Senate Bill 0478

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    Florida Senate - 1998                                   SB 478

    By Senator Forman





    32-599-98

  1                      A bill to be entitled

  2         An act relating to health care; creating s.

  3         641.555, F.S.; creating the

  4         "Managed-Care-Subscriber's Bill of Rights and

  5         Responsibilities"; specifying the purpose of

  6         the act; requiring an organization that offers

  7         a managed-care plan to provide certain

  8         information about the plan to a prospective

  9         subscriber in the plan; requiring that a

10         health-care provider observe certain standards

11         in providing health care for subscribers in a

12         managed-care plan; providing for privacy;

13         providing for access to health care and medical

14         treatment; providing for grievance procedures;

15         providing for disenrollment; providing

16         limitations on experimental research; providing

17         responsibilities of a subscriber in a

18         managed-care plan; creating s. 641.5551, F.S.;

19         requiring that an organization's handbook

20         include the subscriber's rights and

21         responsibilities; requiring that the handbook

22         be written in plain language; providing an

23         effective date.

24

25  Be It Enacted by the Legislature of the State of Florida:

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27         Section 1.  Section 641.555, Florida Statutes, is

28  created to read:

29         641.555  Managed-Care-Subscriber's Bill of Rights and

30  Responsibilities.--

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    Florida Senate - 1998                                   SB 478
    32-599-98




  1         (1)  SHORT TITLE.--This section may be cited as the

  2  "Managed-Care-Subscriber's Bill of Rights and

  3  Responsibilities."

  4         (2)  PURPOSE.--The purpose of this section is to

  5  clarify for prospective and enrolled consumers and health care

  6  providers the minimum set of expectations considered

  7  appropriate with respect to the delivery and receipt of health

  8  care services through managed-care plans. The purpose of this

  9  section is to promote informed consumer decisionmaking and

10  active participation in obtaining health care.

11         (3)  RIGHTS OF PROSPECTIVE SUBSCRIBERS.--A prospective

12  subscriber in a managed-care plan has the right to receive the

13  following information about the plan before enrolling in the

14  plan:

15         (a)  An explanation of the gatekeeping process,

16  including how care is authorized as it pertains to access to

17  all services offered under the plan.

18         (b)  A description of the scope of the benefits and

19  services provided or excluded and how to obtain provided

20  benefits and services. The description must state procedures

21  for obtaining out-of-area coverage and any special benefit

22  requirements, such as copayments or rejection of a claim, that

23  may apply to services obtained outside the coverage of the

24  plan.

25         (c)  A description and an explanation of all fees that

26  may be charged to a subscriber, including costs for

27  out-of-plan care.

28         (d)  A description and an explanation of the policy and

29  procedures for receiving after-hour care and emergency

30  services and care.

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    Florida Senate - 1998                                   SB 478
    32-599-98




  1         (e)  A complete list of the plan's health care

  2  providers and the location of each provider.

  3         (f)  Upon request, a list of all pharmaceuticals

  4  covered by the plan and applicable copayments.

  5         (g)  Performance information with respect to the

  6  managed-care plan, including the average waiting time for

  7  appointments with primary-care providers and specialists, the

  8  results of accreditation organizations or other reports, and

  9  the results of consumer-satisfaction surveys.

10         (h)  Performance information that represents the number

11  and types of grievances filed, including corresponding

12  information with respect to subscribers' satisfaction with the

13  resolution of grievances.

14         (i)  A description and explanation of limitations on

15  services or benefits which apply to a person who has a

16  disability or other long-term prognosis that requires

17  sustained care.

18         (4)  RIGHTS OF SUBSCRIBERS.--The organization that

19  offers a managed-care plan shall recognize that each

20  subscriber is an individual who has unique health care needs,

21  and, because of the importance of respecting each subscriber's

22  personal dignity, shall provide considerate, courteous, and

23  respectful care focused on the subscriber's needs. Each

24  provider shall observe the following standards:

25         (a)  Individual dignity and privacy.--

26         1.  The individual dignity of a subscriber must be

27  respected at all times.

28         2.  A subscriber has a right to privacy, which must be

29  respected to the extent consistent with providing necessary

30  health care and without regard to the subscriber's economic

31  status or source of payment for care.

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    Florida Senate - 1998                                   SB 478
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  1         3.  A disclosure about a subscriber and a disclosure

  2  from a subscriber's records may be made only with written

  3  authorization from the subscriber, except as otherwise

  4  required by law.

  5         (b)  Access to health care.--

  6         1.  A subscriber has a right to health care regardless

  7  of race, national origin, religion, physical limitation, or

  8  source of payment.

  9         2.  A subscriber must be treated for an emergency

10  medical condition.

11         3.  A subscriber must be allowed to select a

12  primary-care provider and specialists from among those offered

13  under the managed-care plan.

14         4.  A subscriber must be allowed to change his

15  primary-care provider or specialty-care provider if the

16  provider is replaced by another plan provider.

17         5.  A subscriber must be notified of a termination of,

18  or change in, benefits, services, providers, and

19  service-delivery sites.

20         (c)  Medical treatment.--

21         1.  A subscriber has the right to high-quality,

22  medically necessary, timely, and appropriate health care to

23  the extent that such care is a benefit or service of the

24  managed-care plan and is consistent with the subscriber's

25  diagnosis and recommended course of treatment.

26         2.  A subscriber must be given the opportunity to

27  participate in decisions involving health care, except when

28  such participation is medically inadvisable or impossible, in

29  which case the opportunity for participation must be given to

30  the subscriber's guardian or a person designated as the

31  subscriber's representative.

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    Florida Senate - 1998                                   SB 478
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  1         3.  A subscriber has the right to receive complete

  2  information, to the degree known, regarding diagnosis, the

  3  planned course of treatment, alternatives, risks, and

  4  prognosis, unless it is medically inadvisable or impossible to

  5  give such information to the subscriber, in which case the

  6  information must be given to the subscriber's guardian or a

  7  person designated as the subscriber's representative.

  8         4.  A subscriber has the right to prompt and thorough

  9  responses to all questions regarding the diagnosis or

10  treatment.

11         5.  A subscriber has a right to a second medical

12  opinion with regard to surgical procedures or when there is a

13  serious injury or illness.

14         6.  A subscriber must be informed of the possible

15  consequences of not complying with recommended treatment

16  regimens.

17         7.  A subscriber must be informed of all health care

18  needs that require follow-up care, and how and where to obtain

19  such care, especially as it relates to care following the

20  receipt of emergency services and care.

21         8.  A subscriber has the right to refuse any treatment,

22  except as otherwise required by law.

23         (d)  Grievance procedures.--

24         1.  A subscriber has the right to express a grievance

25  to the organization or to the appropriate state regulatory

26  agency without fear of retaliation by the organization or its

27  providers.

28         2.  A subscriber must be given a description of the

29  procedure for expressing a grievance, including timeframes for

30  obtaining a response.

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    Florida Senate - 1998                                   SB 478
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  1         3.  A subscriber has the right to appear before a panel

  2  in at least one of the levels of review.

  3         4.  A subscriber has the right to receive a written

  4  response to a grievance which states the organization's

  5  decision and identifies additional recourses available when

  6  the subscriber is unsatisfied with the outcome.

  7         (e)  Disenrollment.--A subscriber who requests to be

  8  disenrolled from a managed-care plan must be promptly

  9  disenrolled by the organization in accord with any relevant

10  state or federal requirements.

11         (f)  Experimental research.--

12         1.  Except as provided under s. 766.103, a subscriber

13  has the right to know whether medical treatment is for the

14  purpose of experimental research and to give consent to

15  participate in the research before the treatment commences.

16         2.  A subscriber has the right to have the experimental

17  nature of the treatment communicated to him, his guardian, or

18  his representative in language that is understandable to an

19  average person of normal intelligence, with the aim of

20  ensuring that the person receiving the information can

21  appreciate and understand any of the known risks associated

22  with the treatment.

23         (5)  SUBSCRIBER RESPONSIBILITIES.--

24         (a)  A subscriber, to the best of his knowledge, is

25  responsible for providing a physician with accurate and

26  complete information about present discomforts, past

27  illnesses, hospitalizations, medications, and other matters

28  relating to the subscriber's health.

29         (b)  A subscriber is responsible for reporting

30  unexpected changes in the subscriber's physical or mental

31  condition to a physician.

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    Florida Senate - 1998                                   SB 478
    32-599-98




  1         (c)  A subscriber is responsible for following the

  2  mutually agreed-upon treatment plan.

  3         (d)  A subscriber is responsible for keeping

  4  appointments and, when unable to do so for any reason, for

  5  notifying the provider with whom the appointment is scheduled.

  6         (e)  A subscriber is responsible for assuring that any

  7  financial obligations are fulfilled as promptly as possible.

  8         Section 2.  Section 641.5551, Florida Statutes, is

  9  created to read:

10         641.5551  Plain language requirement.--Each

11  organization subject to this chapter shall include in its

12  benefit handbook the rights and responsibilities contained in

13  s. 641.555. The rights and responsibilities, as provided in a

14  benefit handbook, must be written in plain language so that a

15  subscriber or prospective subscriber with a reading

16  comprehension level at the 9th grade level can understand what

17  to expect from a plan and what the plan may reasonably expect

18  from its subscribers. Benefit handbooks must be provided to

19  subscribers. A benefit handbook, or a publication that

20  contains the information required by s. 641.555, must be made

21  available to prospective subscribers.

22         Section 3.  This act shall take effect July 1, 1998.

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    Florida Senate - 1998                                   SB 478
    32-599-98




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  2                          SENATE SUMMARY

  3    Creates the Managed-Care Subscriber's Bill of Rights and
      Responsibilities. Provides that a prospective subscriber
  4    in a managed-care plan has the right to receive specified
      information about the plan before enrolling in the plan.
  5    Requires an organization that offers a managed-care plan
      to observe certain standards with respect to the dignity
  6    and privacy of a subscriber, the quality of health care,
      grievance procedures, disenrollment procedures, and
  7    experimental research. Provides requirements with respect
      to a subscriber's responsibilities. Requires that the
  8    subscriber's rights and responsibilities be contained in
      the benefit handbook provided by the organization and
  9    written in plain language. (See bill for details.)

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