CODING: Words stricken are deletions; words underlined are additions.
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Senator Brown-Waite moved the following amendment:
SENATE AMENDMENT
Bill No. CS/HB 1005, 1st Eng.
Amendment No.
CHAMBER ACTION
Senate House
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11 Senator Brown-Waite moved the following amendment:
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13 Senate Amendment (with title amendment)
14 Delete everything after the enacting clause
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16 and insert:
17 Section 1. Section 408.7056, Florida Statutes, is
18 amended to read:
19 408.7056 Statewide Provider and Subscriber Assistance
20 Program.--
21 (1) As used in this section, the term:
22 (a) "Managed care entity" means a health maintenance
23 organization or a prepaid health clinic certified under
24 chapter 641, a prepaid health plan authorized under s.
25 409.912, or an exclusive provider organization certified under
26 s. 627.6472.
27 (b) "Panel" means a statewide provider and subscriber
28 assistance panel selected as provided in subsection (11).
29 (2)(1) The agency for Health Care Administration shall
30 adopt and implement a program to provide assistance to
31 subscribers and providers, including those whose grievances
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SENATE AMENDMENT
Bill No. CS/HB 1005, 1st Eng.
Amendment No.
1 are not resolved by the managed care entity accountable health
2 partnership, health maintenance organization, prepaid health
3 clinic, prepaid health plan authorized pursuant to s. 409.912,
4 or exclusive provider organization to the satisfaction of the
5 subscriber or provider. The program shall consist of one or
6 more panels that meet as often as necessary to timely review,
7 consider, and hear grievances and recommend to the agency or
8 the department any actions that should be taken concerning
9 individual cases heard by the panel. The panel shall hear
10 every grievance filed by subscribers and providers on behalf
11 of subscribers, unless the grievance not consider grievances
12 which:
13 (a) Relates to a managed care entity's Relate to an
14 accountable health partnership's, health maintenance
15 organization's, prepaid health clinic's, prepaid health
16 plan's, or exclusive provider organization's refusal to accept
17 a provider into its network of providers;
18 (b) Is Are a part of a reconsideration appeal through
19 the Medicare appeals process which does not involve a quality
20 of care issue;
21 (c) Is Are related to a health plan not regulated by
22 the state such as an administrative services organization,
23 third-party administrator, or federal employee health benefit
24 program;
25 (d) Is Are related to appeals by in-plan suppliers and
26 providers, unless related to quality of care provided by the
27 plan; or
28 (e) Is Are part of a Medicaid fair hearing pursued
29 under pursuant to 42 C.F.R. ss. 431.220 et seq.
30 (f) Is the basis for an action pending in state or
31 federal court;
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Bill No. CS/HB 1005, 1st Eng.
Amendment No.
1 (g) Is related to an appeal by nonparticipating
2 providers, unless related to the quality of care provided to a
3 subscriber by the managed care entity and the provider is
4 involved in the care provided to the subscriber;
5 (h) Was filed before the subscriber or provider
6 completed the entire internal grievance procedure of the
7 managed care entity, the managed care entity has complied with
8 its timeframes for completing the internal grievance
9 procedure, and the circumstances described in subsection (6)
10 do not apply;
11 (i) Has been resolved to the satisfaction of the
12 subscriber or provider who filed the grievance, unless the
13 managed care entity's initial action is egregious or may be
14 indicative of a pattern of inappropriate behavior;
15 (j) Is limited to seeking damages for pain and
16 suffering, lost wages, or other incidental expenses;
17 (k) Is limited to issues involving conduct of a health
18 care provider or facility, staff member, or employee of a
19 managed care entity which constitute grounds for disciplinary
20 action by the appropriate professional licensing board and is
21 not indicative of a pattern of inappropriate behavior, and the
22 agency or department has reported these grievances to the
23 appropriate professional licensing board or to the health
24 facility regulation section of the agency for possible
25 investigation; or
26 (l) Is withdrawn by the subscriber or provider.
27 Failure of the subscriber or the provider to attend the
28 hearing shall be considered a withdrawal of the grievance.
29 (3) The agency shall review all grievances within 60
30 days after receipt and make a determination whether the
31 grievance shall be heard. Once the agency notifies the panel,
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Amendment No.
1 the subscriber or provider, and the managed care entity that a
2 grievance will be heard by the panel, the panel shall hear the
3 grievance either in the network area or by teleconference no
4 later than 120 days after the date the grievance was filed.
5 The agency shall notify the parties, in writing, by facsimile
6 transmission, or by phone, of the time and place of the
7 hearing. The panel may take testimony under oath, request
8 certified copies of documents, and take similar actions to
9 collect information and documentation that will assist the
10 panel in making findings of fact and a recommendation. The
11 panel shall issue a written recommendation, supported by
12 findings of fact, to the provider or subscriber, to the
13 managed care entity, and to the agency or the department no
14 later than 15 working days after hearing the grievance. If at
15 the hearing the panel requests additional documentation or
16 additional records, the time for issuing a recommendation is
17 tolled until the information or documentation requested has
18 been provided to the panel. The proceedings of the panel are
19 not subject to chapter 120.
20 (4) If, upon receiving a proper patient authorization
21 along with a properly filed grievance, the agency requests
22 medical records from a health care provider or managed care
23 entity, the health care provider or managed care entity that
24 has custody of the records has 10 days to provide the records
25 to the agency. Failure to provide requested medical records
26 may result in the imposition of a fine of up to $500. Each
27 day that records are not produced is considered a separate
28 violation.
29 (5) Grievances that the agency determines pose an
30 immediate and serious threat to a subscriber's health must be
31 given priority over other grievances. The panel may meet at
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Amendment No.
1 the call of the chair to hear the grievances as quickly as
2 possible but no later than 45 days after the date the
3 grievance is filed, unless the panel receives a waiver of the
4 time requirement from the subscriber. The panel shall issue a
5 written recommendation, supported by findings of fact, to the
6 department or the agency within 10 days after hearing the
7 expedited grievance.
8 (6) When the agency determines that the life of a
9 subscriber is in imminent and emergent jeopardy, the chair of
10 the panel may convene an emergency hearing, within 24 hours
11 after notification to the managed care entity and to the
12 subscriber, to hear the grievance. The grievance must be
13 heard notwithstanding that the subscriber has not completed
14 the internal grievance procedure of the managed care entity.
15 The panel shall, upon hearing the grievance, issue a written
16 emergency recommendation, supported by findings of fact, to
17 the managed care entity, to the subscriber, and to the agency
18 or the department for the purpose of deferring the imminent
19 and emergent jeopardy to the subscriber's life. Within 24
20 hours after receipt of the panel's emergency recommendation,
21 the agency or department may issue an emergency order to the
22 managed care entity. An emergency order remains in force
23 until:
24 (a) The grievance has been resolved by the managed
25 care entity;
26 (b) Medical intervention is no longer necessary; or
27 (c) The panel has conducted a full hearing under
28 subsection (3) and issued a recommendation to the agency or
29 the department, and the agency or department has issued a
30 final order.
31 (7) After hearing a grievance, the panel shall make a
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Amendment No.
1 recommendation to the agency or the department which may
2 include specific actions the managed care entity must take to
3 comply with state laws or rules regulating managed care
4 entities.
5 (8) A managed care entity, subscriber, or provider
6 that is affected by a panel recommendation may within 10 days
7 after receipt of the panel's recommendation, or 72 hours after
8 receipt of a recommendation in an expedited grievance, furnish
9 to the agency or department written evidence in opposition to
10 the recommendation or findings of fact of the panel.
11 (9) No later than 30 days after the issuance of the
12 panel's recommendation and, for an expedited grievance, no
13 later than 10 days after the issuance of the panel's
14 recommendation, the agency or the department may adopt the
15 panel's recommendation or findings of fact in a proposed order
16 or an emergency order, as provided in chapter 120, which it
17 shall issue to the managed care entity. The agency or
18 department may issue a proposed order or an emergency order,
19 as provided in chapter 120, imposing fines or sanctions,
20 including those contained in ss. 641.25 and 641.52. The
21 agency or the department may reject all or part of the panel's
22 recommendation. All fines collected under this subsection must
23 be deposited into the Health Care Trust Fund.
24 (10) In determining any fine or sanction to be
25 imposed, the agency and the department may consider the
26 following factors:
27 (a) The severity of the noncompliance, including the
28 probability that death or serious harm to the health or safety
29 of the subscriber will result or has resulted, the severity of
30 the actual or potential harm, and the extent to which
31 provisions of chapter 641 were violated.
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Amendment No.
1 (b) Actions taken by the managed care entity to
2 resolve or remedy any quality-of-care grievance.
3 (c) Any previous incidents of noncompliance by the
4 managed care entity.
5 (d) Any other relevant factors the agency or
6 department considers appropriate in a particular grievance.
7 (2) The program shall include the following:
8 (a) A review panel which may periodically review,
9 consider, and recommend to the agency any actions the agency
10 or the Department of Insurance should take concerning
11 individual cases heard by the panel, as well as the types of
12 grievances which have not been satisfactorily resolved after
13 subscribers or providers have followed the full grievance
14 procedures of the accountable health partnership, health
15 maintenance organization, prepaid health clinic, prepaid
16 health plan, or exclusive provider organization. The
17 proceedings of the grievance panel shall not be subject to the
18 provisions of chapter 120.
19 (11) The review panel shall consist of members
20 employed by the agency and members employed by the department
21 of Insurance, chosen by their respective agencies. The agency
22 may contract with a medical director and a primary care
23 physician who shall provide additional technical expertise to
24 the review panel. The medical director shall be selected from
25 a health maintenance organization with a current certificate
26 of authority to operate in Florida.
27 (b) A plan to disseminate information concerning the
28 program to the general public as widely as possible.
29 (12)(3) Every managed care entity accountable health
30 partnership, health maintenance organization, prepaid health
31 clinic, prepaid health plan authorized pursuant to s. 409.912,
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Amendment No.
1 or exclusive provider organization shall submit a quarterly
2 report to the agency and the department of Insurance listing
3 the number and the nature of all subscribers' and providers'
4 grievances which have not been resolved to the satisfaction of
5 the subscriber or provider after the subscriber or provider
6 follows the entire internal full grievance procedure of the
7 managed care entity organization. The agency shall notify all
8 subscribers and providers included in the quarterly reports of
9 their right to file an unresolved grievance with the panel.
10 (4)(a) The Agency for Health Care Administration may
11 impose an administrative fine, after a formal investigation
12 has been conducted on the accountable health partnership's,
13 health maintenance organization's, prepaid health clinic's,
14 prepaid health plan's, or exclusive provider organization's
15 failure to comply with quality of health services standards
16 set forth in statute or rule. The Agency for Health Care
17 Administration may initiate such an investigation based on the
18 recommendations related to the quality of health services
19 received from the Statewide Provider and Subscriber Assistance
20 Panel pursuant to paragraph (2)(a). The fine shall not exceed
21 $2,500 per violation and in no event shall such fine exceed an
22 aggregate amount of $10,000 for noncompliance arising out of
23 the same action.
24 (b) In determining the amount to be levied for
25 noncompliance under paragraph (a), the following factors shall
26 be considered:
27 1. The severity of the noncompliance, including the
28 probability that death or serious harm to the health or safety
29 of the subscriber will result or has resulted, the severity of
30 actual or potential harm and the extent to which provisions of
31 this part were violated.
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Amendment No.
1 2. Actions taken by the accountable health
2 partnership, health maintenance organization, prepaid health
3 clinic, prepaid health plan, or exclusive provider
4 organization to resolve or remedy any quality of care
5 grievance.
6 3. Any previous incidences of noncompliance by the
7 accountable health partnership, health maintenance
8 organization, prepaid health clinic, prepaid health plan, or
9 exclusive provider organization.
10 (c) All amounts collected pursuant to this subsection
11 shall be deposited into the Health Care Trust Fund.
12 (13)(5) Any information which would identify a
13 subscriber or the spouse, relative, or guardian of a
14 subscriber and which is contained in a report obtained by the
15 Department of Insurance pursuant to this section is
16 confidential and exempt from the provisions of s. 119.07(1)
17 and s. 24(a), Art. I of the State Constitution.
18 (14) A proposed order issued by the agency or
19 department which only requires the managed care entity to take
20 a specific action under subsection (7), is subject to a
21 summary hearing in accordance with s. 120.574, unless all of
22 the parties agree otherwise. If the managed care entity does
23 not prevail at the hearing, the managed care entity must pay
24 reasonable costs and attorney's fees of the agency or the
25 department incurred in that proceeding.
26 Section 2. Subsection (7) of section 641.511, Florida
27 Statutes, is amended to read:
28 641.511 Subscriber grievance reporting and resolution
29 requirements.--
30 (7) Each organization shall send to the agency a copy
31 of its annual and quarterly grievance reports submitted to the
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Bill No. CS/HB 1005, 1st Eng.
Amendment No.
1 Department of Insurance pursuant to s. 408.7056(12)(2).
2 Section 3. There is appropriated to the Agency for
3 Health Care Administration for fiscal year 1998-1999 a total
4 of 6 full-time-equivalent positions and $308,830 from the
5 Health Care Trust Fund for 9 months' funding for the purpose
6 of implementing this act.
7 Section 4. This act shall take effect December 1,
8 1998.
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12 And the title is amended as follows:
13 Delete everything before the enacting clause
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15 and insert:
16 A bill to be entitled
17 An act relating to the Statewide Provider and
18 Subscriber Assistance Program; amending s.
19 408.7056, F.S.; providing definitions; revising
20 criteria and procedures for review of
21 grievances against a managed care entity by the
22 statewide provider and subscriber assistance
23 panel; providing for initial review by the
24 Agency for Health Care Administration;
25 providing time requirements for panel hearings
26 and recommendations, and final orders of the
27 agency or the Department of Insurance;
28 providing for notice; providing requirements
29 for expedited or emergency hearings; providing
30 an exemption from the Administrative Procedures
31 Act; providing for requests for patient
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Amendment No.
1 records; authorizing an administrative fine for
2 failure to timely provide records; providing
3 for furnishing of evidence in opposition to
4 panel recommendations; providing for adoption
5 of panel recommendations in final orders of the
6 agency or department; authorizing imposition of
7 fines and sanctions; requiring certain notice
8 to subscribers and providers of their right to
9 file grievances; providing for summary
10 hearings; providing for administrative
11 procedures; providing for attorney's fees and
12 costs; amending s. 641.511, F.S.; eliminating
13 annual grievance report filing; correcting a
14 cross-reference; providing an appropriation;
15 providing an effective date.
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