The Florida Senate

408.701  Community health purchasing; definitions.--As used in ss. 408.70-408.706, the term:

(1)  "Accountable health partnership" means an organization that integrates health care providers and facilities and assumes risk, in order to provide health care services, as certified by the agency under s. 408.704.

(2)  "Agency" means the Agency for Health Care Administration.

(3)  "Alliance" means a community health purchasing alliance.

(4)  "Alliance member" means:

(a)  A small employer as defined in s. 627.6699, or

(b)  The state, for the purpose of providing health benefits to state employees and their dependents through the state group insurance program and to Medicaid recipients, participants in the MedAccess program, and participants in the Medicaid buy-in program,

if such entities voluntarily choose to join an alliance.

(5)  "Antitrust laws" means federal and state laws intended to protect commerce from unlawful restraints, monopolies, and unfair business practices.

(6)  "Associate alliance member" means any purchaser who joins an alliance for the purposes of participating on the alliance board and receiving data from the alliance at no charge as a benefit of membership.

(7)  "Benefit standard" means a specified set of health services that are the minimum that must be covered under a basic health benefit plan, as defined in s. 627.6699.

(8)  "Business health coalition" means a group of employers organized to share information about health services and insurance coverage, to enable the employers to obtain more cost-effective care for their employees.

(9)  "Community health purchasing alliance" means a state-chartered, nonprofit organization that provides member-purchasing services and detailed information to its members on comparative prices, usage, outcomes, quality, and enrollee satisfaction with accountable health partnerships.

(10)  "Consumer" means an individual user of health care services.

(11)  "Department" means the Department of Insurance.

(12)  "Grievance procedure" means an established set of rules that specify a process for appeal of an organizational decision.

(13)  "Health care provider" or "provider" means a state-licensed or state-authorized facility, a facility principally supported by a local government or by funds from a charitable organization that holds a current exemption from federal income tax under s. 501(c)(3) of the Internal Revenue Code, a licensed practitioner, a county health department established under part I of chapter 154, a patient care center described in s. 391.031, a prescribed pediatric extended care center defined in s. 391.202, a federally supported primary care program such as a migrant health center or a community health center authorized under s. 329 or s. 330 of the United States Public Health Services Act that delivers health care services to individuals, or a community facility that receives funds from the state under the Community Alcohol, Drug Abuse, and Mental Health Services Act and provides mental health services to individuals.

(14)  "Health insurer" or "insurer" means an organization licensed by the department under part III of chapter 624 or part I of chapter 641.

(15)  "Health plan" means any hospital or medical policy or contract or certificate, hospital or medical service plan contract, or health maintenance organization contract as defined in the insurance code or Health Maintenance Organization Act. The term does not include accident-only, specific disease, individual hospital indemnity, credit, dental-only, vision-only, Medicare supplement, long-term care, or disability income insurance; coverage issued as a supplement to liability insurance; workers' compensation or similar insurance; or automobile medical-payment insurance.

(16)  "Health status" means an assessment of an individual's mental and physical condition.

(17)  "Managed care" means systems or techniques generally used by third-party payors or their agents to affect access to and control payment for health care services. Managed-care techniques most often include one or more of the following: prior, concurrent, and retrospective review of the medical necessity and appropriateness of services or site of services; contracts with selected health care providers; financial incentives or disincentives related to the use of specific providers, services, or service sites; controlled access to and coordination of services by a case manager; and payor efforts to identify treatment alternatives and modify benefit restrictions for high-cost patient care.

(18)  "Managed competition" means a process by which purchasers form alliances to obtain information on, and purchase from, competing accountable health partnerships.

(19)  "Medical outcome" means a change in an individual's health status after the provision of health services.

(20)  "Provider network" means an affiliated group of varied health care providers that is established to provide a continuum of health care services to individuals.

(21)  "Purchaser" means an individual, an organization, or the state that makes health-benefit purchasing decisions on behalf of a group of individuals.

(22)  "Self-funded plan" means a group health insurance plan in which the sponsoring organization assumes the financial risk of paying for all covered services provided to its enrollees.

(23)  "Utilization management" means programs designed to control the overutilization of health services by reviewing their appropriateness relative to established standards or norms.

(24)  "24-hour coverage" means the consolidation of such time-limited health care coverage as personal injury protection under automobile insurance into a general health insurance plan.

(25)  "Agent" means a person who is licensed to sell insurance in this state pursuant to chapter 626.

(26)  "Primary care physician" means a physician licensed under chapter 458 or chapter 459 who practices family medicine, general internal medicine, general pediatrics, or general obstetrics/gynecology.

History.--s. 67, ch. 93-129; s. 4, ch. 95-281; s. 108, ch. 97-101; s. 63, ch. 97-237.