CODING: Words stricken are deletions; words underlined are additions.House Bill 0325
Florida House of Representatives - 1997 HB 325
By Representative Maygarden
1 A bill to be entitled
2 An act relating to health maintenance
3 organizations; amending s. 641.315, F.S.;
4 prohibiting provider contracts from restricting
5 a provider's ability to communicate certain
6 information to subscribers; amending s.
7 641.495, F.S.; requiring designation of a
8 state-licensed physician or osteopath as
9 medical director; amending s. 641.51, F.S.;
10 requiring out-of-network referrals to
11 specialists, under certain circumstances;
12 requiring written procedures for standing
13 referrals for individuals who require ongoing
14 specialty care for chronic and disabling
15 conditions; requiring certain continued access
16 to terminated treating providers for
17 subscribers with a life-threatening or a
18 disabling and degenerative condition, and for
19 certain pregnant subscribers; providing
20 limitations; requiring report to the Agency for
21 Health Care Administration of access, quality
22 of care, and customer satisfaction data;
23 requiring adoption of certain recommendations
24 for preventive pediatric health care; amending
25 s. 641.511, F.S.; requiring an expedited
26 grievance procedure for reviewing the denial of
27 urgently needed health care services; providing
28 a time limit; amending s. 641.54, F.S.;
29 requiring disclosure to subscribers, upon
30 request, of certain policies, procedures, and
31 processes relating to authorization and
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1 referral for services, determination of medical
2 necessity, quality of care, prescription drug
3 benefits, confidentiality of medical records,
4 approval or denial of experimental or
5 investigational treatments, addressing the
6 needs of non-English-speaking subscribers, and
7 examining qualifications of and the
8 credentialing of providers; requiring report to
9 the agency of changes in authorization and
10 referral criteria or the process used to
11 determine medical necessity; providing an
12 effective date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Subsection (8) is added to section 641.315,
17 Florida Statutes, 1996 Supplement, to read:
18 641.315 Provider contracts.--
19 (8) A contract between a health maintenance
20 organization and a provider of health care services shall not
21 contain any provision restricting the provider's ability to
22 communicate information to the provider's patient regarding
23 medical care or treatment options for the patient when the
24 provider deems knowledge of such information by the patient to
25 be in the best interest of the health of the patient.
26 Section 2. Subsection (11) is added to section
27 641.495, Florida Statutes, 1996 Supplement, to read:
28 641.495 Requirements for issuance and maintenance of
29 certificate.--
30
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1 (11) The organization shall designate a medical
2 director who is a physician licensed under chapter 458 or
3 chapter 459.
4 Section 3. Subsections (5), (6), (7), (8), (9), and
5 (10) are added to section 641.51, Florida Statutes, to read:
6 641.51 Quality assurance program; second medical
7 opinion requirement.--
8 (5) Each organization shall provide the subscriber
9 with an out-of-network referral when the organization has not
10 contracted with or employed an appropriately trained and
11 experienced specialist to provide medically necessary health
12 care services appropriate to a subscriber's special medical
13 needs.
14 (6) Each organization shall develop and maintain
15 written policies and procedures for the provision of standing
16 referrals to subscribers with chronic and disabling conditions
17 which require ongoing specialty care.
18 (7) Each organization shall allow subscribers to
19 continue care for 60 days with a terminated treating provider
20 when medically necessary, provided the subscriber has a
21 life-threatening condition or a disabling and degenerative
22 condition. Each organization shall allow a subscriber who is
23 in the third trimester of pregnancy to continue care with a
24 terminated treating provider until completion of postpartum
25 care. This subsection shall not apply to treating providers
26 who have been terminated by the organization for cause.
27 (8) Each organization shall release to the agency data
28 which are indicators of access and quality of care. The
29 agency shall develop rules specifying data-reporting
30 requirements for these indicators. The agency shall develop a
31 uniform format for publication of the data to the public. The
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1 agency shall publish such data no less frequently than every 2
2 years.
3 (9) Each organization shall conduct a standardized
4 customer satisfaction survey, as developed by the agency in
5 consultation with the industry, of its membership, at
6 intervals specified by the agency. Survey data shall be
7 submitted to the agency which shall make comparative findings
8 available to the public.
9 (10) Each organization shall adopt recommendations for
10 preventive pediatric health care, as developed by the American
11 Academy of Pediatrics, and set goals to achieve 90-percent
12 compliance for the enrolled pediatric population.
13 Section 4. Subsection (6) is added to section 641.511,
14 Florida Statutes, to read:
15 641.511 Subscriber grievance reporting and resolution
16 requirements.--
17 (6) Each organization shall maintain an expedited
18 grievance procedure for reviewing denials of urgently needed
19 health care services. A procedure for establishing methods
20 for classifying grievances as urgent or emergency grievances
21 shall be developed which shall include time limits within
22 which such grievances must be resolved. However, in no
23 instance shall an emergency grievance procedure take longer
24 than 7 days for resolution.
25 Section 5. Subsections (3), (4), and (5) are added to
26 section 641.54, Florida Statutes, to read:
27 641.54 Hospital and physician Information
28 disclosure.--
29 (3) The organization shall make available to
30 subscribers, upon request, a detailed description of the
31 process used to determine authorization and referral criteria
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1 for health care services. Any change in the organization's
2 authorization and referral criteria shall be reported to the
3 agency immediately.
4 (4) The organization shall make available to
5 subscribers, upon request, a detailed description of the
6 process used to determine whether health care services are
7 "medically necessary." Any change in the organization's
8 definition of "medically necessary" or the process used to
9 determine medical necessity shall be reported to the agency
10 immediately.
11 (5) Each organization shall provide to subscribers,
12 upon request, the following:
13 (a) A description of the organization's quality
14 assurance program.
15 (b) Policies and procedures relating to the
16 organization's prescription drug benefits, including the
17 disclosure, upon request of a subscriber or potential
18 subscriber, of any included and excluded drugs and the use of
19 any formulary.
20 (c) Policies and procedures relating to the
21 confidentiality and disclosure of the subscriber's medical
22 records.
23 (d) The decisionmaking process used for approving or
24 denying experimental or investigational medical treatments.
25 (e) Policies and procedures for addressing the needs
26 of non-English-speaking subscribers.
27 (f) A detailed description of the process used to
28 examine qualifications of and the credentialing of all
29 providers under contract with or employed by the organization.
30 Section 6. This act shall take effect July 1, 1997.
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2 HOUSE SUMMARY
3
Prohibits health maintenance organization (HMO) provider
4 contracts from restricting a provider's ability to
communicate certain information to subscribers. Requires
5 HMO medical directors to be Florida-licensed physicians
or osteopaths. Requires out-of-network referrals to
6 specialists not available within the HMO's network.
Requires written procedures for standing referrals to
7 specialists for individuals with chronic and disabling
conditions. Requires certain continued access to
8 terminated treating providers for subscribers with a
life-threatening or a disabling and degenerative
9 condition, and certain pregnant subscribers. Requires
HMOs to report access, quality of care, and customer
10 satisfaction data to the Agency for Health Care
Administration. Requires adoption of recommendations of
11 th American Academy of Pediatrics for preventive
pediatric health care. Requires an expedited grievance
12 procedure for resolution within 7 days or less of
grievances involving the denial of urgently needed
13 services. Requires HMOs to disclose to subscribers, upon
request, certain policies, procedures, and processes
14 relating to authorization and referral for services,
determination of medical necessity, quality of care,
15 prescription drug benefits, confidentiality of medical
records, approval or denial of experimental or
16 investigational medical treatments, addressing the needs
of non-English-speaking subscribers, and examining
17 qualifications of and the credentialing of providers.
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