Senate Bill 1556c1
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Florida Senate - 1999 CS for SB 1556
By the Committee on Banking and Insurance; and Senators Scott,
Forman, Campbell, Myers, Hargrett, Latvala, Saunders, Geller,
Grant, Casas, King and Dawson-White
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1 A bill to be entitled
2 An act relating to health insurance; amending
3 s. 408.70, F.S.; providing legislative intent
4 for the organization of a nonprofit corporation
5 for providing affordable group health
6 insurance; amending s. 408.701, F.S.; revising
7 definitions; amending s. 408.702, F.S.;
8 creating the Health Alliance for Small
9 Business; deleting authorization for community
10 health purchasing alliances; creating a board
11 of governors for the alliance; specifying
12 organizational requirements; specifying that
13 the alliance is not a state agency;
14 redesignating community health purchasing
15 alliances as regional boards of the alliance;
16 revising provisions related to liability of
17 board members, number and boundary of alliance
18 districts, eligibility for alliance membership,
19 and powers of the state board and regional
20 boards of the alliance; authorizing the Office
21 of the Auditor General to audit and inspect the
22 alliance; prohibiting state agencies from
23 providing certain funds to the alliance without
24 specific legislative approval; amending s.
25 408.703, F.S.; providing eligibility
26 requirements for small employer members of the
27 alliance; amending s. 408.704, F.S.; providing
28 responsibilities for the Agency for Health Care
29 Administration; amending s. 408.7041, F.S.;
30 conforming provisions; amending s. 408.7045,
31 F.S.; revising marketing requirements of the
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1 alliance; amending s. 627.6699, F.S.; revising
2 restrictions related to premium rates for small
3 employer health benefit plans; repealing ss.
4 408.7042, 408.7055, 408.706, F.S., relating to
5 purchasing coverage for state employees and
6 Medicaid recipients through community health
7 purchasing alliances, relating to the
8 establishment of practitioner advisory groups
9 by the Agency for Health Care Administration,
10 and relating to requirements for accountable
11 health partnerships; providing an effective
12 date.
13
14 Be It Enacted by the Legislature of the State of Florida:
15
16 Section 1. Section 408.70, Florida Statutes, is
17 amended to read:
18 408.70 Health Alliance for Small Business Community
19 health purchasing; legislative findings and intent.--It is the
20 intent of the Legislature that a nonprofit corporation, to be
21 known as the "Health Alliance for Small Business," be
22 organized for the purpose of pooling groups of individuals
23 employed by small employers and the dependents of such
24 employees into larger groups in order to facilitate the
25 purchase of affordable group health insurance coverage.
26 (1) The Legislature finds that the current health care
27 system in this state does not provide access to affordable
28 health care for all persons in this state. Almost one in five
29 persons is without health insurance. For many, entry into the
30 health care system is through a hospital emergency room rather
31 than a primary care setting. The availability of preventive
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1 and primary care and managed, family-based care is limited.
2 Health insurance underwriting practices have led to the
3 avoidance, rather than to the sharing, of insurance risks,
4 limiting access to coverages for small-sized employer groups
5 and high-risk populations. Spiraling premium costs have
6 placed health insurance policies out of the reach of many
7 small-sized and medium-sized businesses and their employees.
8 Lack of outcome and cost information has forced individuals
9 and businesses to make critical health care decisions with
10 little guidance or leverage. Health care resources have not
11 been allocated efficiently, leading to excess and unevenly
12 distributed capacity. These factors have contributed to the
13 high cost of health care. Rural and other medically
14 underserved areas have too few health care resources.
15 Comprehensive, first-dollar coverages have allowed individuals
16 to seek care without regard to cost. Provider competition and
17 liability concerns have led to a medical technology arms race.
18 Rather than competing on the basis of price and patient
19 outcome, health care providers compete for patients on the
20 basis of service, equipping themselves with the latest and
21 best technologies. Managed-care and group-purchasing
22 mechanisms are not widely available to small group purchasers.
23 Health care regulation has placed undue burdens on health care
24 insurers and providers, driving up costs, limiting
25 competition, and preventing market-based solutions to cost and
26 quality problems. Health care costs have been increasing at
27 several times the rate of general inflation, eroding employer
28 profits and investments, increasing government revenue
29 requirements, reducing consumer coverages and purchasing
30 power, and limiting public investments in other vital
31 governmental services.
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1 (2) It is the intent of the Legislature that a
2 structured health care competition model, known as "managed
3 competition," be implemented throughout the state to improve
4 the efficiency of the health care markets in this state. The
5 managed competition model will promote the pooling of
6 purchaser and consumer buying power; ensure informed
7 cost-conscious consumer choice of managed care plans; reward
8 providers for high-quality, economical care; increase access
9 to care for uninsured persons; and control the rate of
10 inflation in health care costs.
11 (3) The Legislature intends that state-chartered,
12 nonprofit private purchasing organizations, to be known as
13 "community health purchasing alliances," be established. The
14 community health purchasing alliances shall be responsible for
15 assisting alliance members in securing the highest quality of
16 health care, based on current standards, at the lowest
17 possible prices.
18 Section 2. Section 408.701, Florida Statutes, 1998
19 Supplement, is amended to read:
20 408.701 Health Alliance for Small Business Community
21 health purchasing; definitions.--As used in ss.
22 408.70-408.7045 ss. 408.70-408.706, the term:
23 (1) "Accountable health partnership" means an
24 organization that integrates health care providers and
25 facilities and assumes risk, in order to provide health care
26 services, as certified by the agency under s. 408.704.
27 (1)(2) "Agency" means the Agency for Health Care
28 Administration.
29 (2)(3) "Alliance" means the Health Alliance for Small
30 Business a community health purchasing alliance.
31 (3)(4) "Alliance member" means:
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1 (a) a small employer as defined in s. 627.6699 who, or
2 (b) The state, for the purpose of providing health
3 benefits to state employees and their dependents through the
4 state group insurance program and to Medicaid recipients,
5 participants in the MedAccess program, and participants in the
6 Medicaid buy-in program,
7
8 if such entities voluntarily elects choose to join an
9 alliance.
10 (5) "Antitrust laws" means federal and state laws
11 intended to protect commerce from unlawful restraints,
12 monopolies, and unfair business practices.
13 (6) "Associate alliance member" means any purchaser
14 who joins an alliance for the purposes of participating on the
15 alliance board and receiving data from the alliance at no
16 charge as a benefit of membership.
17 (7) "Benefit standard" means a specified set of health
18 services that are the minimum that must be covered under a
19 basic health benefit plan, as defined in s. 627.6699.
20 (8) "Business health coalition" means a group of
21 employers organized to share information about health services
22 and insurance coverage, to enable the employers to obtain more
23 cost-effective care for their employees.
24 (9) "Community health purchasing alliance" means a
25 state-chartered, nonprofit organization that provides
26 member-purchasing services and detailed information to its
27 members on comparative prices, usage, outcomes, quality, and
28 enrollee satisfaction with accountable health partnerships.
29 (10) "Consumer" means an individual user of health
30 care services.
31 (11) "Department" means the Department of Insurance.
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1 (12) "Grievance procedure" means an established set of
2 rules that specify a process for appeal of an organizational
3 decision.
4 (4)(13) "Health care provider" or "provider" means a
5 state-licensed or state-authorized facility, a facility
6 principally supported by a local government or by funds from a
7 charitable organization that holds a current exemption from
8 federal income tax under s. 501(c)(3) of the Internal Revenue
9 Code, a licensed practitioner, a county health department
10 established under part I of chapter 154, a prescribed
11 pediatric extended care center defined in s. 400.902, a
12 federally supported primary care program such as a migrant
13 health center or a community health center authorized under s.
14 329 or s. 330 of the United States Public Health Services Act
15 that delivers health care services to individuals, or a
16 community facility that receives funds from the state under
17 the Community Alcohol, Drug Abuse, and Mental Health Services
18 Act and provides mental health services to individuals.
19 (5)(14) "Health insurer" or "insurer" means a health
20 insurer or health maintenance organization that is issued a
21 certificate of authority an organization licensed by the
22 Department of Insurance under part III of chapter 624 or part
23 I of chapter 641.
24 (6)(15) "Health plan" or "health insurance" means any
25 health insurance policy or health maintenance organization
26 contract issued by a health insurer hospital or medical policy
27 or contract or certificate, hospital or medical service plan
28 contract, or health maintenance organization contract as
29 defined in the insurance code or Health Maintenance
30 Organization Act. The term does not include accident-only,
31 specific disease, individual hospital indemnity, credit,
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1 dental-only, vision-only, Medicare supplement, long-term care,
2 or disability income insurance; coverage issued as a
3 supplement to liability insurance; workers' compensation or
4 similar insurance; or automobile medical-payment insurance.
5 (7) "Regional board" means the board of directors of
6 each region of the alliance, as established under s.
7 408.702(1).
8 (8) "State board" or "board" means the board of
9 directors of the alliance, as established under s. 408.702(2).
10 (16) "Health status" means an assessment of an
11 individual's mental and physical condition.
12 (17) "Managed care" means systems or techniques
13 generally used by third-party payors or their agents to affect
14 access to and control payment for health care services.
15 Managed-care techniques most often include one or more of the
16 following: prior, concurrent, and retrospective review of the
17 medical necessity and appropriateness of services or site of
18 services; contracts with selected health care providers;
19 financial incentives or disincentives related to the use of
20 specific providers, services, or service sites; controlled
21 access to and coordination of services by a case manager; and
22 payor efforts to identify treatment alternatives and modify
23 benefit restrictions for high-cost patient care.
24 (18) "Managed competition" means a process by which
25 purchasers form alliances to obtain information on, and
26 purchase from, competing accountable health partnerships.
27 (19) "Medical outcome" means a change in an
28 individual's health status after the provision of health
29 services.
30
31
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1 (20) "Provider network" means an affiliated group of
2 varied health care providers that is established to provide a
3 continuum of health care services to individuals.
4 (21) "Purchaser" means an individual, an organization,
5 or the state that makes health-benefit purchasing decisions on
6 behalf of a group of individuals.
7 (22) "Self-funded plan" means a group health insurance
8 plan in which the sponsoring organization assumes the
9 financial risk of paying for all covered services provided to
10 its enrollees.
11 (23) "Utilization management" means programs designed
12 to control the overutilization of health services by reviewing
13 their appropriateness relative to established standards or
14 norms.
15 (24) "24-hour coverage" means the consolidation of
16 such time-limited health care coverage as personal injury
17 protection under automobile insurance into a general health
18 insurance plan.
19 (25) "Agent" means a person who is licensed to sell
20 insurance in this state pursuant to chapter 626.
21 (26) "Primary care physician" means a physician
22 licensed under chapter 458 or chapter 459 who practices family
23 medicine, general internal medicine, general pediatrics, or
24 general obstetrics/ gynecology.
25 Section 3. Section 408.702, Florida Statutes, is
26 amended to read:
27 408.702 Health Alliance for Small Business Community
28 health purchasing alliance; establishment; state and regional
29 boards.--
30 (1) There is created the Health Alliance for Small
31 Business, which shall operate as a nonprofit corporation
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1 organized under chapter 617. The alliance is not a state
2 agency. The alliance shall operate subject to the supervision
3 and approval of a board of directors composed of the chairman
4 of each of the regional boards of the alliance or, in lieu of
5 the chairman, a member of a regional board designated by the
6 chairman of that board.
7 (2)(a) The board of directors of each community health
8 purchasing alliance is redesignated as a regional board of the
9 Health Alliance for Small Business. Each regional board shall
10 operate as a nonprofit corporation organized under chapter
11 617. A regional board is not a state agency.
12 (b) The regional board replacing such community health
13 purchasing alliance shall assume the rights and obligations of
14 each former community health purchasing alliance as necessary
15 to fulfill the former alliance's contractual obligations
16 existing on the effective date of this act. Nothing in this
17 section shall impair or otherwise affect any such contract.
18 (3)(1) There is created a community health purchasing
19 alliance in each of the 11 health service planning districts
20 established under s. 408.032. Each alliance must be operated
21 as a state-chartered, nonprofit private organization organized
22 pursuant to chapter 617. There shall be no liability on the
23 part of, and no cause of action of any nature shall arise
24 against, any member of the board of directors of the a
25 community health purchasing alliance or of any regional board,
26 or their its employees or agents, for any action taken by a
27 the board in the performance of its powers and duties under
28 ss. 408.70-408.7045 ss. 408.70-408.706.
29 (4)(2) The number and geographical boundaries of
30 alliance districts may be revised by the state board Three or
31 fewer alliances located in contiguous districts that are not
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1 primarily urban may merge into a single alliance upon approval
2 of the agency based on upon a showing by the alliance board
3 members that the members of the each alliance would be better
4 served under a combined alliance. If the number or boundaries
5 of regional alliances are revised, the members of the new
6 regional boards for the affected regions must be
7 representative of the members of the former regional boards of
8 the affected regions in a method established by the state
9 board which reasonably provides for proportionate
10 representation of former board members. Board members of each
11 alliance shall serve as the board of the combined alliance.
12 (5)(3) The An alliance is the only entity that is
13 allowed to operate as an alliance in a particular district and
14 must operate for the benefit of its members who are: small
15 employers, as defined in s. 627.6699; the state on behalf of
16 its employees and the dependents of such employees; Medicaid
17 recipients; and associate alliance members. The An alliance
18 is the exclusive entity for the oversight and coordination of
19 alliance member purchases. Any health plan offered through the
20 an alliance must be offered by a health insurer an accountable
21 health partnership and the an alliance may not directly
22 provide insurance; directly contract, for purposes of
23 providing insurance, with a health care provider or provider
24 network; or bear any risk, or form self-insurance plans among
25 its members. An alliance may form a network with other
26 alliances in order to improve services provided to alliance
27 members. Nothing in ss. 408.70-408.7045 ss. 408.70-408.706
28 limits or authorizes the formation of business health
29 coalitions; however, a person or entity that pools together or
30 assists in purchasing health coverage for small employers, as
31 defined in s. 627.6699, state employees and their dependents,
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1 and Medicaid, Medicaid buy-in, and MedAccess recipients may
2 not discriminate in its activities based on the health status
3 or historical or projected claims experience of such employers
4 or recipients.
5 (4) Each alliance shall capitalize on the expertise of
6 existing business health coalitions.
7 (6)(5) Membership or associate membership in the an
8 alliance and participation by health insurers are is
9 voluntary.
10 (7) The state board of the alliance may:
11 (a) Negotiate with health insurers to offer health
12 plans to alliance members in one or more regions under terms
13 and conditions as agreed to between the board, as group
14 policyholder, and the health insurer. The board and the
15 insurer may negotiate and agree to health plan selection,
16 benefit design, premium rates, and other terms of coverage,
17 subject to the requirements of the Florida Insurance Code.
18 (b) Establish minimum requirements of alliance
19 membership, consistent with the definition of the term "small
20 employer" in s. 627.6699, including any documentation that an
21 applicant must submit to establish eligibility for membership.
22 (c) Establish administrative and accounting procedures
23 for its operation and for the operation of the regional
24 boards, and require regional boards to submit program reports
25 to the state board or the agency.
26 (d) Receive and accept grants, loans, advances, or
27 funds from any public or private agency, and receive and
28 accept, from any source, contributions of money, property,
29 labor, or any other thing of value.
30 (e) Hire employees or contract with qualified,
31 independent third parties for any service necessary to carry
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1 out the board's powers and duties, as authorized under ss.
2 408.70-408.7045.
3 (f) Perform any of the activities that may be
4 performed by a regional board under subsection (6), subject to
5 coordination with the regional boards to avoid duplication of
6 effort.
7 (8) Each regional board of the alliance may:
8 (a) Establish conditions of alliance membership
9 consistent with the minimum requirements established by the
10 state board.
11 (b) Provide to alliance members standardized
12 information for comparing health plans offered through the
13 alliance.
14 (c) Offer health plans to alliance members, subject to
15 the terms and conditions agreed to by the state board and
16 participating health insurers.
17 (d) Market and publicize the coverage and services
18 offered by the alliance.
19 (e) Collect premiums from alliance members on behalf
20 of participating health insurers.
21 (f) Assist members in resolving disputes between
22 health insurers and alliance members, consistent with
23 grievance procedures required by law.
24 (g) Set reasonable fees for alliance membership,
25 services offered by the alliance, and late payment of premiums
26 by alliance members for which the alliance is responsible.
27 (h) Receive and accept grants, loans, advances, or
28 funds from any public or private agency, and receive and
29 accept, from any source, contributions of money, property,
30 labor, or any other thing of value.
31
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1 (i) Hire employees or contract with qualified,
2 independent third parties for any service necessary to carry
3 out the regional board's powers and duties as authorized under
4 ss. 408.70-408.7045.
5 (9) No state agency may expend or provide funds to the
6 Alliance that would subsidize the pricing of health insurance
7 policies for its members, unless the Legislature specifically
8 authorizes such expenditure.
9 (6) Each community health purchasing alliance has the
10 following powers, duties, and responsibilities:
11 (a) Establishing the conditions of alliance membership
12 in accordance with ss. 408.70-408.706.
13 (b) Providing to alliance members clear, standardized
14 information on each accountable health partnership and each
15 health plan offered by each accountable health partnership,
16 including information on price, enrollee costs, quality,
17 patient satisfaction, enrollment, and enrollee
18 responsibilities and obligations; and providing accountable
19 health partnership comparison sheets in accordance with agency
20 rule to be used in providing members and their employees with
21 information regarding standard, basic, and specialized
22 coverage that may be obtained through the accountable health
23 partnerships.
24 (c) Annually offering to all alliance members all
25 accountable health partnerships and health plans offered by
26 the accountable health partnerships which meet the
27 requirements of ss. 408.70-408.706, and which submit a
28 responsive proposal as to information necessary for
29 accountable health partnership comparison sheets, and
30 providing assistance to alliance members in selecting and
31
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1 obtaining coverage through accountable health partnerships
2 that meet those requirements.
3 (d) Requesting proposals for the standard and basic
4 health plans, as defined in s. 627.6699, from all accountable
5 health partnerships in the district; providing, in the format
6 required by the alliance in the request for proposals, the
7 necessary information for accountable health partnership
8 comparison sheets; and offering to its members health plans of
9 accountable health partnerships which meet those requirements.
10 (e) Requesting proposals from all accountable health
11 partnerships in the district for specialized benefits approved
12 by the alliance board based on input from alliance members,
13 determining if the proposals submitted by the accountable
14 health partnerships meet the requirements of the request for
15 proposals, and offering them as options through riders to
16 standard plans and basic plans. This paragraph does not limit
17 an accountable health partnership's ability to offer other
18 specialized benefits to alliance members.
19 (f) Distributing to health care purchasers, placing
20 special emphasis on the elderly, retail price data on
21 prescription drugs and their generic equivalents, durable
22 medical equipment, and disposable medical supplies which is
23 provided by the agency pursuant to s. 408.063(3) and (4).
24 (g) Establishing administrative and accounting
25 procedures for the operation of the alliance and members'
26 services, preparing an annual alliance budget, and preparing
27 annual program and fiscal reports on alliance operations as
28 required by the agency.
29 (h) Developing and implementing a marketing plan to
30 publicize the alliance to potential members and associate
31
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1 members and developing and implementing methods for informing
2 the public about the alliance and its services.
3 (i) Developing grievance procedures to be used in
4 resolving disputes between members and the alliance and
5 disputes between the accountable health partnerships and the
6 alliance. Any member of, or accountable health partnership
7 that serves, an alliance may appeal to the agency any
8 grievance that is not resolved by the alliance.
9 (j) Ensuring that accountable health partnerships have
10 grievance procedures to be used in resolving disputes between
11 members and an accountable health partnership. A member may
12 appeal to the alliance any grievance that is not resolved by
13 the accountable health partnership. An accountable health
14 partnership that is a health maintenance organization must
15 follow the grievance procedures established in ss. 408.7056
16 and 641.31(5).
17 (k) Maintaining all records, reports, and other
18 information required by the agency, ss. 408.70-408.706, or
19 other state and local laws.
20 (l) Receiving and accepting grants, loans, advances,
21 or funds from any public or private agency; and receiving and
22 accepting contributions, from any source, of money, property,
23 labor, or any other thing of value.
24 (m) Contracting, as authorized by alliance members,
25 with a qualified, independent third party for any service
26 necessary to carry out the powers and duties required by ss.
27 408.70-408.706.
28 (n) Developing a plan to facilitate participation of
29 providers in the district in an accountable health
30 partnership, placing special emphasis on ensuring
31 participation by minority physicians in accountable health
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1 partnerships if such physicians are available. The use of the
2 term "minority" in ss. 408.70-408.706 is consistent with the
3 definition of "minority person" provided in s. 288.703(3).
4 (o) Ensuring that any health plan reasonably available
5 within the jurisdiction of an alliance, through a preferred
6 provider network, a point of service product, an exclusive
7 provider organization, a health maintenance organization, or a
8 pure indemnity product, is offered to members of the alliance.
9 For the purposes of this paragraph, "pure indemnity product"
10 means a health insurance policy or contract that does not
11 provide different rates of reimbursement for a specified list
12 of physicians and a "point of service product" means a
13 preferred provider network or a health maintenance
14 organization which allows members to select at a higher cost a
15 provider outside of the network or the health maintenance
16 organization.
17 (p) Petitioning the agency for a determination as to
18 the cost-effectiveness of collecting premiums on behalf of
19 participating accountable health partnerships. If determined
20 by the agency to be cost-effective, the alliance may establish
21 procedures for collecting premiums from members and distribute
22 them to the participating accountable health partnerships.
23 This may include the remittance of the share of the group
24 premium paid by both an employer and an enrollee. If an
25 alliance assumes premium collection responsibility, it shall
26 also assume liability for uncollected premium. This liability
27 may be collected through a bad debt surcharge on alliance
28 members to finance the cost of uncollected premiums. The
29 alliance shall pay participating accountable health
30 partnerships their contracting premium amounts on a prepaid
31 monthly basis, or as otherwise mutually agreed upon.
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1 (7) Each alliance shall set reasonable fees for
2 membership in the alliance which will finance all reasonable
3 and necessary costs incurred in administering the alliance.
4 (9)(8) Each regional board alliance shall annually
5 report to the state board on the operations of the alliance in
6 that region, including program and financial operations, and
7 shall provide for annual internal and independent audits.
8 (10)(9) The alliance, the state board, and regional
9 boards A community health purchasing alliance may not engage
10 in any activities for which an insurance agent's license is
11 required by chapter 626.
12 (11)(10) The powers and responsibilities of the a
13 community health purchasing alliance with respect to
14 purchasing health plans services from health insurers
15 accountable health partnerships do not extend beyond those
16 enumerated in ss. 408.70-408.7045 ss. 408.70-408.706.
17 (12) The Office of the Auditor General may audit and
18 inspect the operations and records of the alliance.
19 Section 4. Section 408.703, Florida Statutes, is
20 amended to read:
21 408.703 Small employer members of the alliance
22 community health purchasing alliances; eligibility
23 requirements.--
24 (1) The board agency shall establish conditions of
25 participation in the alliance for small employers, as defined
26 in s. 627.6699, which must include, but need not be limited
27 to:
28 (a) Assurance that the group is a valid small employer
29 and is not formed for the purpose of securing health benefit
30 coverage. This assurance must include requirements for sole
31 proprietors and self-employed individuals which must be based
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1 on a specified requirement for the time that the sole
2 proprietor or self-employed individual has been in business,
3 required filings to verify employment status, and other
4 requirements to ensure that the individual is working.
5 (b) Assurance that the individuals in the small
6 employer group are employees and have not been added for the
7 purpose of securing health benefit coverage.
8 (2) The agency may not require a small employer to pay
9 any portion of premiums as a condition of participation in an
10 alliance.
11 (2)(3) The board agency may require a small employer
12 seeking membership to agree to participate in the alliance for
13 a specified minimum period of time, not to exceed 1 year.
14 (4) If a member small employer offers more than one
15 accountable health partnership or health plan and the employer
16 contributes to coverage of employees or dependents of the
17 employee, the alliance shall require that the employer
18 contribute the same dollar amount for each employee,
19 regardless of the accountable health partnership or benefit
20 plan chosen by the employee.
21 (5) An employer that employs 30 or fewer employees
22 must offer at least 2 accountable health partnerships or
23 health plans to its employees, and an employer that employs 31
24 or more employees must offer 3 or more accountable health
25 partnerships or health plans to its employees.
26 (3)(6) Notwithstanding any other law, if a small
27 employer member loses eligibility to purchase health care
28 through the a community health purchasing alliance solely
29 because the business of the small employer member expands to
30 more than 50 and less than 75 eligible employees, the small
31 employer member may, at its next renewal date, purchase
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1 coverage through the alliance for not more than 1 additional
2 year.
3 Section 5. Section 408.704, Florida Statutes, 1998
4 Supplement, is amended to read:
5 408.704 Agency duties and responsibilities related to
6 the alliance community health purchasing alliances.--
7 (1) The agency shall assist the alliance in purchasing
8 health insurance for its members and supervise its operation.
9 in developing a statewide system of community health
10 purchasing alliances. To this end, the agency is responsible
11 for:
12 (1) Initially and thereafter annually certifying that
13 each community health purchasing alliance complies with ss.
14 408.70-408.706 and rules adopted pursuant to ss.
15 408.70-408.706. The agency may decertify any community health
16 purchasing alliance if the alliance fails to comply with ss.
17 408.70-408.706 and rules adopted by the agency.
18 (2) The agency shall conduct Providing administrative
19 startup funds. Each contract for startup funds is limited to
20 $275,000.
21 (3) Conducting an annual review of the performance of
22 the each alliance to ensure that the alliance is in compliance
23 with ss. 408.70-408.7045 ss. 408.70-408.706. To assist the
24 agency in its review, the each alliance shall submit,
25 quarterly, data to the agency, including, but not limited to,
26 employer enrollment by employer size, industry sector,
27 previous insurance status, and count; number of total eligible
28 employers in the alliance district participating in the
29 alliance; number of insured lives by county and insured
30 category, including employees, dependents, and other insured
31 categories, represented by alliance members; profiles of
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1 potential employer membership by county; premium ranges for
2 each health insurer accountable health partnership for
3 alliance member categories; type and resolution of member
4 grievances; membership fees; and alliance financial
5 statements. A summary of this annual review shall be provided
6 to the Legislature and to each alliance.
7 (3) The agency shall assist the alliance in
8 developing, collecting, and analyzing market information that
9 would support the purchasing decisions of the alliance.
10 (4) Developing accountable health partnership
11 comparison sheets to be used in providing members and their
12 employees with information regarding the accountable health
13 partnership.
14 (5) Establishing a data system for accountable health
15 partnerships.
16 (a) The agency shall establish an advisory data
17 committee comprised of the following representatives of
18 employers, medical providers, hospitals, health maintenance
19 organizations, and insurers:
20 1. Two representatives appointed by each of the
21 following organizations: Associated Industries of Florida,
22 the Florida Chamber of Commerce, the National Federation of
23 Independent Businesses, and the Florida Retail Federation;
24 2. One representative of each of the following
25 organizations: the Florida League of Hospitals, the
26 Association of Voluntary Hospitals of Florida, the Florida
27 Hospital Association, the Florida Medical Association, the
28 Florida Osteopathic Medical Association, the Florida
29 Chiropractic Association, the Florida Chapter of the National
30 Medical Association, the Association of Managed Care
31 Physicians, the Florida Insurance Council, the Florida
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1 Association of Domestic Insurers, the Florida Association of
2 Health Maintenance Organizations; and
3 3. One representative of governmental health care
4 purchasers and three consumer representatives, to be appointed
5 by the agency.
6 (b) The advisory data committee shall issue a report
7 and recommendations on each of the following subjects as each
8 is completed. A final report covering all subjects must be
9 included in the final Florida Health Plan to be submitted to
10 the Legislature on December 31, 1993. The report shall
11 include recommendations regarding:
12 1. Types of data to be collected. Careful
13 consideration shall be given to other data collection projects
14 and standards for electronic data interchanges already in
15 process in this state and nationally, to evaluating and
16 recommending the feasibility and cost-effectiveness of various
17 data collection activities, and to ensuring that data
18 reporting is necessary to support the evaluation of providers
19 with respect to cost containment, access, quality, control of
20 expensive technologies, and customer satisfaction analysis.
21 Data elements to be collected from providers include prices,
22 utilization, patient outcomes, quality, and patient
23 satisfaction. The completion of this task is the first
24 priority of the advisory data committee. The agency shall
25 begin implementing these data collection activities
26 immediately upon receipt of the recommendations, but no later
27 than January 1, 1994. The data shall be submitted by
28 hospitals, other licensed health care facilities, pharmacists,
29 and group practices as defined in s. 455.654(3)(f).
30 2. A standard data set, a standard cost-effective
31 format for collecting the data, and a standard methodology for
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1 reporting the data to the agency, or its designee, and to the
2 alliances. The reporting mechanisms must be designed to
3 minimize the administrative burden and cost to health care
4 providers and carriers. A methodology shall be developed for
5 aggregating data in a standardized format for making
6 comparisons between accountable health partnerships which
7 takes advantage of national models and activities.
8 3. Methods by which the agency should collect,
9 process, analyze, and distribute the data.
10 4. Standards for data interpretation. The advisory
11 data committee shall actively solicit broad input from the
12 provider community, carriers, the business community, and the
13 general public.
14 5. Structuring the data collection process to:
15 a. Incorporate safeguards to ensure that the health
16 care services utilization data collected is reviewed by
17 experienced, practicing physicians licensed to practice
18 medicine in this state;
19 b. Require that carrier customer satisfaction data
20 conclusions are validated by the agency;
21 c. Protect the confidentiality of medical information
22 to protect the patient's identity and to protect the privacy
23 of individual physicians and patients. Proprietary data
24 submitted by insurers, providers, and purchasers are
25 confidential pursuant to s. 408.061; and
26 d. Afford all interested professional medical and
27 hospital associations and carriers a minimum of 60 days to
28 review and comment before data is released to the public.
29 6. Developing a data collection implementation
30 schedule, based on the data collection capabilities of
31 carriers and providers.
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1 (c) In developing data recommendations, the advisory
2 data committee shall assess the cost-effectiveness of
3 collecting data from individual physician providers. The
4 initial emphasis must be placed on collecting data from those
5 providers with whom the highest percentages of the health care
6 dollars are spent: hospitals, large physician group practices,
7 outpatient facilities, and pharmacies.
8 (d) The agency shall, to the maximum extent possible,
9 adopt and implement the recommendations of the advisory data
10 committee. The agency shall report all recommendations of the
11 advisory data committee to the Legislature and submit an
12 implementation plan.
13 (e) The travel expenses of the participants of the
14 advisory data committee must be paid by the participant or by
15 the organization that nominated the participant.
16 (6) Collecting, compiling, and analyzing data on
17 accountable health partnerships and providing statistical
18 information to alliances.
19 (7) Receiving appeals by members of an alliance and
20 accountable health partnerships whose grievances were not
21 resolved by the alliance. The agency shall review these
22 appeals pursuant to chapter 120. Records or reports submitted
23 as a part of a grievance proceeding conducted as provided for
24 under this subsection are confidential and exempt from the
25 provisions of s. 119.07(1) and s. 24(a), Art. I of the State
26 Constitution. Records or reports of patient care quality
27 assurance proceedings obtained or made by any member of a
28 community health purchasing alliance or any member of an
29 accountable health partnership and received by the agency as a
30 part of a proceeding conducted pursuant to this subsection are
31 confidential and exempt from s. 119.07(1) and s. 24(a), Art. I
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1 of the State Constitution. Portions of meetings held pursuant
2 to the provisions of this subsection during which records held
3 confidential pursuant to the provisions of this subsection are
4 discussed are exempt from the provisions of s. 286.011 and s.
5 24(b), Art. I of the State Constitution. All portions of any
6 meeting closed to the public shall be recorded by a certified
7 court reporter. For any portion of a meeting that is closed,
8 the reporter shall record the times of commencement and
9 termination of the meeting, all discussion and proceedings,
10 the names of all persons present at any time, and the names of
11 all persons speaking. No portion of the closed meeting shall
12 be off the record. The court reporter's notes shall be fully
13 transcribed and given to the appropriate records custodian
14 within a reasonable time after the meeting. A copy of the
15 original transcript, with information otherwise confidential
16 or exempt from public disclosure redacted, shall be made
17 available for public inspection and copying 3 years after the
18 date of the closed meeting.
19 Section 6. Section 408.7041, Florida Statutes, is
20 amended to read:
21 408.7041 Antitrust protection.--In addition to the
22 duties described in s. 408.704, the agency shall actively
23 supervise the alliance community health purchasing alliances
24 to ensure that actions that affect market competition are not
25 for private interests, but accomplish the legislative intent
26 found in s. 408.70, so as to provide state and federal
27 antitrust protection of the alliance and state and regional
28 alliances and their board members.
29 Section 7. Section 408.7045, Florida Statutes, is
30 amended to read:
31
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1 408.7045 Community health purchasing Alliance
2 marketing requirements.--
3 (1) The Each alliance shall use appropriate,
4 efficient, and standardized means to notify members of the
5 availability of sponsored health coverage from the alliance.
6 (2) The Each alliance shall make available to members
7 marketing materials that accurately summarize the benefit
8 plans that are offered by its health insurer accountable
9 health partnerships and the rates, costs, and accreditation
10 information relating to those plans.
11 (3) Annually, the alliance shall offer each member
12 small employer all accountable health partnerships available
13 in the alliance and provide them with the appropriate
14 materials relating to those plans. The member small employer
15 may choose which health benefit plans shall be offered to
16 eligible employees and may change the selection each year.
17 The employee may be given options with regard to health plans
18 and the type of managed care system under which his or her
19 benefits will be provided.
20 (4) An alliance may notify the agency of any marketing
21 practices or materials that it finds are contrary to the fair
22 and affirmative marketing requirements of the program. Upon
23 the request of an alliance, the agency shall request the
24 Department of Insurance to investigate the practices and the
25 Department of Insurance may take any action authorized for a
26 violation of the insurance code or the Health Maintenance
27 Organization Act.
28 Section 8. Paragraph (b) of subsection (6) of section
29 627.6699, Florida Statutes, 1998 Supplement, is amended to
30 read:
31 627.6699 Employee Health Care Access Act.--
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1 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
2 (b) For all small employer health benefit plans that
3 are subject to this section and are issued by small employer
4 carriers on or after January 1, 1994, premium rates for health
5 benefit plans subject to this section are subject to the
6 following:
7 1. Small employer carriers must use a modified
8 community rating methodology in which the premium for each
9 small employer must be determined solely on the basis of the
10 eligible employee's and eligible dependent's gender, age,
11 family composition, tobacco use, or geographic area as
12 determined under paragraph (5)(j) (5)(k).
13 2. Rating factors related to age, gender, family
14 composition, tobacco use, or geographic location may be
15 developed by each carrier to reflect the carrier's experience.
16 The factors used by carriers are subject to department review
17 and approval.
18 3. Small employer carriers may not modify the rate for
19 a small employer for 12 months from the initial issue date or
20 renewal date, unless the composition of the group changes or
21 benefits are changed. However, a small employer carrier may
22 modify the rate one time prior to 12 months after the initial
23 issue date for a small employer who enrolls under a previously
24 issued group policy that has a common anniversary date for all
25 employers covered under the policy, if the carrier discloses
26 to the employer in a clear and conspicuous manner the date of
27 the first renewal and the fact that the premium may increase
28 on or after that date and if the insurer demonstrates to the
29 department that efficiencies in administration are achieved
30 and reflected in the rates charged to small employers covered
31 under the policy.
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1 4. A small employer carrier may issue a policy to a
2 group association with rates that reflect a premium credit for
3 expense savings attributable to administrative activities
4 being performed by the group association, if these expense
5 savings are specifically documented in the carrier's rate
6 filing and are approved by the department. Any such credit may
7 not be based on different morbidity assumptions or on any
8 other factor related to the health status or claims experience
9 of the group or its members. Carriers participating in the
10 alliance program, in accordance with ss. 408.700-408.707, may
11 apply a different community rate to business written in that
12 program.
13 (c) For all small employer health benefit plans that
14 are subject to this section, that are issued by small employer
15 carriers before January 1, 1994, and that are renewed on or
16 after January 1, 1995, renewal rates must be based on the same
17 modified community rating standard applied to new business.
18 (d) Notwithstanding s. 627.401(2), this section and
19 ss. 627.410 and 627.411 apply to any health benefit plan
20 provided by a small employer carrier that provides coverage to
21 one or more employees of a small employer regardless of where
22 the policy, certificate, or contract is issued or delivered,
23 if the health benefit plan covers employees or their covered
24 dependents who are residents of this state.
25 Section 9. Sections 408.7042, 408.7055, and 408.706,
26 Florida Statutes, are repealed.
27 Section 10. This act shall take effect upon becoming a
28 law.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 Senate Bill 1556
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subsidize the pricing of health insurance coverage to members
5 of the Alliance, without specific legislative authorization.
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