 Section 10. Paragraph (c) of subsection (5) of section
365 641.51, Florida Statutes, is amended to read:
366 641.51 Quality assurance program; second medical opinion
367 requirement.—
368 (5)
369 (c) For second opinions provided by contract physicians the
370 organization is prohibited from charging a fee to the subscriber
371 in an amount in excess of the subscriber fees established by
372 contract for referral contract physicians. The organization
373 shall pay the amount of all charges, which are usual,
374 reasonable, and customary in the community, for second opinion
375 services performed by a physician not under contract with the
376 organization, but may require the subscriber to be responsible
377 for up to 40 percent of such amount. The organization may
378 require that any tests deemed necessary by a noncontract
379 physician shall be conducted by the organization. The
380 organization may deny reimbursement rights granted under this
381 section in the event the subscriber seeks in excess of three
382 such referrals per year if such subsequent referral costs are
383 deemed by the organization to be evidence that the subscriber
384 has unreasonably overutilized the second opinion privilege. A
385 subscriber thus denied reimbursement under this section shall
386 have recourse to grievance procedures as specified in ss.
387 408.7056, 641.495, and 641.511. The organization’s physician’s
388 professional judgment concerning the treatment of a subscriber
389 derived after review of a second opinion shall be controlling as
390 to the treatment obligations of the health maintenance
391 organization. Treatment not authorized by the health maintenance
392 organization shall be at the subscriber’s expense.
393 Section 11. Subsection (1) of section 641.515, Florida
394 Statutes, is amended to read:
395 641.515 Investigation by the agency.—
396 (1) The agency shall investigate further any quality of
397 care issue contained in recommendations and reports submitted
398 pursuant to ss. 408.7056 and 641.511. The agency shall also
399 investigate further any information that indicates that the
400 organization does not meet accreditation standards or the
401 standards of the review organization performing the external
402 quality assurance assessment pursuant to reports submitted under
403 s. 641.512. Every organization shall submit its books and
404 records and take other appropriate action as may be necessary to
405 facilitate an examination. The agency shall have access to the
406 organization’s medical records of individuals and records of
407 employed and contracted physicians, with the consent of the
408 subscriber or by court order, as necessary to carry out the
409 provisions of this part.
410 Section 12. Subsection (4) of section 641.58, Florida
411 Statutes, is amended to read:
412 641.58 Regulatory assessment; levy and amount; use of
413 funds; tax returns; penalty for failure to pay.—
414 (4) The moneys received and deposited into the Health Care
415 Trust Fund shall be used to defray the expenses of the agency in
416 the discharge of its administrative and regulatory powers and
417 duties under this part, including conducting an annual survey of
418 the satisfaction of members of health maintenance organizations;
419 contracting with physician consultants for the Subscriber
420 Assistance Panel; maintaining offices and necessary supplies,
421 essential equipment, and other materials, salaries and expenses
422 of required personnel; and discharging the administrative and
423 regulatory powers and duties imposed under this part.
424 Section 13. This act shall take effect July 1, 2012.