The Florida Senate

408.001  Florida Health Care Purchasing Cooperative.

408.0014  The Florida Health Access Corporation Act.

408.0015  Short title.

408.002  Legislative findings and intent.

408.004  The Florida Health Plan.

408.005  Legislative findings and intent.

408.006  The Florida Health Plan; goals; report.

408.01  Voluntary private health insurance coverage and insurance cost containment.

408.02  Practice parameters.

408.031  Short title.

408.032  Definitions.

408.033  Local and state health planning.

408.034  Duties and responsibilities of agency; rules.

408.035  Review criteria.

408.036  Projects subject to review.

408.037  Application content.

408.038  Fees.

408.039  Review process.

408.040  Conditions and monitoring.

408.041  Certificate of need required; penalties.

408.042  Limitation on transfer.

408.043  Special provisions.

408.044  Injunction.

408.045  Certificate of need; competitive sealed proposals.

408.0455  Rules; pending proceedings.

408.05  State Center for Health Statistics.

408.061  Data collection; uniform systems of financial reporting; information relating to physician charges; confidentiality of patient records; immunity.

408.062  Research, analyses, studies, and reports.

408.063  Dissemination of health care information.

408.07  Definitions.

408.08  Inspections and audits; violations; penalties; fines; enforcement.

408.09  Assistance on cost containment strategies.

408.10  Consumer complaints.

408.15  Powers of the agency.

408.16  Health Care Trust Fund; moneys to be deposited therein.

408.18  Health Care Community Antitrust Guidance Act; antitrust no-action letter; market-information collection and education.

408.185  Information submitted for review of antitrust issues; confidentiality.

408.20  Assessments; Health Care Trust Fund.

408.30  Effect on existing rules.

408.301  Legislative findings.

408.302  Interagency agreement.

408.40  Public Counsel.

408.50  Prospective payment arrangements.

408.70  Community health purchasing; legislative findings and intent.

408.701  Community health purchasing; definitions.

408.702  Community health purchasing alliance; establishment.

408.703  Small employer members of community health purchasing alliances; eligibility requirements.

408.704  Agency duties and responsibilities related to community health purchasing alliances.

408.7041  Antitrust protection.

408.7042  Purchasing health care for state employees and Medicaid recipients through community health purchasing alliances.

408.7045  Community health purchasing alliance marketing requirements.

408.7055  Practitioner advisory groups.

408.7056  Statewide Provider and Subscriber Assistance Program.

408.706  Community health purchasing alliances; accountable health partnerships.

408.7071  Standardized claim form.

408.90  Legislative findings and intent.

408.901  Definitions.

408.902  MedAccess program; creation; program title.

408.903  Eligibility.

408.904  Benefits.

408.905  Limitations and exclusions.

408.906  Payment of claims.

408.907  Collection of premiums.

408.908  Administration.

408.001  Florida Health Care Purchasing Cooperative.--

(1)  SHORT TITLE.--This section may be cited as the "Florida Health Care Purchasing Cooperative Act."

(2)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--

(a)  There is authorized the "Florida Health Care Purchasing Cooperative," which shall pool the purchasing power for health care services of state and local governmental entities, service providers under contract with such governmental entities, and other entities identified by the cooperative as potential participants in pooled purchasing arrangements. The Florida Health Care Purchasing Cooperative is a nonprofit private corporation organized pursuant to chapter 617 and has all powers necessary to carry out the purposes and provisions of this act, including, but not limited to, the power to receive and accept grants, loans, or advances of funds from any public or private agency and to receive and accept, from any source, contributions of money, property, labor, or any other thing of value.

(b)  Members of the Florida Health Care Purchasing Cooperative are:

1.  All state governmental entities that purchase health care services for clients or for employees through health care coverage;

2.  Local governmental entities, including, but not limited to, counties, municipalities, school districts, and other special districts, that voluntarily become members;

3.  Service providers under contract with governmental entities, which providers may voluntarily become members when the cooperative determines it is appropriate; and

4.  Other entities identified as potential members by the cooperative, such as groups of small employers or part-time employees, which entities may voluntarily become members when the cooperative determines it is appropriate.

(c)  The Florida Health Care Purchasing Cooperative shall:

1.  Establish administrative and accounting procedures for the operation of the corporation.

2.  Secure staff necessary to properly administer the corporation.

3.  Develop and implement a plan to publicize the Florida Health Care Purchasing Cooperative, the eligibility requirements for membership, and the procedures for becoming members of the cooperative and to maintain public awareness of the cooperative and its services.

4.  Identify third-party payors and health care provider networks that serve members of the cooperative.

5.  Collect data on costs and utilization of health care services from members of the cooperative, health care providers that provide services to employees and clients of members of the cooperative, and third-party payors for members of the cooperative.

6.  Compare cost and utilization data collected pursuant to subparagraph 5. with data collected by the Agency for Health Care Administration.

7.  Establish criteria for evaluating health care provider networks and third-party payors, seeking advice from providers and third-party payors serving members of the cooperative.

8.  Evaluate health care provider networks and third-party payors.

9.  Inform members of the cooperative about the results of evaluations of health care provider networks and third-party payors.

(d)  The Florida Health Care Purchasing Cooperative may:

1.  Negotiate and enter into contracts on behalf of its members with health care provider networks and third-party payors for the delivery of health care services;

2.  Negotiate and enter into contracts on behalf of its members with insurance carriers, reinsurers, and third-party administrators for insurance, aggregate stop loss, specific stop loss, and administrative services; and

3.  In geographic areas where cost-effective health care provider networks that provide good quality services do not exist, assist members in developing health care provider networks and negotiate and contract directly with health care providers for the provision of health care services.

4.  Assess the impact of existing or proposed mandated or mandatorily offered health care benefits on members and their employees to determine if such benefits promote the health and well-being of employees through prevention of illness, early detection and treatment of illness, and reduced long-term health care costs.

(3)  BOARD OF DIRECTORS.--

(a)  The Florida Health Care Purchasing Cooperative shall operate subject to the supervision and approval of a board of directors.

(b)  The board of directors shall consist of:

1.  The Director of the Agency for Health Care Administration;

2.  The Deputy Director of the Division of State Health Purchasing of the Agency for Health Care Administration;

3.  The Assistant Secretary for Health Services of the Department of Corrections;

4.  Two persons who are responsible for purchasing health benefits for municipal employees and who are appointed by the Florida League of Cities;

5.  A person who is responsible for purchasing health care benefits for county employees or health care services for county clients and who is appointed by the Florida Association of Counties; and

6.  A person who is responsible for purchasing health care benefits for school district employees and who is appointed by the Florida Association of School Administrators.

The appointed members of the board of directors shall be appointed for 2 years and may be reappointed.

(c)  The board shall adopt bylaws for the corporation which shall contain provisions for the selection of directors to represent members of the cooperative following the initial appointments. The board of directors may increase the number of its directors to provide for representation by members of the cooperative.

(d)  Board members may be reimbursed from funds of the Florida Health Care Purchasing Cooperative, as prescribed by law, for actual and necessary expenses that they incur in performing their duties.

(e)  A member of the board of directors or an employee or agent of the board incurs no liability, and no cause of action may arise against a board member or any employee or agent of the board, for any action taken by the member, employee, or agent in performing his or her powers and duties under this act.

(4)  CONFIDENTIALITY.--

(a)  Patient medical records, patient insurance records, and portions of any other records obtained or generated by the cooperative which contain information that is patient-specific or that otherwise identifies a patient, either directly or indirectly, are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

(b)  Portions of records obtained or generated by the cooperative pursuant to this section which contain client lists, rates or rating methodologies, prices, discount amounts or formulas, contract terms, pricing methodologies, business plans, marketing strategies, client and vendor negotiations, or trade secrets as defined in s. 688.002, are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

History.--s. 94, ch. 91-282; s. 129, ch. 92-279; s. 55, ch. 92-326; s. 9, ch. 93-129; s. 19, ch. 93-260; s. 2, ch. 95-201; s. 247, ch. 96-406; s. 1016, ch. 97-103.

408.0014  The Florida Health Access Corporation Act.--

(1)  SHORT TITLE.--This section may be cited as the "Florida Health Access Corporation Act."

(2)  LEGISLATIVE INTENT.--The Legislature finds that there is insufficient group health insurance coverage available to employees of small businesses in Florida, that uninsured employees of small businesses represent a significant portion of the uncompensated costs of health care providers, and that uninsured individuals have impaired access to health care services and correspondingly lower health status. It is the intent of the Legislature that a nonprofit corporation, to be known as the "Florida Health Access Corporation," be organized for the purpose of pooling groups of individuals employed by small businesses, and the dependents of such employees, into larger groups in order to facilitate a program of affordable group health insurance coverage to uninsured individuals.

(3)  CORPORATION AUTHORIZATION, DUTIES, POWERS.--

(a)  There is authorized the "Florida Health Access Corporation." The Florida Health Access Corporation shall operate in Hillsborough County and a multicounty rural site and such other counties as may be designated by the corporation.

(b)  The Florida Health Access Corporation shall:

1.  Organize employers of 24 or fewer full-time employees and facilitate the provision of group health insurance to such employers and employees and their dependents;

2.  Arrange for the collection of premiums, in an amount to be determined by the board of directors, from all insured individuals to provide for claims paid under group health insurance arrangements and for the administrative expenses incurred or estimated to be incurred during the period for which the premium is paid;

3.  Establish administrative and accounting procedures for the operation of the corporation;

4.  Establish employer and employee eligibility criteria for participation in the program;

5.  Establish participation criteria governing eligibility of insurers or any providers of health care services to participate in the program;

6.  Establish procedures under which applicants to and participants in the program may have grievances reviewed by an impartial body and reported to the board;

7.  Contract with an authorized insurer or insurance administrator to provide administrative services to the corporation if desired or when such services are deemed necessary by the board;

8.  Contract with authorized insurers or any provider of health care services for the provision of services to individuals covered through the program;

9.  Develop and implement a plan to publicize the Florida Health Access Corporation, the eligibility requirements for the program, and the procedures for enrollment in the program, and to maintain public awareness of the corporation and the program;

10.  Secure staff necessary to properly administer the corporation. Staff costs shall be funded from grant funds, state and local matching funds, administrative fees collected from employers and insurers, and other sources of funding arranged by the corporation. The board of directors is authorized to determine the number of staff necessary to administer the corporation, but shall include, at a minimum, an executive director, an assistant director, and a staff assistant; and

11.  Enter into contracts with local agencies to provide onsite marketing and enrollment services necessary to the operation of the corporation.

(c)  The corporation shall set business and employee eligibility standards which shall define a small business and further identify small businesses eligible for participation in the program. Small businesses eligible for participation shall have 24 or fewer full-time employees. Employer eligibility standards shall include a provision that the employer must attest to having offered or provided no other health insurance benefit program in the 6-month period prior to the effective date of participation in the program. The corporation shall make all necessary provisions to prevent the payment of or reimbursement for any claim or expense which may be covered under a separate health insurance or health care services plan under which an individual who participates in the program may be covered. Coverage arranged through the corporation's program is to be considered secondary to any other available coverage held by the individual participating in the program. If such an individual is also eligible for Medicare coverage, the coverage arranged by the corporation shall not pay or reimburse any individual for expenses paid by Medicare. No policy shall be arranged by the corporation which is deemed to be a Medicare supplemental policy as defined in s. 627.672.

(d)  The corporation, which shall be operated as a nonprofit private corporation organized pursuant to chapter 617, shall have all powers necessary or convenient to carry out and effectuate the purposes and provisions of this act, including, but not limited to, the power to receive and accept grants, loans, and, notwithstanding the provisions of ss. 215.42 and 215.422, advances of funds from any public or private agency, for, or in aid of, the purpose of this act, and to receive and accept contributions, from any source, of money, property, labor, or any other thing of value, to be held, used, and applied for said purposes.

(4)  BOARD OF DIRECTORS.--

(a)  The Florida Health Access Corporation shall operate subject to the supervision and approval of a seven-member board of directors, which shall consist of:

1.  Two members, one from an urban county and one from a rural county, who shall represent small businesses whose employees are eligible to participate in the Florida Health Access Corporation;

2.  One member who shall represent consumers eligible to participate in the Florida Health Access Corporation;

3.  One member who shall be a representative of a domestic health care insurer or of a private company which offers a self-insured program of health benefits to employees;

4.  One member who shall be the Director of Health Care Administration or the director's designee;

5.  One member who shall be a representative of the Florida Chamber of Commerce; and

6.  One member who shall be a representative of an employer health coalition.

(b)  The board of directors shall be appointed and may be removed by the Governor. Terms of appointment shall be for 3 years. The board shall appoint the executive director, who shall be responsible for other staff as authorized by the board.

(c)  Board members may be reimbursed from funds of the Florida Health Access Corporation for actual and necessary expenses incurred by them as members, according to state travel and per diem limitations, but may not otherwise be compensated for their services.

(d)  There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member of the board of directors, or its employees or agents, for any action taken by them in performance of their powers and duties under this act.

(5)  LICENSING, FISCAL OPERATION.--

(a)  The corporation shall not be deemed to be an insurer. The officers, directors, and employees of the corporation shall not be deemed to be agents of an insurer. Neither the corporation nor the officers, directors, or employees of the corporation shall be subject to the licensing requirements of the insurance code or the rules of the Department of Insurance. However, the Department of Insurance may require that the marketing representative utilized and compensated by the corporation be licensed as representatives of the insurers or health services providers with whom the corporation may contract.

(b)  The Florida Health Access Corporation program shall be operated in accordance with sound actuarial principles. The board shall have complete fiscal control over the corporation and shall be responsible for all corporate operations.

(c)  The Department of Insurance shall assist the program in determining that proposed premium levels will be sufficient to permit the corporation to operate in an actuarially sound manner.

(d)  The corporation may expend funds through direct reinsurance, by purchasing reinsurance, or by other means approved by the board for the program of health care services and benefits arranged through the corporation. The amount of such expenditure shall not exceed funds allocated from the Public Medical Assistance Trust Fund or other sources of funding arranged by the corporation. Notwithstanding the provisions of s. 216.301, any amount so provided, which is not annually required for such purposes, shall remain available to the corporation, to be supplemented by an annual amount equal to the amount expended in the prior year, for the purpose of meeting funding requirements in succeeding years. Any amount remaining upon the liquidation or dissolution of the corporation shall be returned to the Public Medical Assistance Trust Fund.

History.--s. 16, ch. 87-92; s. 22, ch. 90-295; s. 63, ch. 91-282; s. 10, ch. 93-129; s. 33, ch. 97-103.

Note.--Former s. 409.701.

408.0015  Short title.--Sections 408.0015-408.604 may be cited as the "Health Care Reform Act of 1992."

History.--s. 2, ch. 92-33.

408.002  Legislative findings and intent.--

(1)  The Legislature finds that Florida's health care delivery system requires major reform. Health care costs are increasing at an unacceptably high rate, and access to health care services is declining. At least 2.5 million Floridians are uninsured and many more of our citizens are underinsured, discovering that the insurance they have purchased is often not enough when illness occurs. The Legislature recognizes that unemployed, part-time, and seasonal workers are commonly excluded from employer-based health insurance coverage.

(2)  Therefore, it is the intent of the Legislature to create The Florida Health Plan, the purpose of which is to reform our health care delivery system through providing access to basic health services for all Floridians, reforming our health insurance system, limiting health care cost increases to manageable levels, restructuring health regulation, and establishing a comprehensive health care database. The Legislature intends that The Florida Health Plan include specific goals and timetables for ensuring access to basic affordable health care, cost containment, insurance reform, and a comprehensive health database. Further, the Legislature intends that the plan include an affordable basic health benefit package in order to increase the ability of state residents to purchase health care coverage.

(3)  In recognizing the importance of limiting health care cost increases to the success of The Florida Health Plan, the Legislature intends that the plan contain a comprehensive cost containment program, including a measurable target for the reduction in health care inflation, a state annual health expenditure report, practice parameters, resource utilization reviews, Medicaid buy-in, and pooled purchasing initiatives. Further, the Legislature proposes that the cost containment program portion of The Florida Health Plan include reform in the areas of enhanced health care marketplace competition and improved regulatory programs for market entry, reimbursement mechanisms, administrative efficiencies, and facility and professional licensing.

(4)  The Legislature encourages health care providers, health care purchasers, and the public to participate in a voluntary health care cost control and health care access program. Through participation in such program, the Legislature intends to determine the degree to which participation by state government is required to reform the health care system.

(5)  Finally, the Legislature finds that the distribution of health care responsibilities among multiple state agencies has added excessive costs to the health care delivery system. In order to reduce administrative costs and to improve the state's efficiency in addressing the health care crisis, it is the intent of the Legislature to consolidate health care financing, data collection, and regulatory functions into a single state agency. The Legislature intends that this single state agency serve the Governor and the Legislature in all health-related matters.

History.--s. 3, ch. 92-33.

408.004  The Florida Health Plan.--The Florida Health Plan is hereby created.

History.--s. 5, ch. 92-33.

408.005  Legislative findings and intent.--

(1)  The Legislature finds that health care inflation, a deteriorating health care delivery system, reduced state revenues, changing demographics, and the erosion of private health insurance have converged to create a crisis of reduced access to health services for the poor and the uninsured. The Legislature recognizes that the problem of the health access crisis cannot be solved with the simple expansion of existing programs, but requires major reform of the health care delivery system.

(2)  It is the intent of the Legislature to create The Florida Health Plan in order to provide a vehicle for health reform. The Florida Health Plan shall represent a comprehensive approach to health care reform and shall be composed of multiple strategies. The Legislature intends that The Florida Health Plan address specific goals related to access to basic health services, insurance reforms, data collection and analysis, cost containment, and reforms in regulatory programs that are provided for in this chapter.

History.--s. 6, ch. 92-33.

408.006  The Florida Health Plan; goals; report.--The Legislature hereby establishes primary goals and strategies to guide the development of The Florida Health Plan. These goals and strategies include:

(1)  ACCESS TO HEALTH CARE SERVICES.--Access to health care is an increasing problem for many Floridians, especially for women and young children, part-time employees, employees of small businesses, and the unemployed. The failure of our health care system to be accessible to all residents is not only unacceptable to the Legislature for humanitarian reasons, but also because it results in inappropriate and far more costly use of health resources, a less productive workforce, and a less effective educational system. Therefore, the Legislature establishes the following health access goal for The Florida Health Plan: All Floridians shall be ensured access to a basic health care benefit package as determined by the Legislature, by December 31, 1994.

(a)  To ensure achievement of The Florida Health Plan's health access goal, the agency shall submit to the Legislature interim recommendations for the implementation of The Florida Health Plan health access goal on or before December 31, 1992, and final recommendations on or before December 31, 1993. At a minimum, recommendations shall include proposals for:

1.  Increasing health care coverage through the development of a basic health care benefit package that provides basic health services to all residents of the state, regardless of health condition, age, sex, race, geographic location, employment, or economic status.

2.  Ensuring that an appropriate number and distribution of health care facilities and health personnel are available throughout the state by January 1, 1996.

3.  Providing fair reimbursement to health care providers in a timely and uncomplicated manner.

(b)  In developing its recommendations, the agency shall consider the following:

1.  The role state and local government should assume in the provision of health services, including level of service, sources of funding, and delivery system models. By December 31, 1994, state and local governments, in cooperation with the private sector, shall ensure that all of the unemployed, low-income citizens of the state have access to the basic health benefit package.

2.  The role employers should assume, including whether employer mandates are needed to ensure access and the form such mandates should take. The plan shall ensure that, by December 31, 1994, employees and their dependents have, at a level acceptable to the Legislature, coverage of the basic health care benefit package or employers shall be mandated to provide such coverage. However, in no event shall the Legislature consider any system of employer-mandated coverage unless the Legislature finds that the cost containment goal has been met and mandated coverage is still necessary. The implementing legislation shall consider the potential impact on employment levels and shall provide a mechanism through appeal to the agency for an exemption to mandated coverage upon a showing of hardship.

3.  The role and responsibilities which each individual should assume in obtaining access to health care.

4.  Maximizing federal funding of publicly funded health insurance coverages.

5.  Ensuring coverage for persons who are unable to obtain or afford health insurance coverage because of chronic or acute illnesses.

6.  Ensuring accessible health care services in rural and other medically underserved areas.

(c)  At the time the recommendations are submitted to the Legislature, the agency shall provide the Legislature with a specific proposal to improve access to health care that should be implemented in the event that full access to basic health services has not been obtained for all residents of the state by December 31, 1994.

(2)  COST CONTAINMENT.--

(a)  Despite numerous efforts by the Legislature for at least the last decade to curb health spending, health care costs continue to increase at an unacceptable rate. The increase in health care costs is of concern to the Legislature, not only because increasing costs threaten the ability of the private sector and state and local governments to pay for health care, but also because rapid cost escalations threaten the ability of Florida business to compete in national and international markets. Therefore, the Legislature directs the agency to recommend to the Legislature a cost containment goal, and the means to achieve it, that is based upon an annual rate of increase in the basic health benefit package that will enable such package to remain affordable to businesses and their employees.

(b)  To reach The Florida Health Plan's cost containment goal, the agency shall submit to the Legislature interim recommendations for The Florida Health Plan cost containment goal on or before December 31, 1992, and final recommendations on or before December 31, 1993. The agency's recommendations shall consider the following principles and strategies:

1.  The state shall promote accessibility of primary and preventive care and control the proliferation of tertiary care.

2.  Because resources are limited, health care priorities shall be established. High priority shall be given to those programs that have best been shown to produce good outcomes, to include incentive structures which will respond to the needs of Floridians for good health care value, and to provide a healthy start for the state's youngest residents.

3.  Practice parameters which are scientifically sound should be adopted to ensure the appropriate utilization of services.

4.  Analytical techniques which address variations in health care delivery among providers and from region to region shall be used, which may include small area analysis and practice parameters.

5.  Resource utilization systems that are capable of taking into account resources consumed in the delivery of care for patients with similar diagnoses and outcomes produced in the treatment of like cases should be researched and refined for consideration.

6.  The state employee health insurance program shall ensure an appropriate distribution and utilization of affordable, efficient, and effective high-technology care.

7.  Consolidating the administration of state-funded, state-administered, or state-sponsored health insurance programs.

8.  Proposals for a public and private health insurance payor mechanism designed to simplify provider billing, reduce administrative overhead costs, and maximize government and third-party purchasing power.

9.  Recommending comprehensive changes in the system for handling medical negligence disputes that will ensure a more efficient and equitable method for determining damages and compensating injured parties.

(3)  INSURANCE REFORMS.--The Legislature finds that almost half of the uninsured are at or near poverty, requiring insurance reforms that significantly lower costs. Almost three-quarters of the uninsured are employed or are dependents of employees, and half of these uninsured workers are employed by small businesses. These findings make the expansion of employer-based health care coverage options a priority. Therefore, the Legislature establishes the following insurance reform goal for The Florida Health Plan: On or before July 1, 1994, the state shall institute reforms in private health insurance that shall ensure that employed and unemployed residents have access to basic health insurance coverage.

(a)  To ensure the achievement of The Florida Health Plan's insurance reform goal, the agency shall submit to the Legislature interim recommendations for the implementation of The Florida Health Plan insurance goal on or before December 31, 1992, and final recommendations on or before December 31, 1993.

(b)  In developing recommendations for insurance reforms, the agency shall consider strategies that:

1.  Maximize the number of employed persons and their dependents who are enrolled in employer-sponsored health insurance plans. Coverage should be made available to entire employer groups and not exclude individuals who present high medical risks.

2.  Rely on private providers for the delivery of health services.

3.  Ensure that health insurance coverage for a state resident continues regardless of changes in employers.

4.  Provide that employer groups and individuals are not canceled at renewal time because of high claims costs.

5.  Require insurers to accept all health risks with appropriate protection for extraordinary risks.

6.  Ensure that all residents participate in a public or private health insurance plan.

7.  Ensure that all residents contribute, based on their ability to pay, to the financing of their health insurance coverage.

8.  Provide basic health insurance benefits that promote healthier lifestyles, require persons to assume greater responsibility for their health, and provide early diagnosis and treatment to avoid later and more costly medical interventions.

9.  Provide for uniform billing, payment, and service documentation requirements.

10.  Require employers receiving government contracts and grants to offer health care coverage to all employees.

11.  Implement managed care in public and private health insurance plans.

12.  Reform private health insurance practices to ensure coverage for employees and their dependents, regardless of their health status and employer size, such as proposals for adopting community ratings for employers of all sizes, prohibiting the exclusion of preexisting conditions, and guaranteeing acceptance and continuation of employee groups.

(4)  HEALTH REGULATION.--

(a)  The Legislature finds that a competitive marketplace is lacking in some areas of health care, and, therefore, an appropriate level of regulation is necessary in order to ensure the quality, affordability, and availability of health care services. Further, the Legislature finds that existing health regulatory programs are not well-coordinated, lack clear goals and objectives, contain many archaic administrative rules, are too administratively complex, and require redesign in order to meet the needs of a rapidly evolving health care system. By placing all health regulatory programs into a single state agency, the Legislature intends to begin the process of streamlining and making more cost-effective the regulatory process. In order to complete the task, the Legislature establishes the following health regulation goal: By December 31, 1994, health regulatory programs shall be redesigned and modernized, with an emphasis on efficiency, administrative simplicity, coordination, and protection of the public.

(b)  To ensure the achievement of The Florida Health Plan's health regulation goal, the agency shall submit to the Legislature interim recommendations for achieving the goal on or before December 31, 1992, and final recommendations on or before December 31, 1993. Included in the recommendations shall be proposals to:

1.  Create a consistent theme for all regulatory programs, including the establishment of clear goals and objectives for each regulatory program.

2.  Review all existing administrative rules for the purpose of eliminating archaic or excessively costly rules.

3.  Simplify regulatory programs to ensure that administrative complexity is the minimum necessary to guarantee due process.

4.  Eliminate laws and rules which serve to protect economic interests of health professionals or health providers, at the expense of the public.

5.  Provide for a uniform health regulatory program through the elimination of loopholes and exemptions created for special interest groups.

6.  Redesign market entry controls to provide for uniformity across all health care providers, to limit regulation only to those areas which require regulation due to limited market needs and high capitalization costs, and provide review standards for other services and technologies which do not restrict market entry but, rather, create incentives for high-quality providers to offer these services in ways which meet community needs while discouraging inappropriate utilization and development.

7.  Provide an appropriate level of regulation in areas where market forces have been unsuccessful in constraining rapidly escalating costs.

(5)  DATA COLLECTION, RESEARCH, AND ANALYSIS.--

(a)  The Legislature finds that it is difficult to evaluate the effectiveness of access, cost containment, regulation, and insurance reform strategies without Florida-specific empirical evidence. The collection and analysis of data improves the state's ability to identify major health care issues and to develop a comprehensive health policy for the state. Therefore, the Legislature establishes the following goal for data collection and analysis for The Florida Health Plan: By July 1, 1994, there shall be established an integrated data collection and analysis system that includes data from all health care providers, facilities, and insurers and that will permit assessments of cost-effectiveness, quality of care, and variations in practice parameters.

(b)  To ensure the achievement of The Florida Health Plan's goal for data collection, the agency shall submit to the Legislature interim recommendations for the implementation of The Florida Health Plan's data collection goal on or before December 31, 1992, and final recommendations on or before December 31, 1993. Recommendations shall give consideration to:

1.  Establishing a comprehensive, integrated system of data from health care providers, facilities, and insurers.

2.  Cataloging existing health care data maintained by local, state, and federal agencies, universities, and private organizations.

3.  Publishing an annual state health expenditure report to the Legislature.

History.--s. 7, ch. 92-33; s. 6, ch. 95-144; s. 34, ch. 97-103.

408.01  Voluntary private health insurance coverage and insurance cost containment.--

(1)  The agency shall promote the availability and affordability of health insurance for employers and their employees through pooled health care purchasing arrangements, pooled insuring arrangements for small-sized employers, and other reforms, such as managed care, that aid employers in offering health insurance coverage to their employees. The agency shall submit proposed legislation and resource requirements to the Governor and the Legislature by December 31, 1992, to fully implement this section.

(2)  For the period of July 1, 1992, through December 31, 1994, a voluntary private health insurance coverage program shall encourage each employer to offer basic health insurance to its employees and their dependents. The agency shall establish, by rule, annual health insurance coverage targets, including targets relative to the percentage of employees and their dependents covered and percentage of employers offering coverage by firm size and industry sector.

(3)  From July 1, 1992, through December 31, 1994, a voluntary cost containment program shall encourage employers, insurers, providers, and consumers to substantially reduce the rate of health care cost inflation. This program includes using voluntary price controls, reduced administrative overhead, volume discounting, and other measures to reduce the cost of health care. The agency shall establish, by rule, annual cost containment targets which will provide a benchmark against which participants in the voluntary plan can measure the effectiveness of their specific efforts.

(4)  If voluntary targets are not met, substantially increasing the health insurance coverage of employees and their dependents and reducing the rate of health care costs, the agency may impose other strategies to ensure access to health care that have been approved by the Legislature.

(5)  In order to promote the development of employer-based health insurance options, the agency shall:

(a)  Identify and evaluate incentives, including tax credits, to encourage employers to voluntarily purchase health insurance, join a multiple employer trust, or contribute to a state pool that purchases a private basic benefit health insurance plan for employees.

(b)  Identify and evaluate potential cost containment and quality measures, such as prevention, education, utilization review, and practice parameters.

(c)  Identify and evaluate incentives to stimulate private health insurance companies to seek out employers for the purpose of providing them with affordable basic benefit coverage.

(6)  Prior to the 1993 Regular Session of the Legislature, the agency shall submit to the Legislature the information enumerated in subsection (5) and such other information as may be necessary for the state to provide incentives, including tax incentives, for the purpose of encouraging employers to purchase health insurance, join a multiple health insurance trust, or contribute to a state pool to purchase health insurance for their employees.

(7)  The agency shall establish an advisory council of employers, providers, insurers, and consumers to aid in establishing the voluntary private health insurance coverage and cost containment program and to consider administrative and legislative reforms that will assist the private sector in meeting coverage and cost containment targets.

History.--s. 66, ch. 92-33.

408.02  Practice parameters.--

(1)  The Agency for Health Care Administration shall coordinate the development, endorsement, implementation, and evaluation of scientifically sound, clinically relevant practice parameters in order to reduce unwarranted variation in the delivery of medical treatment, improve the quality of medical care, and promote the appropriate utilization of health care services. "Practice parameters" or "practice guidelines" are defined to mean strategies for patient management that are developed to assist physicians in clinical decisionmaking.

(2)  Every hospital, in conjunction with the hospital medical staff, shall produce outcomes data by diagnosis for each patient treated in the hospital pursuant to the criteria developed under ¹subsection (2). The hospital shall forward such data to the agency in a manner consistent with s. 408.061 on a quarterly basis beginning with the quarter ending June 30, 1994. The report shall also include a description of any practice guideline which has been adopted by the medical staff, as well as outcomes data for persons treated according to such practice guideline. As used in this section, "hospital" means an acute care hospital licensed under chapter 395.

(3)  The agency shall summarize the effectiveness and cost of care outcomes for each diagnosis by hospital, by district, by region, and across the state, as well as by any other grouping which will facilitate the development of clinically relevant practice parameters. The agency shall make the report available to the public and all hospitals throughout the state on an annual basis beginning December 31, 1994. The agency shall also make detail data submitted pursuant to ²subsection (3) available for analysis by others, subject to protection of confidentiality pursuant to s. 408.061.

(4)  The agency, in conjunction with the Florida Medical Association, the Florida Chiropractic Association, the Florida Osteopathic Medical Association, the Florida Podiatric Medical Association, and other health professional associations, and in conjunction with the respective boards within the Division of Medical Quality Assurance, shall develop and may adopt by rule state practice parameters based on the data received under ³subsection (4) as well as on nationally developed practice guidelines. However, practice parameters adopted by rule shall not provide grounds for any administrative action. The agency shall prioritize the development of those practice parameters which involve the greatest utilization of resources either because they are the most costly or because they are the most frequently performed. Prior to the development of practice parameters under this subsection, the agency in conjunction with the various health professional associations may proceed with the development of state practice parameters based on nationally developed practice guidelines.

(5)  The agency, in conjunction with the appropriate health professional associations shall develop and may adopt by rule practice parameters for services provided by diagnostic-imaging centers, radiation therapy services, clinical laboratory services, physical therapy services, and comprehensive rehabilitative services. Practice parameters applicable to diagnostic-imaging services shall be developed by December 31, 1993.

(6)  The agency, in conjunction with the appropriate health professional associations, shall develop and may adopt, by rule, practice parameters and guidelines for the delivery of mammography services.

(7)  Parameters developed pursuant to this section shall be made available to the public and to all hospitals and health professionals throughout the state.

(8)  Procedures shall be instituted which provide for the periodic review and revision of practice parameters based on the latest outcomes data, research findings, technological advancements, and clinical experiences, at least once every 3 years.

(9)  The agency shall establish a demonstration project to evaluate the effectiveness of practice parameters with regard to the costs of defensive medicine and professional liability insurance.

(a)  Under the demonstration project, the agency, in conjunction with the Board of Medicine, shall complete the adoption of as many practice parameters as practical, giving priority to those procedures and diagnoses that account for a significant percentage of total statewide health services and health care costs, no later than July 1, 1994.

(b)  The practice parameters must establish standards of practice designed to avoid liability claims and to increase the defensibility of liability claims when they occur, thereby eliminating the need for physicians to practice defensive medicine.

(c)  The Board of Medicine shall review the practice parameters used in the demonstration project and may adopt them by rule.

(d)  Physicians selected by the agency may elect to:

1.  Participate in the demonstration project; and

2.  Practice in compliance with the practice parameters, beginning no later than October 1, 1994.

(e)  A participating physician who is named as a defendant in a cause of action accruing on or after October 1, 1994, but before October 1, 1998, may introduce evidence of compliance with the practice parameters as an affirmative defense to a liability claim.

(f)  The agency shall review the demonstration project and shall make recommendations to the Legislature by December 31, 1994, as to the effectiveness of practice parameters on reducing the cost of defensive medicine and professional liability insurance and whether using proof of compliance with the parameters as an affirmative defense should apply to all physicians who practice in conformity with the appropriate practice parameters.

History.--s. 67, ch. 92-33; s. 36, ch. 93-129; s. 22, ch. 95-146; s. 4, ch. 95-188; s. 5, ch. 95-201.

¹Note.--Repealed by s. 22, ch. 95-146.

²Note.--Redesignated as subsection (2) by s. 22, ch. 95-146.

³Note.--Redesignated as subsection (3) by s. 22, ch. 95-146.

408.031  Short title.--Sections 408.031-408.045 shall be known and may be cited as the "Health Facility and Services Development Act."

History.--s. 18, ch. 87-92; s. 15, ch. 92-33; s. 7, ch. 95-144.

Note.--Former s. 381.701.

408.032  Definitions.--As used in ss. 408.031-408.045, the term:

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

(2)  "Capital expenditure" means an expenditure, including an expenditure for a construction project undertaken by a health care facility as its own contractor, which, under generally accepted accounting principles, is not properly chargeable as an expense of operation and maintenance, which is made to change the bed capacity of the facility, or substantially change the services or service area of the health care facility, health service provider, or hospice, and which includes the cost of the studies, surveys, designs, plans, working drawings, specifications, initial financing costs, and other activities essential to acquisition, improvement, expansion, or replacement of the plant and equipment.

(3)  "Certificate of need" means a written statement issued by the agency evidencing community need for a new, converted, expanded, or otherwise significantly modified health care facility, health service, or hospice.

(4)  "Commenced construction" means initiation of and continuous activities beyond site preparation associated with erecting or modifying a health care facility, including procurement of a building permit applying the use of agency-approved construction documents, proof of an executed owner/contractor agreement or an irrevocable or binding forced account, and actual undertaking of foundation forming with steel installation and concrete placing.

(5)  "District" means a health service planning district composed of the following counties:

District 1.--Escambia, Santa Rosa, Okaloosa, and Walton Counties.

District 2.--Holmes, Washington, Bay, Jackson, Franklin, Gulf, Gadsden, Liberty, Calhoun, Leon, Wakulla, Jefferson, Madison, and Taylor Counties.

District 3.--Hamilton, Suwannee, Lafayette, Dixie, Columbia, Gilchrist, Levy, Union, Bradford, Putnam, Alachua, Marion, Citrus, Hernando, Sumter, and Lake Counties.

District 4.--Baker, Nassau, Duval, Clay, St. Johns, Flagler, and Volusia Counties.

District 5.--Pasco and Pinellas Counties.

District 6.--Hillsborough, Manatee, Polk, Hardee, and Highlands Counties.

District 7.--Seminole, Orange, Osceola, and Brevard Counties.

District 8.--Sarasota, DeSoto, Charlotte, Lee, Glades, Hendry, and Collier Counties.

District 9.--Indian River, Okeechobee, St. Lucie, Martin, and Palm Beach Counties.

District 10.--Broward County.

District 11.--Dade and Monroe Counties.

(6)  "Expedited review" means the process by which certain types of applications are not subject to the review cycle requirements contained in s. 408.039(1), and the letter of intent requirements contained in s. 408.039(2).

(7)  "Health care facility" means a hospital, long-term care hospital, skilled nursing facility, hospice, intermediate care facility, or intermediate care facility for the developmentally disabled. A facility relying solely on spiritual means through prayer for healing is not included as a health care facility.

(8)  "Health services" means diagnostic, curative, or rehabilitative services and includes alcohol treatment, drug abuse treatment, and mental health services.

(9)  "Home health agency" means an organization, as defined in s. 400.462(4), that is certified or seeks certification as a Medicare home health service provider.

(10)  "Hospice" or "hospice program" means a hospice as defined in part VI of chapter 400.

(11)  "Hospital" means a health care facility licensed under chapter 395.

(12)  "Institutional health service" means a health service which is provided by or through a health care facility and which entails an annual operating cost of $500,000 or more. The agency shall, by rule, adjust the annual operating cost threshold annually using an appropriate inflation index.

(13)  "Intermediate care facility" means an institution which provides, on a regular basis, health-related care and services to individuals who do not require the degree of care and treatment which a hospital or skilled nursing facility is designed to provide, but who, because of their mental or physical condition, require health-related care and services above the level of room and board.

(14)  "Intermediate care facility for the developmentally disabled" means a residential facility licensed under chapter 393 and certified by the Federal Government pursuant to the Social Security Act as a provider of Medicaid services to persons who are mentally retarded or who have a related condition.

(15)  "Long-term care hospital" means a hospital licensed under chapter 395 which meets the requirements of 42 C.F.R. s. 412.23(e) and seeks exclusion from the Medicare prospective payment system for inpatient hospital services.

(16)  "Multifacility project" means an integrated residential and health care facility consisting of independent living units, assisted living facility units, and nursing home beds certificated on or after January 1, 1987, where:

(a)  The aggregate total number of independent living units and assisted living facility units exceeds the number of nursing home beds.

(b)  The developer of the project has expended the sum of $500,000 or more on the certificated and noncertificated elements of the project combined, exclusive of land costs, by the conclusion of the 18th month of the life of the certificate of need.

(c)  The total aggregate cost of construction of the certificated element of the project, when combined with other, noncertificated elements, is $10 million or more.

(d)  All elements of the project are contiguous or immediately adjacent to each other and construction of all elements will be continuous.

(17)  "Nursing home geographically underserved area" means:

(a)  A county in which there is no existing or approved nursing home;

(b)  An area with a radius of at least 20 miles in which there is no existing or approved nursing home; or

(c)  An area with a radius of at least 20 miles in which all existing nursing homes have maintained at least a 95 percent occupancy rate for the most recent 6 months or a 90 percent occupancy rate for the most recent 12 months.

(18)  "Respite care" means short-term care in a licensed health care facility which is personal or custodial and is provided for chronic illness, physical infirmity, or advanced age for the purpose of temporarily relieving family members of the burden of providing care and attendance.

(19)  "Skilled nursing facility" means an institution, or a distinct part of an institution, which is primarily engaged in providing, to inpatients, skilled nursing care and related services for patients who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.

(20)  "Tertiary health service" means a health service which, due to its high level of intensity, complexity, specialized or limited applicability, and cost, should be limited to, and concentrated in, a limited number of hospitals to ensure the quality, availability, and cost-effectiveness of such service. Examples of such service include, but are not limited to, organ transplantation, specialty burn units, neonatal intensive care units, comprehensive rehabilitation, and medical or surgical services which are experimental or developmental in nature to the extent that the provision of such services is not yet contemplated within the commonly accepted course of diagnosis or treatment for the condition addressed by a given service. The agency shall establish by rule a list of all tertiary health services.

(21)  "Regional area" means any of those regional health planning areas established by the agency to which local and district health planning funds are directed to local health councils through the General Appropriations Act.

History.--s. 19, ch. 87-92; s. 19, ch. 88-294; s. 2, ch. 89-308; s. 7, ch. 89-354; s. 21, ch. 91-158; s. 54, ch. 91-221; s. 1, ch. 91-282; ss. 15, 16, ch. 92-33; s. 10, ch. 92-58; s. 22, ch. 93-214; s. 8, ch. 95-144; s. 28, ch. 95-210; s. 2, ch. 95-394; s. 1, ch. 97-270.

Note.--Former s. 381.702.

¹408.033  Local and state health planning.--

(1)  LOCAL HEALTH COUNCILS.--

(a)  Local health councils are hereby established as public or private nonprofit agencies serving the counties of a district or regional area of the agency. The members of each council shall be appointed in an equitable manner by the county commissions having jurisdiction in the respective district. Each council shall be composed of a number of persons equal to 11/2 times the number of counties which compose the district or 12 members, whichever is greater. Each county in a district shall be entitled to at least one member on the council. The balance of the membership of the council shall be allocated among the counties of the district on the basis of population rounded to the nearest whole number; except that in a district composed of only two counties, no county shall have fewer than four members. The appointees shall be representatives of health care providers, health care purchasers, and nongovernmental health care consumers, but not excluding elected government officials. The members of the consumer group shall include a representative number of persons over 60 years of age. A majority of council members shall consist of health care purchasers and health care consumers. The local health council shall provide each county commission a schedule for appointing council members to ensure that council membership complies with the requirements of this paragraph. The members of the local health council shall elect a chair. Members shall serve for terms of 2 years and may be eligible for reappointment.

(b)  Each local health council may:

1.  Develop a district or regional area health plan that is consistent with the objectives and strategies in the state health plan, but that shall permit each local health council to develop strategies and set priorities for implementation based on its unique local health needs. The district or regional area health plan must contain preferences for the development of health services and facilities, which may be considered by the agency in its review of certificate-of-need applications. The district health plan shall be submitted to the agency and updated periodically. The district health plans shall use a uniform format and be submitted to the agency according to a schedule developed by the agency in conjunction with the local health councils. The schedule must provide for coordination between the development of the state health plan and the district health plans and for the development of district health plans by major sections over a multiyear period. The elements of a district plan which are necessary to the review of certificate-of-need applications for proposed projects within the district may be adopted by the agency as a part of its rules.

2.  Advise the agency on health care issues and resource allocations.

3.  Promote public awareness of community health needs, emphasizing health promotion and cost-effective health service selection.

4.  Collect data and conduct analyses and studies related to health care needs of the district, including the needs of medically indigent persons, and assist the agency and other state agencies in carrying out data collection activities that relate to the functions in this subsection.

5.  Monitor the onsite construction progress, if any, of certificate-of-need approved projects and report council findings to the agency on forms provided by the agency.

6.  Advise and assist any regional planning councils within each district that have elected to address health issues in their strategic regional policy plans with the development of the health element of the plans to address the health goals and policies in the State Comprehensive Plan.

7.  Advise and assist local governments within each district on the development of an optional health plan element of the comprehensive plan provided in chapter 163, to assure compatibility with the health goals and policies in the State Comprehensive Plan and district health plan. To facilitate the implementation of this section, the local health council shall annually provide the local governments in its service area, upon request, with:

a.  A copy and appropriate updates of the district health plan;

b.  A report of hospital and nursing home utilization statistics for facilities within the local government jurisdiction; and

c.  Applicable agency rules and calculated need methodologies for health facilities and services regulated under s. 408.034 for the district served by the local health council.

8.  Monitor and evaluate the adequacy, appropriateness, and effectiveness, within the district, of local, state, federal, and private funds distributed to meet the needs of the medically indigent and other underserved population groups.

9.  In conjunction with the Agency for Health Care Administration, plan for services at the local level for persons infected with the human immunodeficiency virus.

10.  Provide technical assistance to encourage and support activities by providers, purchasers, consumers, and local, regional, and state agencies in meeting the health care goals, objectives, and policies adopted by the local health council.

11.  Provide the agency with data required by rule for the review of certificate-of-need applications and the projection of need for health services and facilities in the district.

(c)  Local health councils may conduct public hearings pursuant to s. 408.039(3)(b).

(d)  Each local health council shall enter into a memorandum of agreement with each regional planning council in its district that elects to address health issues in its strategic regional policy plan. In addition, each local health council shall enter into a memorandum of agreement with each local government that includes an optional health element in its comprehensive plan. Each memorandum of agreement must specify the manner in which each local government, regional planning council, and local health council will coordinate its activities to ensure a unified approach to health planning and implementation efforts.

(e)  Local health councils may employ personnel or contract for staffing services with persons who possess appropriate qualifications to carry out the councils' purposes. However, such personnel are not state employees.

(f)  Personnel of the local health councils shall provide an annual orientation to council members about council member responsibilities. The orientation shall include presentations and participation by agency staff.

(g)  Each local health council is authorized to accept and receive, in furtherance of its health planning functions, funds, grants, and services from governmental agencies and from private or civic sources and to perform studies related to local health planning in exchange for such funds, grants, or services. Each local health council shall, no later than January 30 of each year, render an accounting of the receipt and disbursement of such funds received by it to the agency. The agency shall consolidate all such reports and submit such consolidated report to the Legislature no later than March 1 of each year. Funds received by a local health council pursuant to this paragraph shall not be deemed to be a substitute for, or an offset against, any funding provided pursuant to subsection (2).

(2)  FUNDING.--

(a)  The Legislature intends that the cost of local health councils be borne by application fees for certificates of need and by assessments on selected health care facilities subject to facility licensure by the Agency for Health Care Administration, including abortion clinics, assisted living facilities, ambulatory surgical centers, birthing centers, clinical laboratories except community nonprofit blood banks and clinical laboratories operated by practitioners for exclusive use regulated under s. 483.035, home health agencies, hospices, hospitals, intermediate care facilities for the developmentally disabled, nursing homes, and multiphasic testing centers and by assessments on organizations subject to certification by the agency pursuant to chapter 641, part III, including health maintenance organizations and prepaid health clinics.

(b)1.  A hospital licensed under chapter 395, a nursing home licensed under chapter 400, and an assisted living facility licensed under chapter 400 shall be assessed an annual fee based on number of beds.

2.  All other facilities and organizations listed in paragraph (a) shall each be assessed an annual fee of $150.

3.  Facilities operated by the ²Department of Health and Rehabilitative Services or the Department of Corrections and any hospital which meets the definition of rural hospital pursuant to s. 395.602 are exempt from the assessment required in this subsection.

(c)1.  The agency shall, by rule, establish fees for hospitals and nursing homes based on an assessment of $2 per bed. However, no such facility shall be assessed more than a total of $500 under this subsection.

2.  The agency shall, by rule, establish fees for assisted living facilities based on an assessment of $1 per bed. However, no such facility shall be assessed more than a total of $150 under this subsection.

3.  The agency shall, by rule, establish an annual fee of $150 for all other facilities and organizations listed in paragraph (a).

(d)  The agency shall, by rule, establish a facility billing and collection process for the billing and collection of the health facility fees authorized by this subsection.

(e)  A health facility which is assessed a fee under this subsection is subject to a fine of $100 per day for each day in which the facility is late in submitting its annual fee up to maximum of the annual fee owed by the facility. A facility which refuses to pay the fee or fine is subject to the forfeiture of its license.

(f)  The agency shall deposit in the Health Care Trust Fund all health care facility assessments that are assessed under this subsection and proceeds from the certificate-of-need application fees. The agency shall transfer to the Department of Health an amount sufficient to maintain the aggregate funding level for the local health councils as specified in the General Appropriations Act. The remaining certificate-of-need application fees shall be used only for the purpose of administering the Health Facility and Services Development Act.

(3)  DUTIES AND RESPONSIBILITIES OF THE AGENCY.--

(a)  The agency, in conjunction with the local health councils, is responsible for the planning of all health care services in the state and for the preparation of the state health plan.

(b)  The agency shall develop and maintain a comprehensive health care database for the purpose of health planning and for certificate-of-need determinations. The agency or its contractor is authorized to require the submission of information from health facilities, health service providers, and licensed health professionals which is determined by the agency, through rule, to be necessary for meeting the agency's responsibilities as established in this section.

(c)  The agency shall assist personnel of the local health councils in providing an annual orientation to council members about council member responsibilities.

(d)  The agency shall contract with the local health councils for the services specified in subsection (1). All contract funds shall be distributed according to an allocation plan developed by the agency that provides for a minimum and equal funding base for each local health council. Any remaining funds shall be distributed based on adjustments for workload. The agency may also make grants to or reimburse local health councils from federal funds provided to the state for activities related to those functions set forth in this section. The agency may withhold funds from a local health council or cancel its contract with a local health council which does not meet performance standards agreed upon by the agency and local health councils.

History.--s. 20, ch. 87-92; s. 40, ch. 88-380; s. 35, ch. 88-394; s. 1, ch. 89-104; s. 24, ch. 89-294; s. 2, ch. 89-296; s. 15, ch. 89-527; s. 2, ch. 91-48; s. 22, ch. 91-158; ss. 2, 104, ch. 91-282; s. 5, ch. 91-429; ss. 15, 17, ch. 92-33; s. 2, ch. 92-174; s. 66, ch. 92-289; s. 22, ch. 93-120; s. 11, ch. 93-129; s. 33, ch. 93-206; s. 8, ch. 93-267; s. 9, ch. 95-144; s. 29, ch. 95-210; s. 3, ch. 95-394; s. 11, ch. 97-79; s. 1, ch. 97-91; s. 35, ch. 97-103; s. 62, ch. 97-237.

¹Note.--

A.  Section 122, ch. 97-237, provides that "[t]he administrative rules of the agencies involved in this reorganization that are in effect immediately prior to [July 1, 1997] shall remain in effect until specifically changed in the manner provided by law."

B.  Section 123, ch. 97-237, provides that "[t]his act shall not affect the validity of any judicial or administrative proceeding pending on [July 1, 1997], and any agency to which are transferred the powers, duties, and functions relating to the pending proceeding shall be substituted as a party in interest for that proceeding."

²Note.--The Department of Health and Rehabilitative Services was redesignated as the Department of Children and Family Services by s. 5, ch. 96-403, and the Department of Health was created by s. 8, ch. 96-403.

Note.--Former s. 381.703.

408.034  Duties and responsibilities of agency; rules.--

(1)  The agency is designated as the single state agency to issue, revoke, or deny certificates of need and to issue, revoke, or deny exemptions from certificate-of-need review in accordance with the district plans and present and future federal and state statutes. The agency is designated as the state health planning agency for purposes of federal law.

(2)  In the exercise of its authority to issue licenses to health care facilities and health service providers, as provided under chapters 393, 395, and parts II, IV, and VI of chapter 400, the agency may not issue a license to any health care facility, health service provider, hospice, or part of a health care facility which fails to receive a certificate of need for the licensed facility or service.

(3)  The agency shall establish, by rule, uniform need methodologies for health services and health facilities. In developing uniform need methodologies, the agency shall, at a minimum, consider the demographic characteristics of the population, the health status of the population, service use patterns, standards and trends, geographic accessibility, and market economics.

(4)  The agency shall establish by rule a nursing-home-bed-need methodology that reduces the community nursing home bed need for the areas of the state where the agency establishes pilot community diversion programs through the Title XIX aging waiver program.

(5)  The agency may adopt rules necessary to implement ss. 408.031-408.045.

History.--s. 21, ch. 87-92; s. 8, ch. 89-354; s. 1, ch. 91-263; s. 15, ch. 92-33; s. 18, ch. 93-214; s. 10, ch. 95-144; s. 2, ch. 98-85.

Note.--Former s. 381.704.

408.035  Review criteria.--

(1)  The agency shall determine the reviewability of applications and shall review applications for certificate-of-need determinations for health care facilities and health services in context with the following criteria:

(a)  The need for the health care facilities and health services being proposed in relation to the applicable district plan, except in emergency circumstances that pose a threat to the public health.

(b)  The availability, quality of care, efficiency, appropriateness, accessibility, extent of utilization, and adequacy of like and existing health care facilities and health services in the service district of the applicant.

(c)  The ability of the applicant to provide quality of care and the applicant's record of providing quality of care.

(d)  The availability and adequacy of other health care facilities and health services in the service district of the applicant, such as outpatient care and ambulatory or home care services, which may serve as alternatives for the health care facilities and health services to be provided by the applicant.

(e)  Probable economies and improvements in service which may be derived from operation of joint, cooperative, or shared health care resources.

(f)  The need in the service district of the applicant for special equipment and services that are not reasonably and economically accessible in adjoining areas.

(g)  The need for research and educational facilities, including, but not limited to, institutional training programs and community training programs for health care practitioners and for doctors of osteopathic medicine and medicine at the student, internship, and residency training levels.

(h)  The availability of resources, including health personnel, management personnel, and funds for capital and operating expenditures, for project accomplishment and operation; the effects the project will have on clinical needs of health professional training programs in the service district; the extent to which the services will be accessible to schools for health professions in the service district for training purposes if such services are available in a limited number of facilities; the availability of alternative uses of such resources for the provision of other health services; and the extent to which the proposed services will be accessible to all residents of the service district.

(i)  The immediate and long-term financial feasibility of the proposal.

(j)  The special needs and circumstances of health maintenance organizations.

(k)  The needs and circumstances of those entities that provide a substantial portion of their services or resources, or both, to individuals not residing in the service district in which the entities are located or in adjacent service districts. Such entities may include medical and other health professions, schools, multidisciplinary clinics, and specialty services such as open-heart surgery, radiation therapy, and renal transplantation.

(l)  The probable impact of the proposed project on the costs of providing health services proposed by the applicant, upon consideration of factors including, but not limited to, the effects of competition on the supply of health services being proposed and the improvements or innovations in the financing and delivery of health services which foster competition and service to promote quality assurance and cost-effectiveness.

(m)  The costs and methods of the proposed construction, including the costs and methods of energy provision and the availability of alternative, less costly, or more effective methods of construction.

(n)  The applicant's past and proposed provision of health care services to Medicaid patients and the medically indigent.

(o)  The applicant's past and proposed provision of services that promote a continuum of care in a multilevel health care system, which may include, but are not limited to, acute care, skilled nursing care, home health care, and assisted living facilities.

(2)  In cases of capital expenditure proposals for the provision of new health services to inpatients, the agency shall also reference each of the following in its findings of fact:

(a)  That less costly, more efficient, or more appropriate alternatives to such inpatient services are not available and the development of such alternatives has been studied and found not practicable.

(b)  That existing inpatient facilities providing inpatient services similar to those proposed are being used in an appropriate and efficient manner.

(c)  In the case of new construction or replacement construction, that alternatives to the construction, for example, modernization or sharing arrangements, have been considered and have been implemented to the maximum extent practicable.

(d)  That patients will experience serious problems in obtaining inpatient care of the type proposed, in the absence of the proposed new service.

(e)  In the case of a proposal for the addition of beds for the provision of skilled nursing or intermediate care services, that the addition will be consistent with the plans of other agencies of the state responsible for the provision and financing of long-term care, including home health services.

History.--s. 22, ch. 87-92; s. 20, ch. 88-294; s. 15, ch. 92-33; ss. 37, 50, ch. 93-217; s. 30, ch. 95-210; s. 36, ch. 97-103; s. 39, ch. 97-264; s. 2, ch. 97-270.

Note.--Former s. 381.705.

¹408.036  Projects subject to review.--

(1)  APPLICABILITY.--Unless exempt under subsection (3), all health-care-related projects, as described in paragraphs (a)-(k), are subject to review and must file an application for a certificate of need with the agency. The agency is exclusively responsible for determining whether a health-care-related project is subject to review under ss. 408.031-408.045.

(a)  The addition of beds by new construction or alteration.

(b)  The new construction or establishment of additional health care facilities, including a replacement health care facility when the proposed project site is not located on the same site as the existing health care facility.

(c)  The conversion from one type of health care facility to another, including the conversion from one level of care to another, in a skilled or intermediate nursing facility, if the conversion effects a change in the level of care of 10 beds or 10 percent of total bed capacity of the skilled or intermediate nursing facility within a 2-year period. If the nursing facility is certified for both skilled and intermediate nursing care, the provisions of this paragraph do not apply.

(d)  Any increase in licensed bed capacity.

²(e)  Subject to the provisions of paragraph (3)(i), the establishment of a Medicare-certified home health agency, the establishment of a hospice, or the direct provision of such services by a health care facility or health maintenance organization for those other than the subscribers of the health maintenance organization; except that this paragraph does not apply to the establishment of a Medicare-certified home health agency by a facility described in paragraph (3)(h).

(f)  An acquisition by or on behalf of a health care facility or health maintenance organization, by any means, which acquisition would have required review if the acquisition had been by purchase.

(g)  The establishment of inpatient institutional health services by a health care facility, or a substantial change in such services.

(h)  The acquisition by any means of an existing health care facility by any person, unless the person provides the agency with at least 30 days' written notice of the proposed acquisition, which notice is to include the services to be offered and the bed capacity of the facility, and unless the agency does not determine, within 30 days after receipt of such notice, that the services to be provided and the bed capacity of the facility will be changed.

(i)  An increase in the cost of a project for which a certificate of need has been issued when the increase in cost exceeds 20 percent of the originally approved cost of the project, except that a cost overrun review is not necessary when the cost overrun is less than $20,000.

(j)  An increase in the number of psychiatric or rehabilitation beds.

(k)  The establishment of tertiary health services.

(2)  PROJECTS SUBJECT TO EXPEDITED REVIEW.--Unless exempt pursuant to subsection (3), projects subject to an expedited review shall include, but not be limited to:

(a)  Cost overruns, as defined in paragraph (1)(i).

(b)  Research, education, and training programs.

(c)  Shared services contracts or projects.

(d)  A transfer of a certificate of need.

(e)  A 50-percent increase in nursing home beds for a facility incorporated and operating in this state for at least 60 years on or before July 1, 1988, which has a licensed nursing home facility located on a campus providing a variety of residential settings and supportive services. The increased nursing home beds shall be for the exclusive use of the campus residents. Any application on behalf of an applicant meeting this requirement shall be subject to the base fee of $5,000 provided in s. 408.038.

(f)  Combination within one nursing home facility of the beds or services authorized by two or more certificates of need issued in the same planning subdistrict.

(g)  Division into two or more nursing home facilities of beds or services authorized by one certificate of need issued in the same planning subdistrict. Such division shall not be approved if it would adversely affect the original certificate's approved cost.

(h)  Replacement of a health care facility when the proposed project site is located in the same district and within a 1-mile radius of the replaced health care facility.

The agency shall develop rules to implement the provisions for expedited review, including time schedule, application content, and application processing.

(3)  EXEMPTIONS.--Upon request, supported by such documentation as the agency requires, the agency shall grant an exemption from the provisions of subsection (1):

(a)  For the initiation or expansion of obstetric services.

(b)  For any expenditure to replace or renovate any part of a licensed health care facility, provided that the number of licensed beds will not increase and, in the case of a replacement facility, the project site is the same as the facility being replaced.

(c)  For providing respite care services. An individual may be admitted to a respite care program in a hospital without regard to inpatient requirements relating to admitting order and attendance of a member of a medical staff.

²(d)  For hospice services or home health services provided by a rural hospital, as defined in s. 395.602, or for swing beds in such rural hospital in a number that does not exceed one-half of its licensed beds.

(e)  For the conversion of licensed acute care hospital beds to Medicare and Medicaid certified skilled nursing beds in a rural hospital as defined in s. 395.602, so long as the conversion of the beds does not involve the construction of new facilities. The total number of skilled nursing beds, including swing beds, may not exceed one-half of the total number of licensed beds in the rural hospital as of July 1, 1993. Certified skilled nursing beds designated under this paragraph, excluding swing beds, shall be included in the community nursing home bed inventory. A rural hospital which subsequently decertifies any acute care beds exempted under this paragraph shall notify the agency of the decertification, and the agency shall adjust the community nursing home bed inventory accordingly.

(f)  For the addition of nursing home beds at a skilled nursing facility that is part of a retirement community that provides a variety of residential settings and supportive services and that has been incorporated and operated in this state for at least 65 years on or before July 1, 1994. All nursing home beds must not be available to the public but must be for the exclusive use of the community residents.

(g)  For an increase in the bed capacity of a nursing facility licensed for at least 50 beds as of January 1, 1994, under part II of chapter 400 which is not part of a continuing care facility if, after the increase, the total licensed bed capacity of that facility is not more than 60 beds and if the facility has been continuously licensed since 1950 and has received a superior rating on each of its two most recent licensure surveys.

(h)  For the establishment of a Medicare-certified home health agency by a facility certified under chapter 651; a retirement community, as defined in s. 400.404(2)(g); or a residential facility that serves only retired military personnel, their dependents, and the surviving dependents of deceased military personnel. Medicare-reimbursed home health services provided through such agency shall be offered exclusively to residents of the facility or retirement community or to residents of facilities or retirement communities owned, operated, or managed by the same corporate entity. Each visit made to deliver Medicare-reimbursable home health services to a home health patient who, at the time of service, is not a resident of the facility or retirement community shall be a deceptive and unfair trade practice and constitutes a violation of ss. 501.201-501.213.

(i)  For the establishment of a Medicare-certified home health agency. This paragraph shall take effect 90 days after the adjournment sine die of the next regular session of the Legislature occurring after the legislative session in which the Legislature receives a report from the Director of Health Care Administration certifying that the federal Health Care Financing Administration has implemented a per-episode prospective pay system for Medicare-certified home health agencies.

(j)  For an inmate health care facility built by or for the exclusive use of the Department of Corrections as provided in chapter 945. This exemption expires when such facility is converted to other uses.

(k)  For an expenditure by or on behalf of a health care facility to provide a health service exclusively on an outpatient basis.

(l)  For the termination of a health care service.

(m)  For the delicensure of beds. An application submitted under this paragraph must identify the number, the classification, and the name of the facility in which the beds to be delicensed are located.

(n)  For the provision of adult inpatient diagnostic cardiac catheterization services in a hospital.

1.  In addition to any other documentation otherwise required by the agency, a request for an exemption submitted under this paragraph must comply with the following criteria:

a.  The applicant must certify it will not provide therapeutic cardiac catheterization pursuant to the grant of the exemption.

b.  The applicant must certify it will meet and continuously maintain the minimum licensure requirements adopted by the agency governing such programs pursuant to subparagraph 2.

c.  The applicant must certify it will provide a minimum of 2 percent of its services to charity and Medicaid patients.

2.  The agency shall adopt licensure requirements by rule which govern the operation of adult inpatient diagnostic cardiac catheterization programs established pursuant to the exemption provided in this paragraph. The rules shall ensure that such programs:

a.  Perform only adult inpatient diagnostic cardiac catheterization services authorized by the exemption and will not provide therapeutic cardiac catheterization or any other services not authorized by the exemption.

b.  Maintain sufficient appropriate equipment and health personnel to ensure quality and safety.

c.  Maintain appropriate times of operation and protocols to ensure availability and appropriate referrals in the event of emergencies.

d.  Maintain appropriate program volumes to ensure quality and safety.

e.  Provide a minimum of 2 percent of its services to charity and Medicaid patients each year.

3.a.  The exemption provided by this paragraph shall not apply unless the agency determines that the program is in compliance with the requirements of subparagraph 1. and that the program will, after beginning operation, continuously comply with the rules adopted pursuant to subparagraph 2. The agency shall monitor such programs to ensure compliance with the requirements of subparagraph 2.

b.(I)  The exemption for a program shall expire immediately when the program fails to comply with the rules adopted pursuant to sub-subparagraphs 2.a., b., and c.

(II)  Beginning 18 months after a program first begins treating patients, the exemption for a program shall expire when the program fails to comply with the rules adopted pursuant to sub-subparagraphs 2.d. and e.

(III)  If the exemption for a program expires pursuant to sub-sub-subparagraph (I) or sub-sub-subparagraph (II), the agency shall not grant an exemption pursuant to this paragraph for an adult inpatient diagnostic cardiac catheterization program located at the same hospital until 2 years following the date of the determination by the agency that the program failed to comply with the rules adopted pursuant to subparagraph 2.

4.  The agency shall not grant any exemption under this paragraph until the adoption of the rules required under this paragraph, or until March 1, 1998, whichever comes first. However, if final rules have not been adopted by March 1, 1998, the proposed rules governing the exemptions shall be used by the agency to grant exemptions under the provisions of this paragraph until final rules become effective.

³(o)  For any expenditure to provide mobile surgical facilities and related health care services under contract with the Department of Corrections or a private correctional facility operating pursuant to chapter 957.

(p)  For state veterans' nursing homes operated by or on behalf of the Florida Department of Veterans' Affairs in accordance with part II of chapter 296 for which at least 50 percent of the construction cost is federally funded and for which the Federal Government pays a per diem rate not to exceed one-half of the cost of the veterans' care in such state nursing homes. These beds shall not be included in the nursing home bed inventory.

A request for exemption under this subsection may be made at any time and is not subject to the batching requirements of this section.

History.--s. 23, ch. 87-92; s. 21, ch. 88-294; s. 2, ch. 89-527; ss. 3, 16, ch. 91-282; s. 15, ch. 92-33; s. 67, ch. 92-289; s. 30, ch. 93-129; s. 19, ch. 93-214; s. 38, ch. 93-217; ss. 3, 4, ch. 94-206; s. 58, ch. 95-144; s. 143, ch. 95-418; s. 3, ch. 97-270; s. 4, ch. 97-290; s. 3, ch. 98-14; s. 22, ch. 98-80; s. 3, ch. 98-85; s. 8, ch. 98-303.

¹Note.--Section 14, ch. 97-270, provides that "[s]ubject to any final order of the Florida Supreme Court, ss. 408.036(1)(b) and 408.039(5)(c), Florida Statutes, as amended by this act, do not apply to any replacement application filed with the Agency for Health Care Administration prior to or pending a final hearing before the Division of Administrative Hearings as of April 1, 1997. It is the intent of the Legislature that the remaining provisions of this act do not apply to applications that have been filed prior to [July 1, 1997]."

²Note.--Section 143, ch. 95-418, as amended by s. 4, ch. 97-290, provides that "[e]ffective upon this act becoming a law and notwithstanding any provision of law to the contrary, . . . paragraph (f) of subsection (1) and paragraph (h) of subsection (3) [redesignated as paragraph (1)(e) and paragraph (3)(d), respectively, by s. 3, ch. 97-270] of section 408.036, Florida Statutes, as amended by section 19 of chapter 93-214, Laws of Florida, shall not take effect on July 1, 1997, but shall take effect 90 days after the adjournment sine die of the next regular session of the Legislature occurring after the legislative session in which the Legislature receives a report from the Director of Health Care Administration certifying that the federal Health Care Financing Administration has implemented a per-episode prospective pay system for Medicare-certified home health agencies . . . ."

³Note.--Section 10, ch. 98-303, provides that "[m]obile surgical facilities in operation pursuant to a contract with the Department of Corrections entered into prior to [May 29, 1998] shall continue to operate pursuant to such contract and shall only be subject to the provisions of this act subsequent to the effective date of any rules promulgated by the Agency for Health Care Administration relating to mobile surgical facilities."

Note.--Former s. 381.706.

408.037  Application content.--

(1)  An application for a certificate of need must contain:

(a)  A detailed description of the proposed project and statement of its purpose and need in relation to the local health plan and the state health plan.

(b)  A statement of the financial resources needed by and available to the applicant to accomplish the proposed project. This statement must include:

1.  A complete listing of all capital projects, including new health facility development projects and health facility acquisitions applied for, pending, approved, or underway in any state at the time of application, regardless of whether or not that state has a certificate-of-need program or a capital expenditure review program pursuant to s. 1122 of the Social Security Act. The agency may, by rule, require less-detailed information from major health care providers. This listing must include the applicant's actual or proposed financial commitment to those projects and an assessment of their impact on the applicant's ability to provide the proposed project.

2.  A detailed listing of the needed capital expenditures, including sources of funds.

3.  A detailed financial projection, including a statement of the projected revenue and expenses for the first 2 years of operation after completion of the proposed project. This statement must include a detailed evaluation of the impact of the proposed project on the cost of other services provided by the applicant.

(c)  An audited financial statement of the applicant. In an application submitted by an existing health care facility, health maintenance organization, or hospice, financial condition documentation must include, but need not be limited to, a balance sheet and a profit-and-loss statement of the 2 previous fiscal years' operation.

(2)  The applicant must certify that it will license and operate the health care facility. For an existing health care facility, the applicant must be the licenseholder of the facility.

History.--s. 24, ch. 87-92; s. 15, ch. 92-33; s. 4, ch. 97-270.

Note.--Former s. 381.707.

408.038  Fees.--The department shall assess fees on certificate-of-need applications. Such fees shall be for the purpose of funding the functions of the local health councils and the activities of the department and shall be allocated as provided in s. 408.033. The fee shall be determined as follows:

(1)  A minimum base fee of $5,000.

(2)  In addition to the base fee of $5,000, 0.015 of each dollar of proposed expenditure, except that a fee may not exceed $22,000.

History.--s. 25, ch. 87-92; s. 2, ch. 89-104; s. 16, ch. 89-527; s. 4, ch. 91-282; s. 15, ch. 92-33; s. 11, ch. 95-144; s. 17, ch. 97-79.

Note.--Former s. 381.708.

¹408.039  Review process.--The review process for certificates of need shall be as follows:

(1)  REVIEW CYCLES.--The agency by rule shall provide for applications to be submitted on a timetable or cycle basis; provide for review on a timely basis; and provide for all completed applications pertaining to similar types of services or facilities affecting the same service district to be considered in relation to each other no less often than two times a year.

(2)  LETTERS OF INTENT.--

(a)  At least 30 days prior to filing an application, a letter of intent shall be filed by the applicant with the agency, respecting the development of a proposal subject to review. No letter of intent is required for expedited projects as defined by rule by the agency.

(b)  The agency shall provide a mechanism by which applications may be filed to compete with proposals described in filed letters of intent.

(c)  Letters of intent must describe the proposal; specify the number of beds sought, if any; identify the services to be provided and the specific subdistrict location; and identify the applicant.

(d)  Within 21 days after filing a letter of intent, the agency shall publish notice of the filing of letters of intent in the Florida Administrative Weekly and notice that, if requested, a public hearing shall be held at the local level within 21 days after the application is deemed complete. Notices under this paragraph must contain due dates applicable to the cycle for filing applications and for requesting a hearing.

(3)  APPLICATION PROCESSING.--

(a)  An applicant shall file an application with the department, and shall furnish a copy of the application to the local health council and the department. Within 15 days after the applicable application filing deadline established by department rule, the staff of the department shall determine if the application is complete. If the application is incomplete, the staff shall request specific information from the applicant necessary for the application to be complete; however, the staff may make only one such request. If the requested information is not filed with the department within 21 days of the receipt of the staff's request, the application shall be deemed incomplete and deemed withdrawn from consideration.

(b)  Upon the request of any applicant or substantially affected person within 14 days after notice that an application has been filed, a public hearing may be held at the department's discretion if the department determines that a proposed project involves issues of great local public interest. The public hearing shall allow applicants and other interested parties reasonable time to present their positions and to present rebuttal information. A recorded verbatim record of the hearing shall be maintained. The public hearing shall be held at the local level within 21 days after the application is deemed complete.

(4)  STAFF RECOMMENDATIONS.--

(a)  The department's review of and final agency action on applications shall be in accordance with the district plan, and statutory criteria, and the implementing administrative rules. In the application review process, the department shall give a preference, as defined by rule of the department, to an applicant which proposes to develop a nursing home in a nursing home geographically underserved area.

(b)  Within 60 days after all the applications in a review cycle are determined to be complete, the department shall issue its State Agency Action Report and Notice of Intent to grant a certificate of need for the project in its entirety, to grant a certificate of need for identifiable portions of the project, or to deny a certificate of need. The State Agency Action Report shall set forth in writing its findings of fact and determinations upon which its decision is based. If a finding of fact or determination by the department is counter to the district plan of the local health council, the department shall provide in writing its reason for its findings, item by item, to the local health council. If the department intends to grant a certificate of need, the State Agency Action Report or the Notice of Intent shall also include any conditions which the department intends to attach to the certificate of need. The department shall designate by rule a senior staff person, other than the person who issues the final order, to issue State Agency Action Reports and Notices of Intent.

(c)  The department shall publish its proposed decision set forth in the Notice of Intent in the Florida Administrative Weekly within 14 days after the Notice of Intent is issued.

(d)  If no administrative hearing is requested pursuant to subsection (5), the State Agency Action Report and the Notice of Intent shall become the final order of the department. The department shall provide a copy of the final order to the appropriate local health council.

(5)  ADMINISTRATIVE HEARINGS.--

(a)  Within 21 days after publication of notice of the State Agency Action Report and Notice of Intent, any person authorized under paragraph (c) to participate in a hearing may file a request for an administrative hearing; failure to file a request for hearing within 21 days of publication of notice shall constitute a waiver of any right to a hearing and a waiver of the right to contest the final decision of the agency. A copy of the request for hearing shall be served on the applicant.

(b)  Hearings shall be held in Tallahassee unless the administrative law judge determines that changing the location will facilitate the proceedings. The agency shall assign proceedings requiring hearings to the Division of Administrative Hearings of the Department of Management Services within 10 days after the time has expired for requesting a hearing. Except upon unanimous consent of the parties or upon the granting by the administrative law judge of a motion of continuance, hearings shall commence within 60 days after the administrative law judge has been assigned. All parties, except the agency, shall bear their own expense of preparing a transcript. In any application for a certificate of need which is referred to the Division of Administrative Hearings for hearing, the administrative law judge shall complete and submit to the parties a recommended order as provided in ss. 120.569 and 120.57. The recommended order shall be issued within 30 days after the receipt of the proposed recommended orders or the deadline for submission of such proposed recommended orders, whichever is earlier. The division shall adopt procedures for administrative hearings which shall maximize the use of stipulated facts and shall provide for the admission of prepared testimony.

(c)  In administrative proceedings challenging the issuance or denial of a certificate of need, only applicants considered by the agency in the same batching cycle are entitled to a comparative hearing on their applications. Existing health care facilities may initiate or intervene in an administrative hearing upon a showing that an established program will be substantially affected by the issuance of any certificate of need to a competing proposed facility or program within the same district.

(d)  The applicant's failure to strictly comply with the requirements of s. 408.037(1) or paragraph (2)(c) is not cause for dismissal of the application, unless the failure to comply impairs the fairness of the proceeding or affects the correctness of the action taken by the agency.

(e)  The agency shall issue its final order within 45 days after receipt of the recommended order. If the agency fails to take action within such time, or as otherwise agreed to by the applicant and the agency, the applicant may take appropriate legal action to compel the agency to act. When making a determination on an application for a certificate of need, the agency is specifically exempt from the time limitations provided in s. 120.60(1).

(6)  JUDICIAL REVIEW.--

(a)  A party to an administrative hearing for an application for a certificate of need has the right, within not more than 30 days after the date of the final order, to seek judicial review in the District Court of Appeal pursuant to s. 120.68. The department shall be a party in any such proceeding.

(b)  In such judicial review, the court shall affirm the final order of the department, unless the decision is arbitrary, capricious, or not in compliance with ss. 408.031-408.045.

(c)  The court, in its discretion, may award reasonable attorney's fees and costs to the prevailing party if the court finds that there was a complete absence of a justiciable issue of law or fact raised by the losing party.

History.--s. 26, ch. 87-92; s. 9, ch. 89-354; s. 15, ch. 92-33; s. 125, ch. 92-279; s. 55, ch. 92-326; s. 12, ch. 95-144; s. 190, ch. 96-410; s. 18, ch. 97-79; s. 5, ch. 97-270.

¹Note.--Section 14, ch. 97-270, provides that "[s]ubject to any final order of the Florida Supreme Court, ss. 408.036(1)(b) and 408.039(5)(c), Florida Statutes, as amended by this act, do not apply to any replacement application filed with the Agency for Health Care Administration prior to or pending a final hearing before the Division of Administrative Hearings as of April 1, 1997. It is the intent of the Legislature that the remaining provisions of this act do not apply to applications that have been filed prior to [July 1, 1997]."

Note.--Former s. 381.709.

408.040  Conditions and monitoring.--

(1)(a)  The agency may issue a certificate of need predicated upon statements of intent expressed by an applicant in the application for a certificate of need.

1.  Any certificate of need issued for construction of a new hospital or for the addition of beds to an existing hospital shall include a statement of the number of beds approved by category of service, including rehabilitation or psychiatric service, for which the agency has adopted by rule a specialty-bed-need methodology. All beds that are approved, but are not covered by any specialty-bed-need methodology, shall be designated as general.

2.  The agency may consider, in addition to the other criteria specified in s. 408.035, a statement of intent by the applicant to designate a percentage of the beds of the facility for use by patients eligible for care under Title XIX of the Social Security Act. Any certificate of need issued to a nursing home in reliance upon an applicant's statements to provide a specified number of beds for use by residents eligible for care under Title XIX of the Social Security Act must include a statement that such certification is a condition of issuance of the certificate of need. The certificate-of-need program shall notify the Medicaid program office and the Department of Elderly Affairs when it imposes conditions as authorized in this subparagraph in an area in which a community diversion pilot project is implemented.

(b)  A certificateholder may apply to the agency for a modification of conditions imposed under paragraph (a). If the holder of a certificate of need demonstrates good cause why the certificate should be modified, the agency shall reissue the certificate of need with such modifications as may be appropriate. The agency shall by rule define the factors constituting good cause for modification.

(c)  If the holder of a certificate of need fails to comply with a condition upon which the issuance of the certificate was predicated, the agency may assess an administrative fine against the certificateholder in an amount not to exceed $1,000 per failure per day. In assessing the penalty, the agency shall take into account as mitigation the relative lack of severity of a particular failure. Proceeds of such penalties shall be deposited in the Public Medical Assistance Trust Fund.

(2)(a)  Unless the applicant has commenced construction, if the project provides for construction, unless the applicant has incurred an enforceable capital expenditure commitment for a project, if the project does not provide for construction, or unless subject to paragraph (b), a certificate of need shall terminate 18 months after the date of issuance, except in the case of a multifacility project, as defined in s. 408.032, where the certificate of need shall terminate 2 years after the date of issuance. The agency shall monitor the progress of the holder of the certificate of need in meeting the timetable for project development specified in the application with the assistance of the local health council as specified in s. 408.033(1)(b)5., and may revoke the certificate of need, if the holder of the certificate is not meeting such timetable and is not making a good faith effort, as defined by rule, to meet it.

(b)  A certificate of need issued to an applicant holding a provisional certificate of authority under chapter 651 shall terminate 1 year after the applicant receives a valid certificate of authority from the Department of Insurance.

(c)  The certificate-of-need validity period for a project shall be extended by the agency, to the extent that the applicant demonstrates to the satisfaction of the agency that good faith commencement of the project is being delayed by litigation or by governmental action or inaction with respect to regulations or permitting precluding commencement of the project.

(d)  If an application is filed to consolidate two or more certificates as authorized by s. 408.036(2)(f) or to divide a certificate of need into two or more facilities as authorized by s. 408.036(2)(g), the validity period of the certificate or certificates of need to be consolidated or divided shall be extended for the period beginning upon submission of the application and ending when final agency action and any appeal from such action has been concluded. However, no such suspension shall be effected if the application is withdrawn by the applicant.

(3)  The agency shall require the submission of an executed architect's certification of final payment for each certificate-of-need project approved by the agency. Each project that involves construction shall submit such certification to the agency within 30 days following completion of construction.

History.--s. 27, ch. 87-92; s. 22, ch. 88-294; s. 15, ch. 92-33; s. 13, ch. 95-144; s. 6, ch. 97-270; s. 4, ch. 98-85.

Note.--Former s. 381.710.

408.041  Certificate of need required; penalties.--It is unlawful for any person to undertake a project subject to review under ss. 408.031-408.045 without a valid certificate of need. Any person violating the provisions of this section is guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083. Each day of continuing violation shall be considered a separate offense.

History.--s. 28, ch. 87-92; s. 62, ch. 91-224; s. 15, ch. 92-33; s. 14, ch. 95-144.

Note.--Former s. 381.711.

408.042  Limitation on transfer.--The holder of a certificate of need shall not charge a price for the transfer of the certificate of need to another person that exceeds the total amount of the actual costs incurred by the holder in obtaining the certificate of need. Such actual costs must be documented by an affidavit executed by the transferor under oath. A holder who violates this section is guilty of a misdemeanor of the first degree, punishable as provided in s. 775.082, or by a fine not exceeding $10,000, or both.

History.--s. 29, ch. 87-92; s. 15, ch. 92-33; s. 7, ch. 97-270.

Note.--Former s. 381.712.

408.043  Special provisions.--

(1)  OSTEOPATHIC ACUTE CARE HOSPITALS.--When an application is made for a certificate of need to construct or to expand an osteopathic acute care hospital, the need for such hospital shall be determined on the basis of the need for and availability of osteopathic services and osteopathic acute care hospitals in the district. When a prior certificate of need to establish an osteopathic acute care hospital has been issued in a district, and the facility is no longer used for that purpose, the agency may continue to count such facility and beds as an existing osteopathic facility in any subsequent application for construction of an osteopathic acute care hospital.

(2)  HOSPICES.--When an application is made for a certificate of need to establish or to expand a hospice, the need for such hospice shall be determined on the basis of the need for and availability of hospice services in the community. The formula on which the certificate of need is based shall discourage regional monopolies and promote competition. The inpatient hospice care component of a hospice which is a freestanding facility, or a part of a facility, which is primarily engaged in providing inpatient care and related services and is not licensed as a health care facility shall also be required to obtain a certificate of need. Provision of hospice care by any current provider of health care is a significant change in service and therefore requires a certificate of need for such services.

(3)  RURAL HEALTH NETWORKS.--Preference shall be given in the award of a certificate of need to members of certified rural health networks, as provided for in s. 381.0406, subject to the following conditions:

(a)  Need must be shown pursuant to s. 408.035.

(b)  The proposed project must:

1.  Strengthen health care services in rural areas through partnerships between rural care providers; or

2.  Increase access to inpatient health care services for Medicaid recipients or other low-income persons who live in rural areas.

(c)  No preference shall be given under this section for the establishment of skilled nursing facility services by a hospital.

(4)  PRIVATE ACCREDITATION NOT REQUIRED.--Accreditation by any private organization may not be a requirement for the issuance or maintenance of a certificate of need under ss. 408.031-408.045.

History.--s. 30, ch. 87-92; s. 15, ch. 91-282; s. 15, ch. 92-33; s. 31, ch. 93-129; s. 8, ch. 97-270.

Note.--Former s. 381.713.

408.044  Injunction.--Notwithstanding the existence or pursuit of any other remedy, the department may maintain an action in the name of the state for injunction or other process against any person to restrain or prevent the pursuit of a project subject to review under ss. 408.031-408.045, in the absence of a valid certificate of need.

History.--s. 31, ch. 87-92; s. 15, ch. 92-33; s. 15, ch. 95-144.

Note.--Former s. 381.714.

408.045  Certificate of need; competitive sealed proposals.--

(1)  The application, review, and issuance procedures for a certificate of need for an intermediate care facility for the developmentally disabled may be made by the department by competitive sealed proposals.

(2)  The department shall make a decision regarding the issuance of the certificate of need in accordance with the provisions of s. 287.057(15), rules adopted by the department relating to intermediate care facilities for the developmentally disabled, and the criteria in s. 408.035, as further defined by rule.

(3)  Notification of the decision shall be issued to all applicants not later than 28 calendar days after the date responses to a request for proposal are due.

(4)  The procedures provided for under this section are exempt from the batching cycle requirements and the public hearing requirement of s. 408.039.

(5)  The department may use the competitive sealed proposal procedure for determining a certificate of need for other types of health care facilities and services if the department identifies an unmet health care need and when funding in whole or in part for such health care facilities or services is authorized by the Legislature.

History.--s. 3, ch. 83-244; s. 42, ch. 85-81; s. 32, ch. 87-92; s. 3, ch. 89-308; s. 30, ch. 90-268; ss. 15, 18, ch. 92-33; s. 16, ch. 95-144.

Note.--Former s. 381.4961; s. 381.715.

408.0455  Rules; pending proceedings.--The rules of the agency in effect on June 30, 1997, shall remain in effect and shall be enforceable by the agency with respect to ss. 408.031-408.045 until such rules are repealed or amended by the agency, and no judicial or administrative proceeding pending on July 1, 1997, shall be abated as a result of the provisions of ss. 408.031-408.043(1) and (2); s. 408.044; or s. 408.045.

History.--s. 38, ch. 87-92; s. 19, ch. 92-33; s. 74, ch. 92-289; s. 19, ch. 97-79; s. 4, ch. 97-98; s. 9, ch. 97-270.

Note.--Former s. 381.7155.

408.05  State Center for Health Statistics.--

(1)  ESTABLISHMENT.--The agency shall establish a State Center for Health Statistics. The center shall establish a comprehensive health information system to provide for the collection, compilation, coordination, analysis, indexing, dissemination, and utilization of both purposefully collected and extant health-related data and statistics. The center shall be staffed with public health experts, biostatisticians, information system analysts, health policy experts, economists, and other staff necessary to carry out its functions.

(2)  STATISTICS.--The comprehensive health information system operated by the State Center for Health Statistics shall collect data on:

(a)  The extent and nature of illness and disability of the state population, including life expectancy, the incidence of various acute and chronic illnesses, and infant and maternal morbidity and mortality.

(b)  The impact of illness and disability of the state population on the state economy and on other aspects of the well-being of the people in this state.

(c)  Environmental, social, and other health hazards.

(d)  Health knowledge and practices of the people in this state and determinants of health and nutritional practices and status.

(e)  Health resources, including physicians, dentists, nurses, and other health professionals, by specialty and type of practice and acute, long-term care and other institutional care facility supplies and specific services provided by hospitals, nursing homes, home health agencies, and other health care facilities.

(f)  Utilization of health care by type of provider.

(g)  Health care costs and financing, including trends in health care prices and costs, the sources of payment for health care services, and federal, state, and local expenditures for health care.

(h)  Family formation, growth, and dissolution.

(i)  The extent of public and private health insurance coverage in this state.

(j)  The quality of care provided by various health care providers.

(3)  COMPREHENSIVE HEALTH INFORMATION SYSTEM.--In order to produce comparable and uniform health information and statistics, the agency shall perform the following functions:

(a)  Coordinate the activities of state agencies involved in the design and implementation of the comprehensive health information system.

(b)  Undertake research, development, and evaluation respecting the comprehensive health information system.

(c)  Review the statistical activities of the ¹Department of Health and Rehabilitative Services to assure that they are consistent with the comprehensive health information system.

(d)  Develop written agreements with local, state, and federal agencies for the sharing of health-care-related data or using the facilities and services of such agencies. State agencies, local health councils, and other agencies under contract with the ¹Department of Health and Rehabilitative Services shall assist the center in obtaining, compiling, and transferring health-care-related data maintained by state and local agencies. Written agreements must specify the types, methods, and periodicity of data exchanges and specify the types of data that will be transferred to the center.

(e)  The agency shall establish by rule the types of data collected, compiled, processed, used, or shared. Decisions regarding center data sets should be made based on consultation with the Comprehensive Health Information System Advisory Council and other public and private users regarding the types of data which should be collected and their uses.

(f)  The center shall establish standardized means for collecting health information and statistics under laws and rules administered by the agency.

(g)  Establish minimum health-care-related data sets which are necessary on a continuing basis to fulfill the collection requirements of the center and which shall be used by state agencies in collecting and compiling health-care-related data. The agency shall periodically review ongoing health care data collections of the ¹Department of Health and Rehabilitative Services and other state agencies to determine if the collections are being conducted in accordance with the established minimum sets of data.

(h)  Establish advisory standards to assure the quality of health statistical and epidemiological data collection, processing, and analysis by local, state, and private organizations.

(i)  Prescribe standards for the publication of health-care-related data reported pursuant to this section which ensure the reporting of accurate, valid, reliable, complete, and comparable data. Such standards should include advisory warnings to users of the data regarding the status and quality of any data reported by or available from the center.

(j)  Prescribe standards for the maintenance and preservation of the center's data. This should include methods for archiving data, retrieval of archived data, and data editing and verification.

(k)  Ensure that strict quality control measures are maintained for the dissemination of data through publications, studies, or user requests.

(4)  TECHNICAL ASSISTANCE.--The center shall provide technical assistance to persons or organizations engaged in health planning activities in the effective use of statistics collected and compiled by the center. The center shall also provide the following additional technical assistance services:

(a)  Establish procedures identifying the circumstances under which, the places at which, the persons from whom, and the methods by which a person may secure data from the center, including procedures governing requests, the ordering of requests, timeframes for handling requests, and other procedures necessary to facilitate the use of the center's data. To the extent possible, the center should provide current data timely in response to requests from public or private agencies.

(b)  Provide assistance to data sources and users in the areas of database design, survey design, sampling procedures, statistical interpretation, and data access to promote improved health-care-related data sets.

(c)  Identify health care data gaps and seek cooperative agreements with other public or private organizations for meeting documented health care data needs.

(d)  Assist other organizations in developing statistical abstracts of their data sets that could be used by the center.

(e)  Provide statistical support to state agencies with regard to the use of databases maintained by the center.

(f)  To the extent possible, respond to multiple requests for information not currently collected by the center or available from other sources by initiating data collection.

(g)  Maintain detailed information on data maintained by other local, state, federal, and private agencies in order to advise those who use the center of potential sources of data which are requested but which are not available from the center.

(h)  Respond to requests for data which are not available in published form by initiating special computer runs on data sets available to the center.

(5)  PUBLICATIONS; REPORTS; SPECIAL STUDIES.--The center shall provide for the widespread dissemination of data which it collects and analyzes. The center shall have the following publication, reporting, and special study functions:

(a)  The center shall publish and make available periodically to agencies and individuals health statistics publications of general interest, publications providing health statistics on topical health policy issues, publications which provide health status profiles of the people in this state, and other topical health statistics publications.

(b)  The center shall publish, make available, and disseminate, promptly and as widely as practicable, the results of special health surveys, health care research, and health care evaluations conducted or supported under this section. Any publication by the center must include a statement of the limitations on the quality, accuracy, and completeness of the data.

(c)  The center shall provide indexing, abstracting, translation, publication, and other services leading to a more effective and timely dissemination of health care statistics.

(d)  The agency shall prepare and furnish a status report on the establishment of the center by April 1, 1993, to the Governor, the President of the Senate, and the Speaker of the House of Representatives. The report shall include an inventory of health data available in this state, implementation plans and progress made in implementing the functions assigned to the center, and recommendations for further legislation or resources needed to fulfill legislative intent with regard to the center, particularly with regard to establishing a statewide comprehensive health information system. The center shall thereafter be responsible for publishing and disseminating an annual report on the center's activities.

(e)  The center shall be responsible, to the extent resources are available, for conducting a variety of special studies and surveys to expand the health care information and statistics available for health policy analyses, particularly for the review of public policy issues. The center shall develop a process by which users of the center's data are periodically surveyed regarding critical data needs and the results of the survey considered in determining which special surveys or studies will be conducted. The center shall select problems in health care for research, policy analyses, or special data collections on the basis of their local, regional, or state importance; the unique potential for definitive research on the problem; and opportunities for application of the study findings.

(6)  PROVIDER DATA REPORTING.--This section does not confer on the agency the power to demand or require that a health care provider or professional furnish information, records of interviews, written reports, statements, notes, memoranda, or data other than as expressly required by law.

(7)  BUDGET; FEES; TRUST FUND.--

(a)  The Legislature intends that funding for the State Center for Health Statistics be appropriated from the General Revenue Fund.

(b)  The State Center for Health Statistics may apply for and receive and accept grants, gifts, and other payments, including property and services, from any governmental or other public or private entity or person and make arrangements as to the use of same, including the undertaking of special studies and other projects relating to health-care-related topics. Funds obtained pursuant to this paragraph may not be used to offset annual appropriations from the General Revenue Fund.

(c)  The center may charge such reasonable fees for services as the agency prescribes by rule. The established fees may not exceed the reasonable cost for such services. Fees collected may not be used to offset annual appropriations from the General Revenue Fund.

(d)  The agency shall establish a Comprehensive Health Information System Trust Fund as the repository of all funds appropriated to, and fees and grants collected for, services of the State Center for Health Statistics. Any funds, other than funds appropriated to the center from the General Revenue Fund, which are raised or collected by the agency for the operation of the center and which are not needed to meet the expenses of the center for its current fiscal year shall be available to the agency in succeeding years.

(8)  STATE COMPREHENSIVE HEALTH INFORMATION SYSTEM ADVISORY COUNCIL.--

(a)  There is established in the agency the State Comprehensive Health Information System Advisory Council to assist the center in reviewing the comprehensive health information system and to recommend improvements for such system. The council shall consist of the following members:

1.  An employee of the Executive Office of the Governor, to be appointed by the Governor.

2.  An employee of the Department of Insurance, to be appointed by the Insurance Commissioner.

3.  An employee of the Department of Education, to be appointed by the Commissioner of Education.

4.  Ten persons, to be appointed by the Director of Health Care Administration, representing other state and local agencies, state universities, the Florida Association of Business/Health Coalitions, local health councils, professional health-care-related associations, consumers, and purchasers.

(b)  Each member of the council shall be appointed to serve for a term of 4 years from the date of appointment, except that a vacancy shall be filled by appointment for the remainder of the term and except that:

1.  Three of the members initially appointed by the Director of Health Care Administration shall each be appointed for a term of 3 years.

2.  Two of the members initially appointed by the Director of Health Care Administration shall each be appointed for a term of 2 years.

3.  Two of the members initially appointed by the Director of Health Care Administration shall each be appointed for a term of 1 year.

(c)  The council may meet at the call of its chair, at the request of the department, or at the request of a majority of its membership, but at least quarterly.

(d)  Members shall elect a chair annually.

(e)  A majority of the members constitutes a quorum, and the affirmative vote of a majority of a quorum is necessary to take action.

(f)  The council shall maintain minutes of each meeting and shall make such minutes available to any person.

(g)  Members of the council shall serve without compensation but shall be entitled to receive reimbursement for per diem and travel expenses as provided in s. 112.061.

(9)  Nothing in this section shall limit, restrict, affect, or control the collection, analysis, release, or publication of data pursuant to the ²Health Care Cost Containment Act of 1988 or by any state agency pursuant to its statutory authority, duties, or responsibilities.

History.--s. 39, ch. 88-394; s. 1, ch. 90-347; s. 50, ch. 91-297; s. 5, ch. 91-429; s. 14, ch. 92-33; s. 4, ch. 95-201; s. 37, ch. 97-103; s. 10, ch. 98-89.

¹Note.--The Department of Health and Rehabilitative Services was redesignated as the Department of Children and Family Services by s. 5, ch. 96-403, and the Department of Health was created by s. 8, ch. 96-403.

²Note.--Repealed by s. 82, ch. 92-33.

Note.--Former s. 381.0612; s. 381.0401.

408.061  Data collection; uniform systems of financial reporting; information relating to physician charges; confidentiality of patient records; immunity.--

(1)  The agency may require the submission by health care facilities, health care providers, and health insurers of data necessary to carry out the agency's duties. Specifications for data to be collected under this section shall be developed by the agency with the assistance of technical advisory panels including representatives of affected entities, consumers, purchasers, and such other interested parties as may be determined by the agency.

(a)  Data to be submitted by health care facilities may include, but are not limited to: case-mix data, patient admission or discharge data with patient and provider-specific identifiers included, actual charge data by diagnostic groups, financial data, accounting data, operating expenses, expenses incurred for rendering services to patients who cannot or do not pay, interest charges, depreciation expenses based on the expected useful life of the property and equipment involved, and demographic data. Data may be obtained from documents such as, but not limited to: leases, contracts, debt instruments, itemized patient bills, medical record abstracts, and related diagnostic information.

(b)  Data to be submitted by health care providers may include, but are not limited to: Medicare and Medicaid participation, types of services offered to patients, amount of revenue and expenses of the health care provider, and such other data which are reasonably necessary to study utilization patterns.

(c)  Data to be submitted by health insurers may include, but are not limited to: claims, premium, administration, and financial information.

(d)  Data required to be submitted by health care facilities, health care providers, or health insurers shall not include specific provider contract reimbursement information. However, such specific provider reimbursement data shall be reasonably available for onsite inspection by the agency as is necessary to carry out the agency's regulatory duties. Any such data obtained by the agency as a result of onsite inspections may not be used by the state for purposes of direct provider contracting and are confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

(e)  A requirement to submit data shall be adopted by rule if the submission of data is being required of all members of any type of health care facility, health care provider, or health insurer. Rules are not required, however, for the submission of data for a special study mandated by the Legislature or when information is being requested for a single health care facility, health care provider, or health insurer.

(2)  The agency shall, by rule, after consulting with appropriate professional and governmental advisory bodies and holding public hearings and considering existing and proposed systems of accounting and reporting utilized by health care facilities, specify a uniform system of financial reporting for each type of facility based on a uniform chart of accounts developed after considering any chart of accounts developed by the national association for such facilities and generally accepted accounting principles. Such systems shall, to the extent feasible, use existing accounting systems and shall minimize the paperwork required of facilities. This provision shall not be construed to authorize the agency to require health care facilities to adopt a uniform accounting system. As a part of such uniform system of financial reporting, the agency may require the filing of any information relating to the cost to the provider and the charge to the consumer of any service provided in such facility, except the cost of a physician's services which is billed independently of the facility.

(3)  When more than one licensed facility is operated by the reporting organization, the information required by this section shall be reported for each facility separately.

(4)(a)  Within 120 days after the end of its fiscal year, each health care facility shall file with the agency, on forms adopted by the agency and based on the uniform system of financial reporting, its actual financial experience for that fiscal year, including expenditures, revenues, and statistical measures. Such data may be based on internal financial reports which are certified to be complete and accurate by the provider. However, hospitals' actual financial experience shall be their audited actual experience. Nursing homes that do not participate in the Medicare or Medicaid programs shall also submit audited actual experience. Every nursing home shall submit to the agency, in a format designated by the agency, a statistical profile of the nursing home residents. The agency, in conjunction with the Department of Elderly Affairs and the ¹Department of Health and Rehabilitative Services, shall review these statistical profiles and develop recommendations for the types of residents who might more appropriately be placed in their homes or other noninstitutional settings. The agency shall include its findings in the final Florida Health Plan which must be submitted to the Legislature by December 31, 1993. Included in the findings shall be outcome data and cost differential data as part of patient profiles.

(b)  Each nursing home shall also submit a schedule of the charges in effect at the beginning of the fiscal year and any changes that were made during the fiscal year. A nursing home which is certified under Title XIX of the Social Security Act and files annual Medicaid cost reports may substitute copies of such reports and any Medicaid audits to the agency in lieu of a report and audit required under this subsection. For such facilities, the agency may require only information in compliance with this chapter that is not contained in the Medicaid cost report. Facilities that are certified under Title XVIII, but not Title XIX, of the Social Security Act must submit a report as developed by the agency. This report shall be substantially the same as the Medicaid cost report and shall not require any more information than is contained in the Medicare cost report unless that information is required of all nursing homes. The audit under Title XVIII shall satisfy the audit requirement under this subsection.

(5)  In addition to information submitted in accordance with subsection (4), each nursing home shall track and file with the agency, on a form adopted by the agency, data related to each resident's admission, discharge, or conversion to Medicaid; health and functional status; plan of care; and other information pertinent to the resident's placement in a nursing home.

(6)  Any nursing home which assesses residents a separate charge for personal laundry services shall submit to the agency data on the monthly charge for such services, excluding drycleaning. For facilities that charge based on the amount of laundry, the most recent schedule of charges and the average monthly charge shall be submitted to the agency.

(7)  The agency may require other reports based on the uniform system of financial reporting necessary to accomplish the purposes of this chapter.

(8)  Portions of patient records obtained or generated by the agency containing the name, residence or business address, telephone number, social security or other identifying number, or photograph of any person or the spouse, relative, or guardian of such person, or any other identifying information which is patient-specific or otherwise identifies the patient, either directly or indirectly, are confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

(9)  The identity of any health care provider, health care facility, or health insurer who submits any data which is proprietary business information to the agency pursuant to the provisions of this section shall remain confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution. As used in this section, "proprietary business information" shall include, but not be limited to, information relating to specific provider contract reimbursement information; information relating to security measures, systems, or procedures; and information concerning bids or other contractual data, the disclosure of which would impair efforts to contract for goods or services on favorable terms or would injure the affected entity's ability to compete in the marketplace. Notwithstanding the provisions of this subsection, any information obtained or generated pursuant to the provisions of ²s. 407.61, either by the ³Health Care Cost Containment Board or by the Agency for Health Care Administration upon transfer to that agency of the duties and functions of the ³Health Care Cost Containment Board, is not confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution. Such proprietary business information may be used in published analyses and reports or otherwise made available for public disclosure in such manner as to preserve the confidentiality of the identity of the provider. This exemption shall not limit the use of any information used in conjunction with investigation or enforcement purposes under the provisions of s. 455.621.

(10)  No health care facility, health care provider, health insurer, or other reporting entity or its employees or agents shall be held liable for civil damages or subject to criminal penalties either for the reporting of patient data to the agency or for the release of such data by the agency as authorized by this chapter.

(11)  The agency shall be the primary source for collection and dissemination of health care data. No other agency of state government may gather data from a health care provider licensed or regulated under this chapter without first determining if the data is currently being collected by the agency and affirmatively demonstrating that it would be more cost-effective for an agency of state government other than the agency to gather the health care data. The director shall ensure that health care data collected by the divisions within the agency is coordinated. It is the express intent of the Legislature that all health care data be collected by a single source within the agency and that other divisions within the agency, and all other agencies of state government, obtain data for analysis, regulation, and public dissemination purposes from that single source. Confidential information may be released to other governmental entities or to parties contracting with the agency to perform agency duties or functions as needed in connection with the performance of the duties of the receiving entity. The receiving entity or party shall retain the confidentiality of such information as provided for herein.

(12)  The agency shall cooperate with local health councils and the state health planning agency with regard to health care data collection and dissemination and shall cooperate with state agencies in any efforts to establish an integrated health care database.

(13)  It is the policy of this state that philanthropic support for health care should be encouraged and expanded, especially in support of experimental and innovative efforts to improve the health care delivery system.

(14)  For purposes of determining reasonable costs of services furnished by health care facilities, unrestricted grants, gifts, and income from endowments shall not be deducted from any operating costs of such health care facilities, and, in addition, the following items shall not be deducted from any operating costs of such health care facilities:

(a)  An unrestricted grant or gift, or income from such a grant or gift, which is not available for use as operating funds because of its designation by the health care facility's governing board.

(b)  A grant or similar payment which is made by a governmental entity and which is not available, under the terms of the grant or payment, for use as operating funds.

(c)  The sale or mortgage of any real estate or other capital assets of the health care facility which the health care facility acquired through a gift or grant and which is not available for use as operating funds under the terms of the gift or grant or because of its designation by the health care facility's governing board, except for recovery of the appropriate share of gains and losses realized from the disposal of depreciable assets.

History.--s. 68, ch. 92-33; s. 14, ch. 93-129; ss. 3, 4, ch. 95-201; s. 248, ch. 96-406; s. 40, ch. 97-98; s. 11, ch. 98-89; s. 27, ch. 98-166.

¹Note.--The Department of Health and Rehabilitative Services was redesignated as the Department of Children and Family Services by s. 5, ch. 96-403, and the Department of Health was created by s. 8, ch. 96-403.

²Note.--Repealed by s. 19, ch. 98-89.

³Note.--Sections 82 and 83, ch. 92-33, abolished the Health Care Cost Containment Board and transferred all powers, duties and functions, records, personnel, property, and unexpended balances of appropriations, allocations, or other funds of the board to the Agency for Health Care Administration.

408.062  Research, analyses, studies, and reports.--

(1)  The agency shall have the authority to conduct research, analyses, and studies relating to health care costs and access to and quality of health care services as access and quality are affected by changes in health care costs. Such research, analyses, and studies shall include, but not be limited to, research and analysis relating to:

(a)  The financial status of any health care facility or facilities subject to the provisions of this chapter.

(b)  The impact of uncompensated charity care on health care facilities and health care providers.

(c)  The state's role in assisting to fund indigent care.

(d)  The availability and affordability of health insurance for small businesses.

(e)  Total health care expenditures in the state according to the sources of payment and the type of expenditure.

(f)  The quality of health services, using techniques such as small area analysis, severity adjustments, and risk-adjusted mortality rates.

(g)  The development of an alternative uniform system of financial reporting of gross revenues per adjusted admission, based on the American Institute of Certified Public Accounts' Hospital Audit and Accounting Guide, which also measures the services provided by a hospital to charity, medically indigent, and other underinsured patients. Recommendations for the development of an alternative uniform system of financial reporting shall be submitted to the Legislature by July 1, 1993.

(h)  The development of physician payment systems which are capable of taking into account the amount of resources consumed and the outcomes produced in the delivery of care.

(i)  The impact of subacute admissions on hospital revenues and expenses for purposes of calculating adjusted admissions as defined in s. 408.07.

(2)  The agency shall evaluate data from nursing home financial reports and shall document and monitor:

(a)  Total revenues, annual change in revenues, and revenues by source and classification, including contributions for a resident's care from the resident's resources and from the family and contributions not directed toward any specific resident's care.

(b)  Average resident charges by geographic region, payor, and type of facility ownership.

(c)  Profit margins by geographic region and type of facility ownership.

(d)  Amount of charity care provided by geographic region and type of facility ownership.

(e)  Resident days by payor category.

(f)  Experience related to Medicaid conversion as reported under s. 408.061.

(g)  Other information pertaining to nursing home revenues and expenditures.

The findings of the agency shall be included in an annual report to the Governor and Legislature by January 1 each year.

(3)  The agency may assess annually the caesarean section rate in Florida hospitals using the analysis methodology that the agency determines most appropriate. To assist the agency in determining the impact of this chapter on Florida hospitals' caesarean section rates, each provider hospital, as defined in s. 383.336, shall notify the agency of the date of implementation of the practice parameters and the date of the first meeting of the hospital peer review board created pursuant to this chapter. The agency shall use these dates in monitoring any change in provider hospital caesarean section rates. An annual report based on this monitoring and assessment shall be submitted to the Governor, the Speaker of the House of Representatives, and the President of the Senate by the agency, with the first annual report due January 1, 1993.

(4)  The agency may also prepare such summaries and compilations or other supplementary reports based on the information analyzed by the agency under this section, as will advance the purposes of this chapter.

(5)(a)  The agency may conduct data-based studies and evaluations and make recommendations to the Legislature and the Governor concerning exemptions, the effectiveness of limitations of referrals, restrictions on investment interests and compensation arrangements, and the effectiveness of public disclosure. Such analysis may include, but need not be limited to, utilization of services, cost of care, quality of care, and access to care. The agency may require the submission of data necessary to carry out this duty, which may include, but need not be limited to, data concerning ownership, Medicare and Medicaid, charity care, types of services offered to patients, revenues and expenses, patient-encounter data, and other data reasonably necessary to study utilization patterns and the impact of health care provider ownership interests in health-care-related entities on the cost, quality, and accessibility of health care.

(b)  The agency may collect such data from any health facility as a special study.

History.--s. 69, ch. 92-33; s. 12, ch. 93-129; s. 12, ch. 98-89.

408.063  Dissemination of health care information.--

(1)  The agency, relying on data collected pursuant to this chapter, shall establish a reliable, timely, and consistent information system that distributes information and serves as the basis for the agency's public education programs. The agency shall seek advice from consumers, health care purchasers, health care providers, health care facilities, health insurers, and local health councils in the development and implementation of its information system. Whenever appropriate, the agency shall use the local health councils for the dissemination of information and education of the public.

(2)  The agency shall publish and disseminate information to the public which will enhance informed decisionmaking in the selection of health care providers, facilities, and services. Such publications may identify average charges for specified services, lengths of stay associated with established diagnostic groups, readmission rates, mortality rates, recommended guidelines for selection and use of health care providers, health care facilities, and health care services, and such other information as the agency deems appropriate.

(3)  The agency shall educate consumers and health care purchasers by conducting or sponsoring seminars and other educational programs at locations throughout the state.

(4)  The agency shall serve as a clearinghouse for information concerning:

(a)  Innovations in the delivery of health care services and the enhancement of competition in the health care market.

(b)  Federal and state legislative initiatives affecting the private health care delivery system and governmental health care programs.

(c)  Health promotion, illness prevention, and wellness in the work setting.

(5)  The agency shall publish annually a comprehensive report of state health expenditures. The report shall identify:

(a)  The contribution of health care dollars made by all payors.

(b)  The dollars expended by type of health care service in Florida.

(6)  The staff of the agency may conduct or sponsor consumer information and education seminars at locations throughout the state and may hold public hearings to solicit consumer concerns or complaints relating to health care costs and make recommendations to the agency for study, action, or investigation.

History.--s. 70, ch. 92-33; s. 13, ch. 98-89.

408.07  Definitions.--As used in this chapter, with the exception of ss. 408.031-408.045, the term:

(1)  "Accepted" means that the agency has found that a report or data submitted by a health care facility or a health care provider contains all schedules and data required by the agency and has been prepared in the format specified by the agency, and otherwise conforms to applicable rule or Florida Hospital Uniform Reporting System manual requirements regarding reports in effect at the time such report was submitted, and the data are mathematically reasonable and accurate.

(2)  "Adjusted admission" means the sum of acute and intensive care admissions divided by the ratio of inpatient revenues generated from acute, intensive, ambulatory, and ancillary patient services to gross revenues. If a hospital reports only subacute admissions, then "adjusted admission" means the sum of subacute admissions divided by the ratio of total inpatient revenues to gross revenues.

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

(4)  "Alcohol or chemical dependency treatment center" means an organization licensed under chapter 397.

(5)  "Ambulatory care center" means an organization which employs or contracts with licensed health care professionals to provide diagnosis or treatment services predominantly on a walk-in basis and the organization holds itself out as providing care on a walk-in basis. Such an organization is not an ambulatory care center if it is wholly owned and operated by five or fewer health care providers.

(6)  "Ambulatory surgical center" means a facility licensed as an ambulatory surgical center under chapter 395.

(7)  "Audited actual data" means information contained within financial statements examined by an independent, Florida-licensed, certified public accountant in accordance with generally accepted auditing standards, but does not include data within a financial statement about which the certified public accountant does not express an opinion or issues a disclaimer.

(8)  "Birth center" means an organization licensed under s. 383.305.

(9)  "Cardiac catheterization laboratory" means a freestanding facility that employs or contracts with licensed health care professionals to provide diagnostic or therapeutic services for cardiac conditions such as cardiac catheterization or balloon angioplasty.

(10)  "Case mix" means a calculated index for each health care facility or health care provider, based on patient data, reflecting the relative costliness of the mix of cases to that facility or provider compared to a state or national mix of cases.

(11)  "Clinical laboratory" means a facility licensed under s. 483.091, excluding: any hospital laboratory defined under s. 483.041(5); any clinical laboratory operated by the state or a political subdivision of the state; any blood or tissue bank where the majority of revenues are received from the sale of blood or tissue and where blood, plasma, or tissue is procured from volunteer donors and donated, processed, stored, or distributed on a nonprofit basis; and any clinical laboratory which is wholly owned and operated by physicians who are licensed pursuant to chapter 458 or chapter 459 and who practice in the same group practice, and at which no clinical laboratory work is performed for patients referred by any health care provider who is not a member of that same group practice.

(12)  "Comprehensive rehabilitative hospital" or "rehabilitative hospital" means a hospital licensed by the agency as a specialty hospital as defined in s. 395.002; provided that the hospital provides a program of comprehensive medical rehabilitative services and is designed, equipped, organized, and operated solely to deliver comprehensive medical rehabilitative services, and further provided that all licensed beds in the hospital are classified as "comprehensive rehabilitative beds" pursuant to s. 395.003(4), and are not classified as "general beds."

(13)  "Consumer" means any person other than a person who administers health activities, is a member of the governing body of a health care facility, provides health services, has a fiduciary interest in a health facility or other health agency or its affiliated entities, or has a material financial interest in the rendering of health services.

(14)  "Continuing care facility" means a facility licensed under chapter 651.

(15)  "Cross-subsidization" means that the revenues from one type of hospital service are sufficiently higher than the costs of providing such service as to offset some of the costs of providing another type of service in the hospital. Cross-subsidization results from the lack of a direct relationship between charges and the costs of providing a particular hospital service or type of service.

(16)  "Deductions from gross revenue" or "deductions from revenue" means reductions from gross revenue resulting from inability to collect payment of charges. For hospitals, such reductions include contractual adjustments; uncompensated care; administrative, courtesy, and policy discounts and adjustments; and other such revenue deductions, but also includes the offset of restricted donations and grants for indigent care.

(17)  "Diagnostic-imaging center" means a freestanding outpatient facility that provides specialized services for the diagnosis of a disease by examination and also provides radiological services. Such a facility is not a diagnostic-imaging center if it is wholly owned and operated by physicians who are licensed pursuant to chapter 458 or chapter 459 and who practice in the same group practice and no diagnostic-imaging work is performed at such facility for patients referred by any health care provider who is not a member of that same group practice.

(18)  "FHURS" means the Florida Hospital Uniform Reporting System developed by the agency.

(19)  "Freestanding" means that a health facility bills and receives revenue which is not directly subject to the hospital assessment for the Public Medical Assistance Trust Fund as described in s. 395.701.

(20)  "Freestanding radiation therapy center" means a facility where treatment is provided through the use of radiation therapy machines that are registered under s. 404.22 and the provisions of the Florida Administrative Code implementing s. 404.22. Such a facility is not a freestanding radiation therapy center if it is wholly owned and operated by physicians licensed pursuant to chapter 458 or chapter 459 who practice within the specialty of diagnostic or therapeutic radiology.

(21)  "GRAA" means gross revenue per adjusted admission.

(22)  "Gross revenue" means the sum of daily hospital service charges, ambulatory service charges, ancillary service charges, and other operating revenue. Gross revenues do not include contributions, donations, legacies, or bequests made to a hospital without restriction by the donors.

(23)  "Health care facility" means an ambulatory surgical center, a hospice, a nursing home, a hospital, a diagnostic-imaging center, a freestanding or hospital-based therapy center, a clinical laboratory, a home health agency, a cardiac catheterization laboratory, a medical equipment supplier, an alcohol or chemical dependency treatment center, a physical rehabilitation center, a lithotripsy center, an ambulatory care center, a birth center, or a nursing home component licensed under chapter 400 within a continuing care facility licensed under chapter 651.

(24)  "Health care provider" means a health care professional licensed under chapter 458, chapter 459, chapter 460, chapter 461, chapter 463, chapter 464, chapter 465, chapter 466, part I, part III, part IV, part V, or part X of chapter 468, chapter 483, chapter 484, chapter 486, chapter 490, or chapter 491.

(25)  "Health care purchaser" means an employer in the state, other than a health care facility, health insurer, or health care provider, who provides health care coverage for her or his employees.

(26)  "Health insurer" means any insurance company authorized to transact health insurance in the state, any insurance company authorized to transact health insurance or casualty insurance in the state that is offering a minimum premium plan or stop-loss coverage for any person or entity providing health care benefits, any self-insurance plan as defined in s. 624.031, any health maintenance organization authorized to transact business in the state pursuant to part I of chapter 641, any prepaid health clinic authorized to transact business in the state pursuant to part II of chapter 641, any multiple-employer welfare arrangement authorized to transact business in the state pursuant to ss. 624.436-624.45, or any fraternal benefit society providing health benefits to its members as authorized pursuant to chapter 632.

(27)  "Home health agency" means an organization licensed under part IV of chapter 400.

(28)  "Hospice" means an organization licensed under part VI of chapter 400.

(29)  "Hospital" means a health care institution licensed by the Agency for Health Care Administration as a hospital under chapter 395.

(30)  "Lithotripsy center" means a freestanding facility that employs or contracts with licensed health care professionals to provide diagnosis or treatment services using electro-hydraulic shock waves.

(31)  "Local health council" means the agency defined in s. 408.033.

(32)  "Market basket index" means the Florida hospital input price index (FHIPI), which is a statewide market basket index used to measure inflation in hospital input prices weighted for the Florida-specific experience which uses multistate regional and state-specific price measures, when available. The index shall be constructed in the same manner as the index employed by the Secretary of the United States Department of Health and Human Services for determining the inflation in hospital input prices for purposes of Medicare reimbursement.

(33)  "Medical equipment supplier" means an organization that provides medical equipment and supplies used by health care providers and health care facilities in the diagnosis or treatment of disease.

(34)  "Net revenue" means gross revenue minus deductions from revenue.

(35)  "New hospital" means a hospital in its initial year of operation as a licensed hospital and does not include any facility which has been in existence as a licensed hospital, regardless of changes in ownership, for over 1 calendar year.

(36)  "Nursing home" means a facility licensed under s. 400.062 or, for resident level and financial data collection purposes only, any institution licensed under chapter 395 and which has a Medicare or Medicaid certified distinct part used for skilled nursing home care, but does not include a facility licensed under chapter 651.

(37)  "Operating expenses" means total expenses excluding income taxes.

(38)  "Other operating revenue" means all revenue generated from hospital operations other than revenue directly associated with patient care.

(39)  "Physical rehabilitation center" means an organization that employs or contracts with health care professionals licensed under part I or part III of chapter 468 or chapter 486 to provide speech, occupational, or physical therapy services on an outpatient or ambulatory basis.

(40)  "Prospective payment arrangement" means a financial agreement negotiated between a hospital and an insurer, health maintenance organization, preferred provider organization, or other third-party payor which contains, at a minimum, the elements provided for in s. 408.50.

(41)  "Rate of return" means the financial indicators used to determine or demonstrate reasonableness of the financial requirements of a hospital. Such indicators shall include, but not be limited to: return on assets, return on equity, total margin, and debt service coverage.

(42)  "Rural hospital" means an acute care hospital licensed under chapter 395, having 100 or fewer licensed beds and an emergency room, located in an area defined as rural by the United States Census, and which is:

(a)  The sole provider within a county with a population density of no greater than 100 persons per square mile;

(b)  An acute care hospital, in a county with a population density of no greater than 100 persons per square mile, which is at least 30 minutes of travel time, on normally traveled roads under normal traffic conditions, from another acute care hospital within the same county; or

(c)  A hospital supported by a tax district or subdistrict whose boundaries encompass a population of 100 persons or fewer per square mile.

Population densities used in this subsection must be based upon the most recently completed United States census.

(43)  "Special study" means a nonrecurring data-gathering and analysis effort designed to aid the agency in meeting its responsibilities pursuant to this chapter.

(44)  "Teaching hospital" means any hospital formally affiliated with an accredited medical school which exhibits activity in the area of medical education as reflected by at least seven different resident physician specialties and the presence of 100 or more resident physicians.

History.--s. 71, ch. 92-33; s. 75, ch. 92-289; s. 13, ch. 93-129; s. 39, ch. 93-217; s. 17, ch. 95-144; s. 38, ch. 97-103; s. 2, ch. 98-14; s. 2, ch. 98-21; s. 14, ch. 98-89.

408.08  Inspections and audits; violations; penalties; fines; enforcement.--

(1)  The agency may inspect and audit books and records of individual or corporate ownership, including books and records of related organizations with which a health care provider or a health care facility had transactions, for compliance with this chapter. Upon presentation of a written request for inspection to a health care provider or a health care facility by the agency or its staff, the health care provider or the health care facility shall make available to the agency or its staff for inspection, copying, and review all books and records relevant to the determination of whether the health care provider or the health care facility has complied with this chapter.

(2)  Any health care facility that refuses to file a report, fails to timely file a report, files a false report, or files an incomplete report and upon notification fails to timely file a complete report required under s. 408.061; that violates this section, s. 408.061, or s. 408.20, or rule adopted thereunder; or that fails to provide documents or records requested by the agency under this chapter shall be punished by a fine not exceeding $1,000 per day for each day in violation, to be imposed and collected by the agency. Pursuant to rules adopted by the agency, the agency may, upon a showing of good cause, grant a one-time extension of any deadline for a health care facility to timely file a report as required by this section, s. 408.061, ¹s. 408.072, or s. 408.20.

(3)  Any health care provider that refuses to file a report, fails to timely file a report, files a false report, or files an incomplete report and upon notification fails to timely file a complete report required under s. 408.061; that violates this section, s. 408.061, or s. 408.20, or rule adopted thereunder; or that fails to provide documents or records requested by the agency under this chapter shall be referred to the appropriate licensing board which shall take appropriate action against the health care provider.

(4)  If a health insurer does not comply with the requirements of s. 408.061, the agency shall report a health insurer's failure to comply to the Department of Insurance, which shall take into account the failure by the health insurer to comply in conjunction with its approval authority under s. 627.410. The agency shall adopt any rules necessary to carry out its responsibilities required by this subsection.

(5)  Refusal to file, failure to timely file, or filing false or incomplete reports or other information required to be filed under the provisions of this chapter, failure to pay or failure to timely pay any assessment authorized to be collected by the agency, or violation of any other provision of this chapter or lawfully entered order of the agency or rule adopted under this chapter, shall be punished by a fine not exceeding $1,000 a day for each day in violation, to be fixed, imposed, and collected by the agency. Each day in violation shall be considered a separate offense.

(6)  Notwithstanding any other provisions of this chapter, when a hospital alleges that a factual determination made by the agency is incorrect, the burden of proof shall be on the hospital to demonstrate that such determination is, in light of the total record, not supported by a preponderance of the evidence. The burden of proof remains with the hospital in all cases involving administrative agency action.

History.--s. 73, ch. 92-33; s. 77, ch. 92-289; s. 16, ch. 93-129; s. 23, ch. 95-146; s. 15, ch. 98-89; s. 1, ch. 98-120.

¹Note.--Repealed by s. 19, ch. 98-89.

408.09  Assistance on cost containment strategies.--The agency shall:

(1)  Assist purchasers and employers who seek technical assistance from the agency for the purpose of cost-effective purchasing of health care.

(2)  Develop cost containment strategies for use by providers, employers, or consumers of health care.

(3)  Develop an outreach program to assist small business to include cost containment initiatives for small business health insurance plans.

(4)  Assist existing health coalitions and local health councils as needed in carrying out their respective goals in an efficient and effective manner.

History.--s. 75, ch. 92-33.

408.10  Consumer complaints.--The agency shall:

(1)  Publish and make available to the public a toll-free telephone number for the purpose of handling consumer complaints and shall serve as a liaison between consumer entities and other private entities and governmental entities for the disposition of problems identified by consumers of health care.

(2)  Be empowered to investigate consumer complaints relating to problems with health care facilities' billing practices and issue reports to be made public in any cases where the agency determines the health care facility has engaged in billing practices which are unreasonable and unfair to the consumer.

History.--s. 76, ch. 92-33.

408.15  Powers of the agency.--In addition to the powers granted to the agency elsewhere in this chapter, the agency is authorized to:

(1)  Enter into contracts and execute all instruments necessary or convenient for carrying out its business.

(2)  Acquire, own, hold, dispose of, and encumber personal property and to lease real property in exercising its powers and performing its duties.

(3)  Enter into agreements with any federal, state, or municipal agency, or other public institution, or with any private individual, partnership, firm, corporation, association, or other entity.

(4)  Establish ad hoc advisory committees to expand public participation in agency decisions and draw on the experience of representatives from all areas of health insurance, financing, cost containment, and operations, including, but not limited to, providers, consumers, third-party payors, businesses, and academicians.

(5)  Establish such staff as needed to carry out the purposes of this chapter.

(6)  Apply for and receive and accept grants, gifts, and other payments, including property and services, from any governmental or other public and private entity or person and make arrangements as to the use of same, including undertaking special studies and other projects related to The Florida Health Plan. Funds obtained under this subsection may be used as matching funds for public or private grants.

(7)  Seek federal statutory changes and any waivers of federal laws or regulations that will aid in implementing The Florida Health Plan and related health care reforms. This may include seeking amendments to:

(a)  The Employee Retirement and Income Security Act of 1974 to permit greater state regulation of employer insurance plans.

(b)  The Medicaid program to permit alternative organizational alignments, elimination of all program eligibility requirements except income, and a moratorium on further federal mandates.

(c)  The Medicare program to seek state administration of benefits, provider payments, or case management of beneficiaries.

(d)  Federal tax laws to permit a 100-percent tax deduction for all private health insurance plans, including those of self-employed persons and unincorporated employers, and reform of the flexible sharing account requirements to maximize pretax health care expenditures.

(e)  Other federal programs to permit full implementation of The Florida Health Plan and related state health care reforms.

(8)  Adopt rules pursuant to ss. 120.536(1) and 120.54 to implement the provisions of this chapter.

(9)  Hold public hearings, conduct investigations, and subpoena witnesses, papers, records, and documents in connection therewith. The agency may administer oaths or affirmations in any hearing or investigation.

(10)  Exercise all other powers which are reasonably necessary or essential to carry out the expressed intent, objects, and purposes of this chapter, unless specifically prohibited in this chapter.

(11)  Grant extensions of time for compliance with any filing requirement of this chapter.

History.--s. 77, ch. 92-33; s. 111, ch. 98-200.

408.16  Health Care Trust Fund; moneys to be deposited therein.--

(1)  There is created in the State Treasury a special fund to be designated as the Health Care Trust Fund, which shall be used in the operation of the Agency for Health Care Administration in the performance of the various functions and duties required of it by law.

(2)  All fees, license fees, and other charges collected by the agency shall be deposited in the State Treasury to the credit of the Health Care Trust Fund, to be used in the operation of the agency as authorized by the Legislature. However, penalties and interest assessed and collected by the agency shall not be deposited in the trust fund but shall be deposited in the General Revenue Fund. The Health Care Trust Fund shall be subject to the service charge imposed pursuant to chapter 215.

(3)  The agency shall maintain separate revenue and expenditure accounts in the Health Care Trust Fund for every provider licensed by the agency.

(4)  All other moneys in the Health Care Trust Fund shall be for the use of the agency in the performance of its functions and duties as provided by law, subject to the fiscal and budgetary provisions of general law and the General Appropriations Act.

History.--s. 50, ch. 92-33; s. 23, ch. 93-129; s. 36, ch. 96-418; s. 59, ch. 97-261.

Note.--Former s. 455.2205.

408.18  Health Care Community Antitrust Guidance Act; antitrust no-action letter; market-information collection and education.--

(1)  This section may be cited as the "Florida Health Care Community Antitrust Guidance Act."

(2)  This section is created to provide instruction to the health care community in a time of tremendous change, and to resolve, as completely as possible, the problem of antitrust uncertainty that may deter mergers, joint ventures, or other business activities that can improve the delivery of health care, without creating costly, time-consuming regulations that can lead to more litigation and delay.

(3)  For purposes of this section, the term:

(a)  "Health care community" means all licensed health care providers, insurers, networks, purchasers, and other participants in the health care system.

(b)  "Antitrust no-action letter" means a letter that states the intention of the Attorney General's office not to take antitrust enforcement actions with respect to the requesting party, based on the specific facts then presented, as of the date the letter is issued.

(4)(a)  Members of the health care community who seek antitrust guidance may request a review of their proposed business activity by the Attorney General's office. In conducting its review, the Attorney General's office may seek whatever documentation, data, or other material it deems necessary from the Agency for Health Care Administration, the State Center for Health Statistics, and the Department of Insurance.

(b)  In order to receive an antitrust no-action letter, a member of the health care community must submit in writing to the Attorney General's office a request for an antitrust no-action letter.

(c)  The requesting parties are under an affirmative obligation to make full, true, and accurate disclosure with respect to the activities for which the antitrust no-action letter is requested. Requests relating to unnamed persons or companies may not be answered. Each request must be accompanied by all relevant material information; relevant data, including background information; complete copies of all operative documents; the provisions of law under which the request arises; and detailed statements of all collateral oral understandings, if any.

(d)  All parties requesting the antitrust no-action letter must provide the Attorney General's office with whatever additional information or documents the Attorney General's office requests for its review of the matter.

(5)  The Attorney General's office shall act on the no-action letter request within 90 days after it receives all information necessary to complete its review.

(6)  At the completion of its review of a request for an antitrust no-action letter, the Attorney General's office shall do one of the following:

(a)  Issue the antitrust no-action letter;

(b)  Decline to issue any type of letter; or

(c)  Take such other position or action as it considers appropriate.

(7)  The recipient of a no-action letter must annually file with the Attorney General's office an affidavit stating that there has been no change in the facts the recipient has presented, at which time the Attorney General may renew the no-action letter. As long as there is no change in any material fact, the Attorney General's office is estopped from bringing any action pursuant to the antitrust laws concerning any specific conduct that is the subject of the no-action letter. Further, the no-action letter, if it meets the requirements of the Florida Evidence Code, is admissible in any court proceeding in this state. The Attorney General's office remains free to bring an action or proceeding based on a different set of facts presented.

(8)  The Agency for Health Care Administration shall coordinate all existing data received, such as the hospital patient discharge database, ambulatory patient database, ambulatory facilities' financial data, health facility licensure and certification tracking system, health facility plans and construction data, local health council data, Medicaid data, provider claims data, psychiatric hospital discharge data, pharmaceutical data, licensure data of health maintenance organizations, licensure data of health insurers, health care practitioner licensure data, hospital financial database, health facility utilization and projected need data, nursing home financial database, nursing home patient database, and joint venture database. This information shall be made available to the Attorney General's office, as needed.

(9)  When the member of the health care community seeking the no-action letter is regulated by the Department of Insurance, the Department of Insurance shall make available to the Attorney General's office, as needed, any information it maintains in its regulatory capacity.

History.--s. 12, ch. 96-223; s. 98, ch. 97-261.

Note.--Former s. 455.277.

408.185  Information submitted for review of antitrust issues; confidentiality.--The following information held by the Office of the Attorney General, which is submitted by a member of the health care community pursuant to a request for an antitrust no-action letter shall be confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution for 1 year after the date of submission.

(1)  Documents that reveal trade secrets as defined in s. 688.002.

(2)  Preferred provider organization contracts.

(3)  Health maintenance organization contracts.

(4)  Documents that reveal a health care provider's marketing plan.

(5)  Proprietary confidential business information as defined in s. 364.183(3).

This section is subject to the Open Government Sunset Review Act of 1995 in accordance with s. 119.15, and shall stand repealed on October 2, 2001, unless reviewed and saved from repeal by reenactment of the Legislature.

History.--s. 1, ch. 96-373; s. 99, ch. 97-261.

Note.--Former s. 455.2775.

408.20  Assessments; Health Care Trust Fund.--

(1)  The data collection and analysis activities of the agency shall be financed, in part, by an assessment on:

(a)  Hospitals in an amount to be determined annually by the agency, but not to exceed 0.04 percent of the gross operating expenses of each hospital for the provision of hospital services for its last fiscal year. Every new hospital shall pay its initial assessment upon being licensed by the state and shall base its assessment payment during the first year of operation upon its projections for gross operating expenses for that year. Each hospital under new ownership shall pay its initial assessment for the first year of operation under new ownership based on its gross operating expenses for the last fiscal year under previous ownership. The assessments shall be levied and collected quarterly.

(b)  Nursing homes in an amount set by the agency to cover the agency's approved budget. The agency shall calculate the amount to be collected per bed, rounded to the nearest whole dollar. All assessments collected under this section which are due after the date of notification by the agency shall be at a rate sufficient to cover the agency's approved budget. Assessments shall be levied and collected annually by the agency. Each new nursing home shall pay its initial assessment upon being licensed, and each nursing home under new ownership shall pay its initial assessment under the new ownership based on its number of beds.

(2)  All moneys collected are to be deposited into the Health Care Trust Fund created pursuant to s. 408.16.

(3)  Any amounts raised by the collection of assessments provided for in this section which are not required to meet appropriations in the budget act for the current fiscal year shall be available to the agency in succeeding years.

(4)  Hospitals operated by the ¹Department of Health and Rehabilitative Services or the Department of Corrections are exempt from the assessments required under this section.

History.--s. 78, ch. 92-33; s. 34, ch. 96-418; s. 174, ch. 98-166.

¹Note.--The Department of Health and Rehabilitative Services was redesignated as the Department of Children and Family Services by s. 5, ch. 96-403, and the Department of Health was created by s. 8, ch. 96-403.

408.30  Effect on existing rules.--Nothing contained in this chapter is intended to repeal or modify any of the existing rules of the ¹Health Care Cost Containment Board, as adopted to implement chapter 88-394, Laws of Florida, unless such rule or part thereof is in direct conflict with the provisions of this chapter; provided that any budget or budget amendment for fiscal years beginning prior to May 1, 1992, shall be filed and reviewed pursuant to chapter 88-394, Laws of Florida, and rules adopted by the board pursuant thereto. Rules of the ¹Health Care Cost Containment Board existing on March 24, 1992, shall remain in effect and shall be enforceable by the agency as created by chapter 92-33, Laws of Florida, until such rules are repealed or amended by the agency, and no judicial or administrative proceeding pending on March 24, 1992, shall be abated as a result of the provisions of this chapter.

History.--s. 79, ch. 92-33.

¹Note.--Sections 82 and 83, ch. 92-33, abolished the Health Care Cost Containment Board and transferred all powers, duties and functions, records, personnel, property, and unexpended balances of appropriations, allocations, or other funds of the board to the Agency for Health Care Administration.

408.301  Legislative findings.--The Legislature has found that access to quality, affordable, health care for all Floridians is an important goal for the state. The Legislature has charged the Agency for Health Care Administration with the responsibility of developing the Florida Health Plan for assuring access to health care for all Floridians. At the same time, the Legislature recognizes that there are Floridians with special health care and social needs which require particular attention. The people served by the ¹Department of Health and Rehabilitative Services are examples of citizens with special needs. The Legislature further recognizes that the Medicaid program is an intricate part of the service delivery system for the special needs citizens served by or through the ¹Department of Health and Rehabilitative Services. The Agency for Health Care Administration is not a service provider and does not develop or direct programs for the special needs citizens served by or through the ¹Department of Health and Rehabilitative Services. Therefore, it is the intent of the Legislature that the Agency for Health Care Administration work closely with the ¹Department of Health and Rehabilitative Services in developing plans for assuring access to all Floridians in order to assure that the needs of special citizens are met.

History.--s. 18, ch. 93-129.

¹Note.--The Department of Health and Rehabilitative Services was redesignated as the Department of Children and Family Services by s. 5, ch. 96-403, and the Department of Health was created by s. 8, ch. 96-403.

408.302  Interagency agreement.--

(1)  The Agency for Health Care Administration shall enter into an interagency agreement with the ¹Department of Health and Rehabilitative Services to assure coordination and cooperation in serving special needs citizens. The agreement shall include the requirement that the secretary of the ¹Department of Health and Rehabilitative Services approve, prior to adoption, any rule developed by the Agency for Health Care Administration where such rule has a direct impact on the mission of the ¹Department of Health and Rehabilitative Services, its program, or its budget.

(2)  For rules which indirectly impact on the mission of the ¹Department of Health and Rehabilitative Services, its programs, or its budget, the concurrence of the secretary of the ¹Department of Health and Rehabilitative Services on the rule is required.

(3)  For all other rules developed by the Agency for Health Care Administration, coordination with the ¹Department of Health and Rehabilitative Services is encouraged.

(4)  The interagency agreement shall also include any other provisions necessary to ensure a continued cooperative working relationship between the Agency for Health Care Administration and the ¹Department of Health and Rehabilitative Services as each strives to meet the needs of the citizens of Florida.

History.--s. 19, ch. 93-129.

¹Note.--The Department of Health and Rehabilitative Services was redesignated as the Department of Children and Family Services by s. 5, ch. 96-403, and the Department of Health was created by s. 8, ch. 96-403.

408.40  Public Counsel.--

(1)  Notwithstanding any other provisions of this chapter, the Public Counsel shall represent the public in any proceeding before the agency or its advisory panels in any administrative hearing conducted pursuant to chapter 120 or before any other state and federal agencies and courts in any issue before the agency, any court, or any agency. With respect to any such proceeding, the Public Counsel is subject to the provisions of and may use the powers granted to him or her by ss. 350.061-350.0614.

(2)  The Public Counsel shall:

(a)  Recommend to the agency, by petition, the commencement of any proceeding or action or to appear, in the name of the state or its citizens, in any proceeding or action before the agency and urge therein any position that he or she deems to be in the public interest, whether consistent or inconsistent with positions previously adopted by the agency, and use therein all forms of discovery available to attorneys in civil actions generally, subject to protective orders of the agency, which shall be reviewable by summary procedure in the circuit courts of this state.

(b)  Have access to and use of all files, records, and data of the agency available to any other attorney representing parties in a proceeding before the agency.

(c)  In any proceeding in which he or she has participated as a party, seek review of any determination, finding, or order of the agency, or of any administrative law judge, or any hearing officer or hearing examiner designated by the agency, in the name of the state or its citizens.

(d)  Prepare and issue reports, recommendations, and proposed orders to the agency, the Governor, and the Legislature on any matter or subject within the jurisdiction of the agency, and to make such recommendations as he or she deems appropriate for legislation relative to agency procedures, rules, jurisdiction, personnel, and functions.

(e)  Appear before other state agencies, federal agencies, and state and federal courts in connection with matters under the jurisdiction of the agency, in the name of the state or its citizens.

History.--s. 80, ch. 92-33; s. 192, ch. 96-410; s. 1017, ch. 97-103; s. 16, ch. 98-89.

408.50  Prospective payment arrangements.--

(1)  Hospitals as defined in s. 395.002, and health insurers regulated pursuant to parts VI and VII of chapter 627, shall establish prospective payment arrangements that provide hospitals with financial incentives to contain costs. Each hospital shall enter into a rate agreement with each health insurer which represents 10 percent or more of the private-pay patients of the hospital to establish a prospective payment arrangement. Hospitals and health insurers regulated pursuant to this section shall report annually the results of each specific prospective payment arrangement adopted by each hospital and health insurer to the board. The agency shall report a health insurer's failure to comply to the Department of Insurance, which shall take into account the failure by the health insurer to comply in conjunction with its approval authority under s. 627.410. The agency shall adopt any rules necessary to carry out its responsibilities required by this section.

(2)  The prospective payment system established pursuant to this section shall include, at a minimum, the following elements:

(a)  A maximum allowable payment amount established for individual hospital products, services, patient diagnoses, patient day, patient admission, or per insured, or any combination thereof, which is preset at the beginning of the budget year of the hospital and fixed for the entirety of that budget year, except when extenuating and unusual circumstances acceptable to the department warrant renegotiation.

(b)  Timely payment to the hospital by the insurer or the insured, or both, of the maximum allowable payment amount, as so negotiated by the insurer or group of insurers.

(c)  Acceptance by the hospital of the maximum payment amount as payment in full, which shall include any deductible or coinsurance provided for in the insurer's benefit plan.

(d)  Utilization reviews for appropriateness of treatment.

(e)  Preadmission screening of nonemergency admissions.

(3)  Nothing contained in this section prohibits the inclusion of deductibles, coinsurance, or other cost containment provisions in any health insurance policy.

History.--s. 81, ch. 92-33.

408.70  Community health purchasing; legislative findings and intent.--

(1)  The Legislature finds that the current health care system in this state does not provide access to affordable health care for all persons in this state. Almost one in five persons is without health insurance. For many, entry into the health care system is through a hospital emergency room rather than a primary care setting. The availability of preventive and primary care and managed, family-based care is limited. Health insurance underwriting practices have led to the avoidance, rather than to the sharing, of insurance risks, limiting access to coverages for small-sized employer groups and high-risk populations. Spiraling premium costs have placed health insurance policies out of the reach of many small-sized and medium-sized businesses and their employees. Lack of outcome and cost information has forced individuals and businesses to make critical health care decisions with little guidance or leverage. Health care resources have not been allocated efficiently, leading to excess and unevenly distributed capacity. These factors have contributed to the high cost of health care. Rural and other medically underserved areas have too few health care resources. Comprehensive, first-dollar coverages have allowed individuals to seek care without regard to cost. Provider competition and liability concerns have led to a medical technology arms race. Rather than competing on the basis of price and patient outcome, health care providers compete for patients on the basis of service, equipping themselves with the latest and best technologies. Managed-care and group-purchasing mechanisms are not widely available to small group purchasers. Health care regulation has placed undue burdens on health care insurers and providers, driving up costs, limiting competition, and preventing market-based solutions to cost and quality problems. Health care costs have been increasing at several times the rate of general inflation, eroding employer profits and investments, increasing government revenue requirements, reducing consumer coverages and purchasing power, and limiting public investments in other vital governmental services.

(2)  It is the intent of the Legislature that a structured health care competition model, known as "managed competition," be implemented throughout the state to improve the efficiency of the health care markets in this state. The managed competition model will promote the pooling of purchaser and consumer buying power; ensure informed cost-conscious consumer choice of managed care plans; reward providers for high-quality, economical care; increase access to care for uninsured persons; and control the rate of inflation in health care costs.

(3)  The Legislature intends that state-chartered, nonprofit private purchasing organizations, to be known as "community health purchasing alliances," be established. The community health purchasing alliances shall be responsible for assisting alliance members in securing the highest quality of health care, based on current standards, at the lowest possible prices.

History.--s. 66, ch. 93-129.

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 prescribed pediatric extended care center defined in s. 400.902, 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; s. 31, ch. 98-288.

408.702  Community health purchasing alliance; establishment.--

(1)  There is created a community health purchasing alliance in each of the 11 health service planning districts established under s. 408.032. Each alliance must be operated as a state-chartered, nonprofit private organization organized pursuant to chapter 617. There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member of the board of directors of a community health purchasing alliance, or its employees or agents, for any action taken by the board in the performance of its powers and duties under ss. 408.70-408.706.

(2)  Three or fewer alliances located in contiguous districts that are not primarily urban may merge into a single alliance upon approval of the agency based upon a showing by the alliance board members that the members of each alliance would be better served under a combined alliance. Board members of each alliance shall serve as the board of the combined alliance.

(3)  An alliance is the only entity that is allowed to operate as an alliance in a particular district and must operate for the benefit of its members who are: small employers, as defined in s. 627.6699; the state on behalf of its employees and the dependents of such employees; Medicaid recipients; and associate alliance members. An alliance is the exclusive entity for the oversight and coordination of alliance member purchases. Any health plan offered through an alliance must be offered by an accountable health partnership and an alliance may not directly provide insurance; directly contract, for purposes of providing insurance, with a health care provider or provider network; or bear any risk, or form self-insurance plans among its members. An alliance may form a network with other alliances in order to improve services provided to alliance members. Nothing in ss. 408.70-408.706 limits or authorizes the formation of business health coalitions; however, a person or entity that pools together or assists in purchasing health coverage for small employers, as defined in s. 627.6699, state employees and their dependents, and Medicaid, Medicaid buy-in, and MedAccess recipients may not discriminate in its activities based on the health status or historical or projected claims experience of such employers or recipients.

(4)  Each alliance shall capitalize on the expertise of existing business health coalitions.

(5)  Membership or associate membership in an alliance is voluntary.

(6)  Each community health purchasing alliance has the following powers, duties, and responsibilities:

(a)  Establishing the conditions of alliance membership in accordance with ss. 408.70-408.706.

(b)  Providing to alliance members clear, standardized information on each accountable health partnership and each health plan offered by each accountable health partnership, including information on price, enrollee costs, quality, patient satisfaction, enrollment, and enrollee responsibilities and obligations; and providing accountable health partnership comparison sheets in accordance with agency rule to be used in providing members and their employees with information regarding standard, basic, and specialized coverage that may be obtained through the accountable health partnerships.

(c)  Annually offering to all alliance members all accountable health partnerships and health plans offered by the accountable health partnerships which meet the requirements of ss. 408.70-408.706, and which submit a responsive proposal as to information necessary for accountable health partnership comparison sheets, and providing assistance to alliance members in selecting and obtaining coverage through accountable health partnerships that meet those requirements.

(d)  Requesting proposals for the standard and basic health plans, as defined in s. 627.6699, from all accountable health partnerships in the district; providing, in the format required by the alliance in the request for proposals, the necessary information for accountable health partnership comparison sheets; and offering to its members health plans of accountable health partnerships which meet those requirements.

(e)  Requesting proposals from all accountable health partnerships in the district for specialized benefits approved by the alliance board based on input from alliance members, determining if the proposals submitted by the accountable health partnerships meet the requirements of the request for proposals, and offering them as options through riders to standard plans and basic plans. This paragraph does not limit an accountable health partnership's ability to offer other specialized benefits to alliance members.

(f)  Distributing to health care purchasers, placing special emphasis on the elderly, retail price data on prescription drugs and their generic equivalents, durable medical equipment, and disposable medical supplies which is provided by the agency pursuant to s. 408.063(3) and (4).

(g)  Establishing administrative and accounting procedures for the operation of the alliance and members' services, preparing an annual alliance budget, and preparing annual program and fiscal reports on alliance operations as required by the agency.

(h)  Developing and implementing a marketing plan to publicize the alliance to potential members and associate members and developing and implementing methods for informing the public about the alliance and its services.

(i)  Developing grievance procedures to be used in resolving disputes between members and the alliance and disputes between the accountable health partnerships and the alliance. Any member of, or accountable health partnership that serves, an alliance may appeal to the agency any grievance that is not resolved by the alliance.

(j)  Ensuring that accountable health partnerships have grievance procedures to be used in resolving disputes between members and an accountable health partnership. A member may appeal to the alliance any grievance that is not resolved by the accountable health partnership. An accountable health partnership that is a health maintenance organization must follow the grievance procedures established in ss. 408.7056 and 641.31(5).

(k)  Maintaining all records, reports, and other information required by the agency, ss. 408.70-408.706, or other state and local laws.

(l)  Receiving and accepting grants, loans, advances, or funds from any public or private agency; and receiving and accepting contributions, from any source, of money, property, labor, or any other thing of value.

(m)  Contracting, as authorized by alliance members, with a qualified, independent third party for any service necessary to carry out the powers and duties required by ss. 408.70-408.706.

(n)  Developing a plan to facilitate participation of providers in the district in an accountable health partnership, placing special emphasis on ensuring participation by minority physicians in accountable health partnerships if such physicians are available. The use of the term "minority" in ss. 408.70-408.706 is consistent with the definition of "minority person" provided in s. 288.703(3).

(o)  Ensuring that any health plan reasonably available within the jurisdiction of an alliance, through a preferred provider network, a point of service product, an exclusive provider organization, a health maintenance organization, or a pure indemnity product, is offered to members of the alliance. For the purposes of this paragraph, "pure indemnity product" means a health insurance policy or contract that does not provide different rates of reimbursement for a specified list of physicians and a "point of service product" means a preferred provider network or a health maintenance organization which allows members to select at a higher cost a provider outside of the network or the health maintenance organization.

(p)  Petitioning the agency for a determination as to the cost-effectiveness of collecting premiums on behalf of participating accountable health partnerships. If determined by the agency to be cost-effective, the alliance may establish procedures for collecting premiums from members and distribute them to the participating accountable health partnerships. This may include the remittance of the share of the group premium paid by both an employer and an enrollee. If an alliance assumes premium collection responsibility, it shall also assume liability for uncollected premium. This liability may be collected through a bad debt surcharge on alliance members to finance the cost of uncollected premiums. The alliance shall pay participating accountable health partnerships their contracting premium amounts on a prepaid monthly basis, or as otherwise mutually agreed upon.

(7)  Each alliance shall set reasonable fees for membership in the alliance which will finance all reasonable and necessary costs incurred in administering the alliance.

(8)  Each alliance shall annually report on the operations of the alliance, including program and financial operations, and shall provide for annual internal and independent audits.

(9)  A community health purchasing alliance may not engage in any activities for which an insurance agent's license is required.

(10)  The powers and responsibilities of a community health purchasing alliance with respect to purchasing services from accountable health partnerships do not extend beyond those enumerated in ss. 408.70-408.706.

History.--s. 68, ch. 93-129; s. 1, ch. 97-45; s. 10, ch. 97-270.

408.703  Small employer members of community health purchasing alliances; eligibility requirements.--

(1)  The agency shall establish conditions of participation for small employers, as defined in s. 627.6699, which must include, but need not be limited to:

(a)  Assurance that the group is a valid small employer and is not formed for the purpose of securing health benefit coverage. This assurance must include requirements for sole proprietors and self-employed individuals which must be based on a specified requirement for the time that the sole proprietor or self-employed individual has been in business, required filings to verify employment status, and other requirements to ensure that the individual is working.

(b)  Assurance that the individuals in the small employer group are employees and have not been added for the purpose of securing health benefit coverage.

(2)  The agency may not require a small employer to pay any portion of premiums as a condition of participation in an alliance.

(3)  The agency may require a small employer seeking membership to agree to participate in the alliance for a specified minimum period of time, not to exceed 1 year.

(4)  If a member small employer offers more than one accountable health partnership or health plan and the employer contributes to coverage of employees or dependents of the employee, the alliance shall require that the employer contribute the same dollar amount for each employee, regardless of the accountable health partnership or benefit plan chosen by the employee.

(5)  An employer that employs 30 or fewer employees must offer at least 2 accountable health partnerships or health plans to its employees, and an employer that employs 31 or more employees must offer 3 or more accountable health partnerships or health plans to its employees.

(6)  Notwithstanding any other law, if a small employer member loses eligibility to purchase health care through a community health purchasing alliance solely because the business of the small employer member expands to more than 50 and less than 75 eligible employees, the small employer member may, at its next renewal date, purchase coverage through the alliance for not more than 1 additional year.

History.--s. 69, ch. 93-129; s. 2, ch. 97-45.

408.704  Agency duties and responsibilities related to community health purchasing alliances.--The agency shall assist in developing a statewide system of community health purchasing alliances. To this end, the agency is responsible for:

(1)  Initially and thereafter annually certifying that each community health purchasing alliance complies with ss. 408.70-408.706 and rules adopted pursuant to ss. 408.70-408.706. The agency may decertify any community health purchasing alliance if the alliance fails to comply with ss. 408.70-408.706 and rules adopted by the agency.

(2)  Providing administrative startup funds. Each contract for startup funds is limited to $275,000.

(3)  Conducting an annual review of the performance of each alliance to ensure that the alliance is in compliance with ss. 408.70-408.706. To assist the agency in its review, each alliance shall submit, quarterly, data to the agency, including, but not limited to, employer enrollment by employer size, industry sector, previous insurance status, and count; number of total eligible employers in the alliance district participating in the alliance; number of insured lives by county and insured category, including employees, dependents, and other insured categories, represented by alliance members; profiles of potential employer membership by county; premium ranges for each accountable health partnership for alliance member categories; type and resolution of member grievances; membership fees; and alliance financial statements. A summary of this annual review shall be provided to the Legislature and to each alliance.

(4)  Developing accountable health partnership comparison sheets to be used in providing members and their employees with information regarding the accountable health partnership.

(5)  Establishing a data system for accountable health partnerships.

(a)  The agency shall establish an advisory data committee comprised of the following representatives of employers, medical providers, hospitals, health maintenance organizations, and insurers:

1.  Two representatives appointed by each of the following organizations: Associated Industries of Florida, the Florida Chamber of Commerce, the National Federation of Independent Businesses, and the Florida Retail Federation;

2.  One representative of each of the following organizations: the Florida League of Hospitals, the Association of Voluntary Hospitals of Florida, the Florida Hospital Association, the Florida Medical Association, the Florida Osteopathic Medical Association, the Florida Chiropractic Association, the Florida Chapter of the National Medical Association, the Association of Managed Care Physicians, the Florida Insurance Council, the Florida Association of Domestic Insurers, the Florida Association of Health Maintenance Organizations; and

3.  One representative of governmental health care purchasers and three consumer representatives, to be appointed by the agency.

(b)  The advisory data committee shall issue a report and recommendations on each of the following subjects as each is completed. A final report covering all subjects must be included in the final Florida Health Plan to be submitted to the Legislature on December 31, 1993. The report shall include recommendations regarding:

1.  Types of data to be collected. Careful consideration shall be given to other data collection projects and standards for electronic data interchanges already in process in this state and nationally, to evaluating and recommending the feasibility and cost-effectiveness of various data collection activities, and to ensuring that data reporting is necessary to support the evaluation of providers with respect to cost containment, access, quality, control of expensive technologies, and customer satisfaction analysis. Data elements to be collected from providers include prices, utilization, patient outcomes, quality, and patient satisfaction. The completion of this task is the first priority of the advisory data committee. The agency shall begin implementing these data collection activities immediately upon receipt of the recommendations, but no later than January 1, 1994. The data shall be submitted by hospitals, other licensed health care facilities, pharmacists, and group practices as defined in s. 455.654(3)(f).

2.  A standard data set, a standard cost-effective format for collecting the data, and a standard methodology for reporting the data to the agency, or its designee, and to the alliances. The reporting mechanisms must be designed to minimize the administrative burden and cost to health care providers and carriers. A methodology shall be developed for aggregating data in a standardized format for making comparisons between accountable health partnerships which takes advantage of national models and activities.

3.  Methods by which the agency should collect, process, analyze, and distribute the data.

4.  Standards for data interpretation. The advisory data committee shall actively solicit broad input from the provider community, carriers, the business community, and the general public.

5.  Structuring the data collection process to:

a.  Incorporate safeguards to ensure that the health care services utilization data collected is reviewed by experienced, practicing physicians licensed to practice medicine in this state;

b.  Require that carrier customer satisfaction data conclusions are validated by the agency;

c.  Protect the confidentiality of medical information to protect the patient's identity and to protect the privacy of individual physicians and patients. Proprietary data submitted by insurers, providers, and purchasers are confidential pursuant to s. 408.061; and

d.  Afford all interested professional medical and hospital associations and carriers a minimum of 60 days to review and comment before data is released to the public.

6.  Developing a data collection implementation schedule, based on the data collection capabilities of carriers and providers.

(c)  In developing data recommendations, the advisory data committee shall assess the cost-effectiveness of collecting data from individual physician providers. The initial emphasis must be placed on collecting data from those providers with whom the highest percentages of the health care dollars are spent: hospitals, large physician group practices, outpatient facilities, and pharmacies.

(d)  The agency shall, to the maximum extent possible, adopt and implement the recommendations of the advisory data committee. The agency shall report all recommendations of the advisory data committee to the Legislature and submit an implementation plan.

(e)  The travel expenses of the participants of the advisory data committee must be paid by the participant or by the organization that nominated the participant.

(6)  Collecting, compiling, and analyzing data on accountable health partnerships and providing statistical information to alliances.

(7)  Receiving appeals by members of an alliance and accountable health partnerships whose grievances were not resolved by the alliance. The agency shall review these appeals pursuant to chapter 120. Records or reports submitted as a part of a grievance proceeding conducted as provided for under this subsection are confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution. Records or reports of patient care quality assurance proceedings obtained or made by any member of a community health purchasing alliance or any member of an accountable health partnership and received by the agency as a part of a proceeding conducted pursuant to this subsection are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution. Portions of meetings held pursuant to the provisions of this subsection during which records held confidential pursuant to the provisions of this subsection are discussed are exempt from the provisions of s. 286.011 and s. 24(b), Art. I of the State Constitution. All portions of any meeting closed to the public shall be recorded by a certified court reporter. For any portion of a meeting that is closed, the reporter shall record the times of commencement and termination of the meeting, all discussion and proceedings, the names of all persons present at any time, and the names of all persons speaking. No portion of the closed meeting shall be off the record. The court reporter's notes shall be fully transcribed and given to the appropriate records custodian within a reasonable time after the meeting. A copy of the original transcript, with information otherwise confidential or exempt from public disclosure redacted, shall be made available for public inspection and copying 3 years after the date of the closed meeting.

History.--s. 70, ch. 93-129; ss. 6, 7, ch. 95-201; s. 249, ch. 96-406; s. 28, ch. 98-166.

408.7041  Antitrust protection.--In addition to the duties described in s. 408.704, the agency shall actively supervise the community health purchasing alliances to ensure that actions that affect market competition are not for private interests, but accomplish the legislative intent found in s. 408.70, so as to provide state and federal antitrust protection of alliances and their board members.

History.--s. 71, ch. 93-129.

408.7042  Purchasing health care for state employees and Medicaid recipients through community health purchasing alliances.--

(1)  Pursuant to legislative approval as provided in s. 110.123, and prior to the purchase of health care for state employees and their dependents through community health purchasing alliances, the Agency for Health Care Administration shall consult with collective bargaining organizations that represent state employees, the Department of Management Services, and the administrator of the state group insurance program. Legislative approval for such purchase of health care is not required, however, if the employee benefit package remains unchanged, or is enhanced, the quality of care is increased, and there is no additional cost to the state or its employees. The purchase of health care for state employees and their dependents through a community health purchasing alliance will be determined by the ability of the alliance to meet or exceed the benefit standard that has been collectively bargained. When purchasing health care for state employees and the dependents of such employees through community health purchasing alliances, the Department of Management Services shall annually offer to all employees the opportunity to select from health plans offered by all accountable health partnerships in the district in which the employee lives. The Department of Management Services shall make available to state employees accountable health partnerships that offer health plans through health maintenance organizations, exclusive provider organizations, preferred provider organizations, and managed-care pure indemnity plans. An accountable health partnership is not required to provide all four types of health plans, but all four types of plans must be made available through multiple accountable health partnerships to state employees, if the Department of Management Services elects to purchase health care for state employees through community health purchasing alliances. The Department of Management Services shall offer a minimum of five health maintenance organizations and five preferred provider organizations, where available to state employees. The agency shall select the accountable health partnerships based upon appropriate objective criteria, including premium price, access to quality care, and member satisfaction.

(2)  When purchasing health care for Medicaid, MedAccess, and Medicaid buy-in recipients through community health purchasing alliances, the agency shall ensure that the claims experiences, rates, and charges for such recipients are not commingled with those of other alliance members. However, the claims experiences, rates, and charges for Medicaid recipients, participants in the MedAccess program, and participants in the Medicaid buy-in program shall not be commingled with those of other alliance members. Prior to providing medical benefits to Medicaid recipients through a community health purchasing alliance, the agency shall seek consultation with the Legislature pursuant to the provisions of s. 216.177(2). The state shall offer to all Medicaid, MedAccess, and Medicaid buy-in recipients the opportunity to select health plans from all accountable health partnerships, including providers that have a Medicaid managed-care contract or MediPass, that has been approved by the United States Health Care Financing Administration, or from physicians and facilities that participate in MediPass, in the district in which the recipient lives. For purposes of the purchase of health care for such recipients, current ¹Medicard providers, including providers participating in the MediPass program and entities with Medicaid managed-care contracts are accountable health partnerships. An entity that provides managed-care for Medicaid recipients pursuant to a contract must obtain a certificate of authority from the agency. Purchase of health care for Medicaid, MedAccess, and Medicaid buy-in recipients by the agency through community health purchasing alliances may not result in a reduction of benefits or any increased costs for such recipients without prior legislative approval.

History.--s. 72, ch. 93-129.

¹Note.--The reference to "Medicard providers" may be intended to refer to Medicaid providers.

408.7045  Community health purchasing alliance marketing requirements.--

(1)  Each alliance shall use appropriate, efficient, and standardized means to notify members of the availability of sponsored health coverage from the alliance.

(2)  Each alliance shall make available to members marketing materials that accurately summarize the benefit plans that are offered by its accountable health partnerships and the rates, costs, and accreditation information relating to those plans.

(3)  Annually, the alliance shall offer each member small employer all accountable health partnerships available in the alliance and provide them with the appropriate materials relating to those plans. The member small employer may choose which health benefit plans shall be offered to eligible employees and may change the selection each year. The employee may be given options with regard to health plans and the type of managed care system under which his or her benefits will be provided.

(4)  An alliance may notify the agency of any marketing practices or materials that it finds are contrary to the fair and affirmative marketing requirements of the program. Upon the request of an alliance, the agency shall request the Department of Insurance to investigate the practices and the Department of Insurance may take any action authorized for a violation of the insurance code or the Health Maintenance Organization Act.

History.--s. 73, ch. 93-129; s. 39, ch. 97-103.

408.7055  Practitioner advisory groups.--

(1)  The agency shall by rule establish criteria and conditions for the formation and certification of practitioner advisory groups that may provide practitioner input into the utilization review, administration, coverage, cost-effective medical management, and other operational decisions, except prices or fees, to be made by accountable health partnerships consistent with state and federal antitrust laws.

(2)  No practitioner shall be required to join a practitioner advisory group in order to negotiate with any accountable health partnership.

(3)  Nothing in this section shall authorize any practitioner advisory group or any of its members to boycott or threaten to boycott any accountable health partnership that does not accept the proposals made by a practitioner advisory group.

(4)  The agency shall monitor and annually certify that each practitioner advisory group complies with this section and any implementing rules enacted by the agency. The agency may decertify any practitioner advisory group which fails to comply with this section or any implementing rules enacted by the agency.

(5)  No accountable health partnership shall be required to accept any recommendations of a practitioner advisory group.

(6)  Notice of each meeting of a practitioner advisory group must be provided to the agency at least 3 days prior to the meeting, and such meeting shall be open to representatives of the agency.

History.--s. 75, ch. 93-129.

408.7056  Statewide Provider and Subscriber Assistance Program.--

(1)  As used in this section, the term:

(a)  "Managed care entity" means a health maintenance organization or a prepaid health clinic certified under chapter 641, a prepaid health plan authorized under s. 409.912, or an exclusive provider organization certified under s. 627.6472.

(b)  "Panel" means a statewide provider and subscriber assistance panel selected as provided in subsection (11).

(2)  The agency shall adopt and implement a program to provide assistance to subscribers and providers, including those whose grievances are not resolved by the managed care entity to the satisfaction of the subscriber or provider. The program shall consist of one or more panels that meet as often as necessary to timely review, consider, and hear grievances and recommend to the agency or the department any actions that should be taken concerning individual cases heard by the panel. The panel shall hear every grievance filed by subscribers and providers on behalf of subscribers, unless the grievance:

(a)  Relates to a managed care entity's refusal to accept a provider into its network of providers;

(b)  Is part of a reconsideration appeal through the Medicare appeals process which does not involve a quality of care issue;

(c)  Is related to a health plan not regulated by the state such as an administrative services organization, third-party administrator, or federal employee health benefit program;

(d)  Is related to appeals by in-plan suppliers and providers, unless related to quality of care provided by the plan;

(e)  Is part of a Medicaid fair hearing pursued under 42 C.F.R. ss. 431.220 et seq.;

(f)  Is the basis for an action pending in state or federal court;

(g)  Is related to an appeal by nonparticipating providers, unless related to the quality of care provided to a subscriber by the managed care entity and the provider is involved in the care provided to the subscriber;

(h)  Was filed before the subscriber or provider completed the entire internal grievance procedure of the managed care entity, the managed care entity has complied with its timeframes for completing the internal grievance procedure, and the circumstances described in subsection (6) do not apply;

(i)  Has been resolved to the satisfaction of the subscriber or provider who filed the grievance, unless the managed care entity's initial action is egregious or may be indicative of a pattern of inappropriate behavior;

(j)  Is limited to seeking damages for pain and suffering, lost wages, or other incidental expenses;

(k)  Is limited to issues involving conduct of a health care provider or facility, staff member, or employee of a managed care entity which constitute grounds for disciplinary action by the appropriate professional licensing board and is not indicative of a pattern of inappropriate behavior, and the agency or department has reported these grievances to the appropriate professional licensing board or to the health facility regulation section of the agency for possible investigation; or

(l)  Is withdrawn by the subscriber or provider. Failure of the subscriber or the provider to attend the hearing shall be considered a withdrawal of the grievance.

(3)  The agency shall review all grievances within 60 days after receipt and make a determination whether the grievance shall be heard. Once the agency notifies the panel, the subscriber or provider, and the managed care entity that a grievance will be heard by the panel, the panel shall hear the grievance either in the network area or by teleconference no later than 120 days after the date the grievance was filed. The agency shall notify the parties, in writing, by facsimile transmission, or by phone, of the time and place of the hearing. The panel may take testimony under oath, request certified copies of documents, and take similar actions to collect information and documentation that will assist the panel in making findings of fact and a recommendation. The panel shall issue a written recommendation, supported by findings of fact, to the provider or subscriber, to the managed care entity, and to the agency or the department no later than 15 working days after hearing the grievance. If at the hearing the panel requests additional documentation or additional records, the time for issuing a recommendation is tolled until the information or documentation requested has been provided to the panel. The proceedings of the panel are not subject to chapter 120.

(4)  If, upon receiving a proper patient authorization along with a properly filed grievance, the agency requests medical records from a health care provider or managed care entity, the health care provider or managed care entity that has custody of the records has 10 days to provide the records to the agency. Failure to provide requested medical records may result in the imposition of a fine of up to $500. Each day that records are not produced is considered a separate violation.

(5)  Grievances that the agency determines pose an immediate and serious threat to a subscriber's health must be given priority over other grievances. The panel may meet at the call of the chair to hear the grievances as quickly as possible but no later than 45 days after the date the grievance is filed, unless the panel receives a waiver of the time requirement from the subscriber. The panel shall issue a written recommendation, supported by findings of fact, to the department or the agency within 10 days after hearing the expedited grievance.

(6)  When the agency determines that the life of a subscriber is in imminent and emergent jeopardy, the chair of the panel may convene an emergency hearing, within 24 hours after notification to the managed care entity and to the subscriber, to hear the grievance. The grievance must be heard notwithstanding that the subscriber has not completed the internal grievance procedure of the managed care entity. The panel shall, upon hearing the grievance, issue a written emergency recommendation, supported by findings of fact, to the managed care entity, to the subscriber, and to the agency or the department for the purpose of deferring the imminent and emergent jeopardy to the subscriber's life. Within 24 hours after receipt of the panel's emergency recommendation, the agency or department may issue an emergency order to the managed care entity. An emergency order remains in force until:

(a)  The grievance has been resolved by the managed care entity;

(b)  Medical intervention is no longer necessary; or

(c)  The panel has conducted a full hearing under subsection (3) and issued a recommendation to the agency or the department, and the agency or department has issued a final order.

(7)  After hearing a grievance, the panel shall make a recommendation to the agency or the department which may include specific actions the managed care entity must take to comply with state laws or rules regulating managed care entities.

(8)  A managed care entity, subscriber, or provider that is affected by a panel recommendation may within 10 days after receipt of the panel's recommendation, or 72 hours after receipt of a recommendation in an expedited grievance, furnish to the agency or department written evidence in opposition to the recommendation or findings of fact of the panel.

(9)  No later than 30 days after the issuance of the panel's recommendation and, for an expedited grievance, no later than 10 days after the issuance of the panel's recommendation, the agency or the department may adopt the panel's recommendation or findings of fact in a proposed order or an emergency order, as provided in chapter 120, which it shall issue to the managed care entity. The agency or department may issue a proposed order or an emergency order, as provided in chapter 120, imposing fines or sanctions, including those contained in ss. 641.25 and 641.52. The agency or the department may reject all or part of the panel's recommendation. All fines collected under this subsection must be deposited into the Health Care Trust Fund.

(10)  In determining any fine or sanction to be imposed, the agency and the department may consider the following factors:

(a)  The severity of the noncompliance, including the probability that death or serious harm to the health or safety of the subscriber will result or has resulted, the severity of the actual or potential harm, and the extent to which provisions of chapter 641 were violated.

(b)  Actions taken by the managed care entity to resolve or remedy any quality-of-care grievance.

(c)  Any previous incidents of noncompliance by the managed care entity.

(d)  Any other relevant factors the agency or department considers appropriate in a particular grievance.

(11)  The panel shall consist of members employed by the agency and members employed by the department, chosen by their respective agencies. The agency may contract with a medical director and a primary care physician who shall provide additional technical expertise to the panel. The medical director shall be selected from a health maintenance organization with a current certificate of authority to operate in Florida.

(12)  Every managed care entity shall submit a quarterly report to the agency and the department listing the number and the nature of all subscribers' and providers' grievances which have not been resolved to the satisfaction of the subscriber or provider after the subscriber or provider follows the entire internal grievance procedure of the managed care entity. The agency shall notify all subscribers and providers included in the quarterly reports of their right to file an unresolved grievance with the panel.

(13)  Any information which would identify a subscriber or the spouse, relative, or guardian of a subscriber and which is contained in a report obtained by the Department of Insurance pursuant to this section is confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

(14)  A proposed order issued by the agency or department which only requires the managed care entity to take a specific action under subsection (7) is subject to a summary hearing in accordance with s. 120.574, unless all of the parties agree otherwise. If the managed care entity does not prevail at the hearing, the managed care entity must pay reasonable costs and attorney's fees of the agency or the department incurred in that proceeding.

(15)(a)  Any information which would identify a subscriber or the spouse, relative, or guardian of a subscriber which is contained in a document, report, or record prepared or reviewed by the panel or obtained by the agency pursuant to this section is confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

(b)  Meetings of the panel shall be open to the public unless the provider or subscriber whose grievance will be heard requests a closed meeting or the agency or the Department of Insurance determines that information of a sensitive personal nature which discloses the subscriber's medical treatment or history; or information which constitutes a trade secret as defined by s. 812.081; or information relating to internal risk management programs as defined in s. 641.55(5)(c), (6), and (8) may be revealed at the panel meeting, in which case that portion of the meeting during which such sensitive personal information, trade secret information, or internal risk management program information is discussed shall be exempt from the provisions of s. 286.011 and s. 24(b), Art. I of the State Constitution. All closed meetings shall be recorded by a certified court reporter.

This subsection is subject to the Open Government Sunset Review Act of 1995 in accordance with s. 119.15, and shall stand repealed on October 2, 2003, unless reviewed and saved from repeal through reenactment by the Legislature.

History.--ss. 1, 32, 47, ch. 85-177; s. 15, ch. 88-388; ss. 123, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 76, ch. 93-129; s. 23, ch. 95-398; s. 3, ch. 96-199; s. 250, ch. 96-406; s. 24, ch. 96-418; s. 1, ch. 98-10; s. 1, ch. 98-256.

Note.--Former s. 641.311; (4) former s. 119.07(3)(s).

408.706  Community health purchasing alliances; accountable health partnerships.--

(1)  An accountable health partnership may be created by health care providers, health maintenance organizations, and health insurers, for the purpose of providing health care services to alliance members.

(2)  Each accountable health partnership that seeks to offer services to members of an alliance must first obtain agency designation. The agency shall adopt rules in accordance with ss. 408.70-408.706 for designating accountable health partnerships in each district. To qualify as an accountable health partnership, an applicant must submit information considered sufficient by the agency, in a format prescribed by the agency, to satisfactorily demonstrate that the partnership:

(a)  Is licensed or certified and in good standing with the department and the licensure agency for participating providers;

(b)  Has demonstrated the capacity to administer the health plans it is offering;

(c)  Has the ability, experience, and structure to arrange for the appropriate level and type of health care services;

(d)  Has the ability, policies, and procedures to conduct utilization management;

(e)  Has the ability to achieve, monitor, and evaluate the quality and cost-effectiveness of care provided by its provider network;

(f)  Has the ability to assure enrollees adequate access to providers of health care, including geographic availability and adequate numbers and types;

(g)  Has the ability and procedures to monitor access to its provider network;

(h)  Has a satisfactory grievance procedure and the ability to respond to enrollees' calls, questions, and complaints;

(i)  Has the ability to use medical outcome data to educate network providers, update utilization review procedures, and recommend modifications to benefit designs;

(j)  Has the ability to recruit and retain health care practitioners who are minorities as defined in s. 288.703(3), with special emphasis on the recruitment and retention of African-American health care providers; and

(k)  Has the ability and policies that allow patients to receive care in the most appropriate, least restrictive setting.

If an accountable health partnership is accredited by a nationally recognized accrediting body or federal agency whose standards are acceptable to the agency, or if it is qualified or accredited as a health maintenance organization, the accountable health partnership may be deemed to meet the requirements of paragraphs (a)-(h).

(3)  The agency shall establish a designation fee to be paid by each accountable health partnership to cover the agency's cost in performing the designation review.

(4)  An accountable health partnership shall:

(a)  Require all providers that are part of the partnership to report medical outcomes in accordance with agency standards.

(b)  Comply with all rating, underwriting, claims-handling, sales, solicitation, licensing, and unfair trade practices and other provisions of the Florida Insurance Code or of chapter 641.

(5)  An accountable health partnership may provide services to more than one community health purchasing alliance.

(6)  If an accountable health partnership elects to terminate its contract with an alliance member, the accountable health partnership must provide advance notice of its decision to the alliance at least 120 days prior to the nonrenewal of any health plan by the accountable health partnership.

(7)  An accountable health partnership shall maintain records and submit reports to the alliance as required by ss. 408.70-408.706.

(8)  An accountable health partnership shall use the services of a licensed agent for the solicitation of insurance or procurement of applications or any other activities for which a health insurance agent's license is required.

(9)  An accountable health partnership may not require any greater coverage for professional liability insurance than is currently required by the state law.

(10)  Notwithstanding any provision of this act to the contrary, if an accountable health partnership has entered into a contract with providers or facilities licensed or permitted under chapter 465 for the purpose of providing prescribed medicine services, an individual may use an independent pharmacy which is not a party to the contract, if such independent pharmacy selected agrees to provide the service at a rate equal to or less than the rate set forth in the contract negotiated by the accountable health partnership with parties to the contract and such independent pharmacy meets all of the qualifications for participation in the accountable health partnership including, but not limited to, qualifications related to professional education, skills, experience; documentation of the appropriateness, overuse or underuse of services as identified by utilization review mechanisms and criteria; and previous restrictions or sanctions imposed by licensing bodies, and favorable professional liability history. Nothing in this section applies to any health maintenance organization established under part I of chapter 641 which maintains an in-house pharmacy that is permitted under chapter 465. For the purposes of this subsection, the term "independent pharmacy" means a pharmacy facility which is not part of a group of affiliated pharmacy facilities which are under common ownership directly or indirectly in which the group has greater than 12 pharmacy facilities in the state or has directly or indirectly any interest in any facilities licensed under another state's laws for the purpose of providing prescribed medicine services, and the term "pharmacy facility" means a pharmacy facility which is permitted by the Board of Pharmacy in accordance with chapter 465.

(11)  The ability to recruit and retain alliance district health care providers in its provider network. For provider networks initially formed in an alliance district after July 1, 1993, an accountable health partnership shall make offers as to provider participation in its provider network to relevant alliance district health care providers for at least 60 percent of the available provider positions. A provider who is made an offer may participate in an accountable health partnership as long as the provider abides by the terms and conditions of the provider network contract, provides services at a rate or price equal to the rate or price negotiated by the accountable health partnership, and meets all of the accountable health partnership's qualifications for participation in its provider networks including, but not limited to, network adequacy criteria. For purposes of this subsection, "alliance district health care provider" means a health care provider who is licensed under chapter 458, chapter 459, chapter 460, chapter 461, chapter 464, or chapter 465 who has practiced in Florida for more than 1 year within the alliance district served by the accountable health partnership.

(12)(a)  Each accountable health partnership shall establish a panel of providers from its provider network to review and make recommendations to the accountable health partnership on the health plans and issues related to the plans offered by the accountable health partnership through the community health purchasing alliance.

(b)  No accountable health partnership shall be required to accept any recommendations of the panel.

(13)(a)  The agency shall suspend or revoke its designation of an accountable health partnership that fails to continue to meet the requirements of this section.

(b)  The agency shall expedite proceedings to determine whether the designation of the accountable health partnership should be suspended or revoked.

History.--s. 77, ch. 93-129; s. 6, ch. 94-96.

408.7071  Standardized claim form.--

(1)  The Agency for Health Care Administration shall develop a standardized claims form to be used by insurers and health care providers licensed in this state.

(2)  In order to develop the standardized claim form, the agency shall appoint a 15-person committee. The committee shall consist of:

(a)  The director of the Agency for Health Care Administration, or the director's designee.

(b)  The Insurance Commissioner, or the commissioner's designee.

(c)  Two representatives of hospitals.

(d)  Five representatives of physicians: two licensed under chapter 458, one licensed under chapter 459, one licensed under chapter 460, and one licensed under chapter 461.

(e)  Two representatives of health insurers.

(f)  Two representatives of health maintenance organizations.

(g)  Two representatives of consumers.

(3)  The committee shall issue a draft of the standardized claims form to the Agency for Health Care Administration by October 1, 1993. The agency may return the form to the committee for modification on a schedule that allows the agency to include the standardized claim form in the final Florida Health Plan, which must be submitted to the Legislature by December 1, 1993.

History.--s. 81, ch. 93-129; s. 41, ch. 97-103.

408.90  Legislative findings and intent.--The Legislature finds that 2.5 million Floridians do not have access to health insurance coverage, often because the premiums are unaffordable. It is the intent of the Legislature to provide a state health insurance program for those people who are without health insurance so that they may have access to preventive and primary care services. The state health insurance program shall offer basic, affordable health care services to those Floridians who have not had access to the private health insurance market. The Legislature intends that the state program shall target the uninsured and not those who currently have private health insurance coverage.

History.--s. 37, ch. 93-129.

408.901  Definitions.--As used in ss. 408.901-408.908, except as otherwise specifically provided, the term:

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

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

(3)  "Applicant" means a person who provides a written application to the agency for enrollment in the MedAccess program but whose application has not received final action.

(4)  "Eligible person" means any person who meets the residency requirements of ss. 408.901-408.908.

(5)  "Employer" means the state, its political subdivisions, any individual, partnership, association, corporation, or business trust, or any person or group of persons, acting in the interest of any employer in relation to an employee.

(6)  "Fund" means the Licensure Fees Trust Fund.

(7)  "Health services" means a set of basic health services covered by the MedAccess Program.

(8)  "Member" means a Florida resident who has enrolled in the MedAccess program provided in ss. 408.901-408.908.

(9)  "Participating provider" means any person who has a current provider agreement with the agency and who is authorized to furnish covered health services pursuant to ss. 408.901-408.908. The agency shall integrate county health departments, federally funded primary care centers, and other outpatient clinics as participating providers in the health insurance program.

(10)  "Premium" means the consideration paid or to be paid to the agency for the issuance of health insurance coverage provided by the MedAccess program.

(11)  "MedAccess" means the state health program created pursuant to ss. 408.901-408.908.

History.--s. 38, ch. 93-129; s. 109, ch. 97-101.

408.902  MedAccess program; creation; program title.--

(1)  Effective July 1, 1994, there is hereby created the MedAccess program to be administered by the Agency for Health Care Administration. The MedAccess program shall not be subject to the requirements of the Department of Insurance or chapter 627. The director of the agency shall appoint an administrator of the MedAccess program which shall be located in the Division of State Health Purchasing.

(2)  If the necessary federal waivers are obtained and state and federal funds are available to establish a Medicaid buy-in program pursuant to s. 409.914, the MedAccess program shall remain available to those members who do not qualify for enrollment or who do not choose to enroll in the Medicaid buy-in program.

History.--s. 39, ch. 93-129.

408.903  Eligibility.--

(1)  Every resident of this state who has a gross family income that is equal to or below 250 percent of the federal poverty level and who meets the requirements of this section is eligible to enroll in the MedAccess program. For purposes of ss. 408.901-408.908, a resident is defined as a person who has established a domicile in the state for a period of at least 6 months. As used in this section, the term "resident" shall mean United States citizens or United States legal permanent residents.

(2)  A person or family who applies for enrollment in the MedAccess program must provide documentation that demonstrates he or she has not been covered by a health insurance policy in the 12-month period prior to the effective date of enrollment in the program.

(3)  A person or family who is currently eligible for health care benefits under Medicare or the Florida Medicaid program is not eligible for enrollment in the MedAccess program. However, a person may convert to the program upon losing eligibility either for Medicare or Medicaid or upon disenrolling from the Medicaid buy-in program established pursuant to s. 409.914.

(4)  The agency shall not use any information related to an applicant's assets in determining eligibility for the program.

(5)  Applicants for the program shall complete an application form developed by the agency and shall provide information related to the family dependents to be enrolled and supply documentation concerning family income and place of residence.

(6)  Applications for enrollment in the MedAccess program shall be submitted to the agency during a single month-long open enrollment period each year. The agency shall review all completed applications within 45 days of receipt. Applicants who satisfy the eligibility criteria and have paid their initial premium shall be notified by the agency of the effective date of coverage.

(7)  The agency may request verification of continued eligibility from members once every 12 months.

(8)  The program may disenroll any member due to failure to meet eligibility criteria, nonpayment of premium, or good cause.

(9)  Enrollment in the MedAccess program is subject to eligibility and fiscal limitations and shall be renewed annually.

(10)  If the Agency for Health Care Administration obtains the necessary federal waivers to implement a Medicaid buy-in program, members of the MedAccess program who qualify shall be entitled to transfer their enrollment to the Medicaid buy-in program.

History.--s. 41, ch. 93-129.

408.904  Benefits.--

(1)  Every eligible person who enrolls in the MedAccess program is entitled to receive benefits for any covered service furnished within this state by a participating provider.

(2)  Covered health services include:

(a)  Physician services. Those services delivered by a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 463 that are medically necessary for the treatment of an injury, illness, or disease. Physician services shall not include those services that are clinically unproven, experimental, or purely for cosmetic purposes. Each member is limited to 12 physician visits per calendar year, excluding those visits related to annual or periodic physical examinations for wellness pursuant to paragraph (g) or for immunizations.

(b)  Hospital inpatient services. Those services provided for the treatment of a member who is admitted as an inpatient by a licensed physician or dentist to a hospital licensed under part I of chapter 395 up to a limit of 10 days per calendar year per member.

(c)  Hospital outpatient services. Those services provided to a member in the outpatient portion of a hospital licensed under part I of chapter 395, up to a limit of $1,000 per calendar year per member, that are preventive, diagnostic, therapeutic, or palliative.

(d)  Laboratory services. Professional laboratory services ordered by a licensed physician or other licensed practitioner of the healing arts and provided in a laboratory that meets the requirements for Medicare participation and is licensed under chapter 483.

(e)  X-ray services. Radiological services ordered by a licensed physician or other licensed practitioner of the healing arts and that are provided by a licensed professional.

(f)  Family planning services. Drugs and supplies that will enable a member to plan family size.

(g)  Health appraisals, including physician examinations and related tests. Routine annual physical examinations conducted by or under the direction of a licensed physician, without regard to medical necessity, in order to detect disease, disability, or other physical or mental conditions. These services include well-baby and well-child screening and diagnostic services provided on a periodic basis to members under the age of 21.

(h)  Immunizations.

(i)  Advanced registered nurse practitioner services.

(j)  Outpatient mental health visits and substance abuse treatment. Outpatient mental health visits provided by community mental health centers as provided in chapter 394 and by a mental health therapist licensed under chapter 490 or chapter 491 and substance abuse treatment provided by a center licensed under ¹chapter 396 or chapter 397, up to a total of five visits per calendar year per member.

(3)  Covered health services do not include any of the following:

(a)  Surgery solely for cosmetic purposes.

(b)  Prescribed drugs.

(c)  Nursing home services.

(d)  Medical examinations conducted and medical reports prepared for either purchasing or renewing life insurance or participating as a plaintiff or defendant in a civil action for the recovery or settlement of damages.

(e)  Clinically unproven or experimental procedures.

History.--s. 42, ch. 93-129.

¹Note.--Repealed by s. 48, ch. 93-39.

408.905  Limitations and exclusions.--

(1)  The MedAccess program shall not cover benefits that are provided as part of workers' compensation insurance.

(2)  The MedAccess program shall exclude coverage for preexisting conditions, except pregnancy, during a period of 12 months following the effective date of coverage as long as:

(a)  The condition manifested itself within a period of 6 months before the effective date of coverage; or

(b)  Medical advice or treatment was recommended or received within 6 months before the effective date of coverage.

(3)  In addition to the limitations otherwise provided in ss. 408.901-408.908, the MedAccess program shall not include coverage for outpatient prescription drugs, eyeglasses, dental services, custodial care, or emergency services for nonemergent conditions.

(4)  Any member of the MedAccess program who is determined to be at "high risk" by a participating primary care provider shall, upon renewal, agree to be placed in a case management system when it is determined by the program to be in the best interest of the member and the MedAccess program.

(5)  No person on whose behalf the program has paid out $500,000 in covered benefits is eligible for continued coverage in the MedAccess program.

History.--s. 43, ch. 93-129.

408.906  Payment of claims.--

(1)  The agency is designated as the single state agency authorized to make payments for health services covered under the MedAccess program. These payments shall be made only for services included in the MedAccess program and shall be made only on behalf of eligible members in accordance with the provisions of ss. 408.901-408.908.

(2)  The agency shall pay claims for covered health services provided to members at the same reimbursement rates and fees that are provided under the Florida Medicaid program, pursuant to s. 409.908.

History.--s. 44, ch. 93-129.

408.907  Collection of premiums.--

(1)  Premiums collected from members or from employers on behalf of members shall be made in accordance with rules adopted by the agency.

(2)  Premiums collected shall be deposited in the Licensure Fees Trust Fund of the agency. Moneys in this fund shall be used solely for the administration of the MedAccess program.

(3)  Employers are encouraged to participate in the payment of all or a portion of their employees' premium obligation. The agency is authorized to offer discounts to the premium obligation to those employers who pay at least 50 percent of the premium and who collect the premium from the employees on behalf of the agency.

(4)  The agency is authorized to contract with agents who may refer individuals to the MedAccess program and may pay those agents a modest referral fee if the individual's application is accepted for enrollment in the MedAccess program.

(5)  The agency is directed to develop strategies for marketing MedAccess to increase public awareness about the state program.

History.--s. 45, ch. 93-129.

408.908  Administration.--The agency shall be responsible for:

(1)  Developing a network of health care providers for providing managed health care services on a statewide basis.

(2)  Performing all eligibility and administrative claims payment functions relating to the program.

(3)  Evaluating the eligibility of each claim for payment under the program.

(4)  Establishing a premium billing procedure for the collection of premiums from insured persons.

(5)  Developing a schedule of copayments and deductibles that will encourage the use of preventive and primary care services, will deter members from overutilizing services, and will discourage the use of expensive, technology-driven services.

(6)  Marketing the MedAccess program.

(7)  Providing that the direct and indirect expenses of the program are fully covered by the collection of premiums from members of the MedAccess program.

(8)  Establishing policy and budget guidelines for the MedAccess program.

(9)  Adopting rules to carry out the provisions of ss. 408.901-408.908.

(10)  Implementing and administering the MedAccess program.

(11)  Providing to the public and to health care providers information concerning the MedAccess program.

(12)  Ensuring that the quality of service provided under the MedAccess program meets the standards of the community.

(13)  Identifying and eliminating health care providers who engage in fraudulent or abusive activities related to the MedAccess program.

(14)  Evaluating the adequacy of the services covered by the MedAccess program, the accessibility of the program to the uninsured, and the effectiveness of the MedAccess program in reducing the number of uninsured persons in the state.

History.--s. 46, ch. 93-129.