Senate Bill 1892
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Florida Senate - 1999 SB 1892
By Senator Saunders
25-1157A-99
1 A bill to be entitled
2 An act relating to health care; amending s.
3 408.7056, F.S.; revising standards and
4 procedures for hearing grievances under the
5 statewide provider and subscriber assistance
6 program; revising panel membership; providing
7 for the issuance and judicial review of final
8 orders; amending s. 641.51, F.S.; revising
9 requirements for indicators of access and
10 quality of care which health maintenance
11 organizations and prepaid health clinics must
12 submit to the Agency for Health Care
13 Administration; deleting a requirement that
14 each such organization conduct a customer
15 satisfaction survey; revising guidelines
16 relating to recommendations for preventive
17 pediatric health care which must be submitted
18 to the agency; amending s. 641.58, F.S.;
19 revising guidelines for expending moneys from
20 the Health Care Trust Fund; creating the Health
21 Care Information Council within the Agency for
22 Health Care Administration; providing for
23 council membership, terms of office, and
24 election of officers; providing for
25 reimbursement for travel and per diem expenses;
26 providing for an executive director, staff, and
27 consultants; providing duties of the council;
28 providing an effective date.
29
30 Be It Enacted by the Legislature of the State of Florida:
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1 Section 1. Subsections (2), (9), (11), and (14) of
2 section 408.7056, Florida Statutes, 1998 Supplement, are
3 amended to read:
4 408.7056 Statewide Provider and Subscriber Assistance
5 Program.--
6 (2) The agency shall adopt and implement a program to
7 provide assistance to subscribers and providers, including
8 those whose grievances are not resolved by the managed care
9 entity to the satisfaction of the subscriber or provider. The
10 program shall consist of one or more panels that meet as often
11 as necessary to timely review, consider, and hear grievances
12 and recommend to the agency or the department any actions that
13 should be taken concerning individual cases heard by the
14 panel. The panel shall hear every grievance filed by
15 subscribers and providers on behalf of subscribers, unless the
16 grievance:
17 (a) Relates to a managed care entity's refusal to
18 accept a provider into its network of providers;
19 (b) Is part of an internal grievance in a Medicare
20 managed care entity or a reconsideration appeal through the
21 Medicare appeals process which does not involve a quality of
22 care issue;
23 (c) Is related to a health plan not regulated by the
24 state such as an administrative services organization,
25 third-party administrator, or federal employee health benefit
26 program;
27 (d) Is related to appeals by in-plan suppliers and
28 providers, unless related to quality of care provided by the
29 plan;
30 (e) Is part of a Medicaid fair hearing pursued under
31 42 C.F.R. ss. 431.220 et seq.;
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Florida Senate - 1999 SB 1892
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1 (f) Is the basis for an action pending in state or
2 federal court;
3 (g) Is related to an appeal by nonparticipating
4 providers, unless related to the quality of care provided to a
5 subscriber by the managed care entity and the provider is
6 involved in the care provided to the subscriber;
7 (h) Was filed before the subscriber or provider
8 completed the entire internal grievance procedure of the
9 managed care entity, the managed care entity has complied with
10 its timeframes for completing the internal grievance
11 procedure, and the circumstances described in subsection (6)
12 do not apply;
13 (i) Has been resolved to the satisfaction of the
14 subscriber or provider who filed the grievance, unless the
15 managed care entity's initial action is egregious or may be
16 indicative of a pattern of inappropriate behavior;
17 (j) Is limited to seeking damages for pain and
18 suffering, lost wages, or other incidental expenses, including
19 accrued interest on unpaid balances, court costs, and
20 transportation costs associated with grievance procedures;
21 (k) Is limited to issues involving conduct of a health
22 care provider or facility, staff member, or employee of a
23 managed care entity which constitute grounds for disciplinary
24 action by the appropriate professional licensing board and is
25 not indicative of a pattern of inappropriate behavior, and the
26 agency or department has reported these grievances to the
27 appropriate professional licensing board or to the health
28 facility regulation section of the agency for possible
29 investigation; or
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1 (l) Is withdrawn by the subscriber or provider.
2 Failure of the subscriber or the provider to attend the
3 hearing shall be considered a withdrawal of the grievance.
4 (9) No later than 30 days after the issuance of the
5 panel's recommendation and, for an expedited grievance, no
6 later than 10 days after the issuance of the panel's
7 recommendation, the agency or the department may adopt the
8 panel's recommendation or findings of fact in a final proposed
9 order or an emergency order, as provided in chapter 120, which
10 it shall issue to the managed care entity. The agency or
11 department may issue a proposed order or an emergency order,
12 as provided in chapter 120, imposing fines or sanctions,
13 including those contained in ss. 641.25 and 641.52. The
14 agency or the department may reject all or part of the panel's
15 recommendation. All fines collected under this subsection must
16 be deposited into the Health Care Trust Fund.
17 (11) The panel shall consist of members employed by
18 the agency and members employed by the department, chosen by
19 their respective agencies, a consumer, a physician as a
20 standing member, and rotating physicians who provide specific
21 expertise as appropriate to the case being heard. The agency
22 may contract with a medical director and a primary care
23 physician who shall provide additional technical expertise to
24 the panel. The medical director shall be selected from a
25 health maintenance organization with a current certificate of
26 authority to operate in Florida.
27 (14) A final proposed order issued by the agency or
28 department which only requires the managed care entity to take
29 a specific action under subsection (7) is subject to judicial
30 review under s. 120.68 a summary hearing in accordance with s.
31 120.574, unless all of the parties agree otherwise. If the
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1 managed care entity does not prevail at judicial review the
2 hearing, the managed care entity must pay reasonable costs and
3 attorney's fees of the agency or the department incurred in
4 that proceeding.
5 Section 2. Subsections (8), (9), and (10) of section
6 641.51, Florida Statutes, are amended to read:
7 641.51 Quality assurance program; second medical
8 opinion requirement.--
9 (8) Each organization shall release to the agency data
10 that which are indicators of access and quality of care. The
11 agency shall develop rules specifying data-reporting
12 requirements for these indicators. The indicators shall
13 include the following characteristics:
14 (a) They must relate to access and quality of care
15 measures.
16 (b) They must be consistent with data collected
17 pursuant to accreditation activities and standards.
18 (c) They must be consistent with frequency
19 requirements under the accreditation process.
20 (d) They must include chronic disease management
21 measures.
22 (e) They must relate to preventive health care for
23 adults and children.
24 (f) They must include prenatal care measures.
25 (g) They must include child health checkup measures.
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27 The agency shall develop by rule a uniform format for
28 publication of the data for the public which shall contain
29 explanations of the data collected and the relevance of such
30 data. The agency shall publish such data no less frequently
31 than every 2 years.
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1 (9) Each organization shall conduct a standardized
2 customer satisfaction survey, as developed by the agency by
3 rule, of its membership at intervals specified by the agency.
4 The survey shall be consistent with surveys required by
5 accrediting organizations and may contain up to 10 additional
6 questions based on concerns specific to Florida. Survey data
7 shall be submitted to the agency, which shall make comparative
8 findings available to the public.
9 (9)(10) Each organization shall adopt recommendations
10 for preventive pediatric health care consistent with child
11 health checkup early periodic screening, diagnosis, and
12 treatment requirements developed for the Medicaid program.
13 Each organization shall establish goals to achieve 80-percent
14 compliance by July 1, 1998, and 90-percent compliance by July
15 1, 1999, for their enrolled pediatric population.
16 Section 3. Subsection (4) of section 641.58, Florida
17 Statutes, is amended, and subsections (8), (9), (10), and (11)
18 are added to that section, to read:
19 641.58 Regulatory assessment; levy and amount; use of
20 funds; tax returns; penalty for failure to pay.--
21 (4) The moneys so received and deposited into the
22 Health Care Trust Fund shall be used to defray the expenses of
23 the agency in the discharge of its administrative and
24 regulatory powers and duties under this part, including the
25 administration of the Health Care Information Council,
26 conducting an annual health maintenance organization member
27 satisfaction survey, contracting with physician consultants
28 for the statewide provider and subscriber assistance panel,
29 the maintaining of offices and necessary supplies, essential
30 equipment and other materials, salaries and expenses of
31 required personnel, and all other legitimate expenses relating
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1 to the discharge of the administrative and regulatory powers
2 and duties imposed under such part.
3 (8) There is created a Health Care Information Council
4 within the Agency for Health Care Administration. The council
5 is located within the agency for administrative purposes but
6 shall independently exercise the powers and duties assigned to
7 it under this section.
8 (a) The council shall consist of 11 members, including
9 the director of the Agency for Health Care Administration or
10 the director's designee, the Insurance Commissioner or the
11 commissioner's designee, 3 members appointed by the Governor,
12 3 members appointed by the President of the Senate, and 3
13 members appointed by the Speaker of the House of
14 Representatives. The appointments must be made so as to
15 achieve a balance among managed care organizations, providers,
16 and consumers.
17 (b) Council members shall be appointed for staggered
18 terms of no more than 2 years. Any member who is appointed to
19 fill a vacancy occurring because of a member's death,
20 resignation, or ineligibility for membership shall serve only
21 for the remainder of the term of his or her predecessor or
22 until a successor is appointed and qualifies. Any member who,
23 without cause, fails to attend two consecutive meetings may be
24 removed by the Governor.
25 (c) The council shall annually elect its chairperson
26 and vice chairperson. The council shall meet at least
27 quarterly, at the call of its chairperson or at the request of
28 a majority of its membership. A majority of the members of the
29 council constitutes a quorum.
30 (d) Membership on the council does not disqualify a
31 member from holding any other public office or being employed
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1 by a public entity except that a member of the Legislature may
2 not serve on the council.
3 (e) Members of the council shall serve without
4 compensation but are entitled to reimbursement for per diem
5 and travel expenses as provided by s. 112.061.
6 (9) The council shall employ an executive director and
7 such staff as is necessary, within the limits of legislative
8 appropriations. The council may retain such consultants as it
9 considers necessary for accomplishing its mission. Neither the
10 executive director nor any consultant retained by the council
11 may have been a contract vendor of the Department of Insurance
12 or of the Agency for Health Care Administration.
13 (10) The Health Care Information Council shall act in
14 an advisory capacity to the Governor, the Legislature, the
15 Department of Insurance, and the Agency for Health Care
16 Administration on matters of health care accountability and
17 consumer information. The role of the council includes, but is
18 not limited to:
19 (a) Contracting with an independent contractor to
20 administer an annual survey of member satisfaction for all
21 health maintenance organizations, including the Medicare,
22 Medicaid, and commercial product lines;
23 (b) Selecting the instrument and the sampling design
24 to meet the member satisfaction survey requirements of health
25 maintenance organizations' accreditation organizations;
26 (c) Producing an HMO report card; and
27 (d) Making comparative survey results available to
28 health maintenance organizations and the public.
29 (11) In addition to the member satisfaction survey
30 results, the HMO report card must include benefit
31 availability, physician qualifications, payment arrangements,
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1 copayments, and the quality indicators provided in s.
2 641.51(8)(d), (e), (f), and (g).
3 Section 4. This act shall take effect upon becoming a
4 law.
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7 SENATE SUMMARY
8 Relates to health care. Revises standards and procedures
for hearing grievances under the statewide provider and
9 subscriber assistance program. Revises panel membership.
Provides for the issuance and judicial review of final
10 orders. Revises requirements for indicators of access and
quality of care which health maintenance organizations
11 and prepaid health clinics must submit to the Agency for
Health Care Administration. Deletes a requirement that
12 each such organization conduct a customer satisfaction
survey. Revises guidelines relating to recommendations
13 for preventive pediatric health care which must be
submitted to the agency. Revises guidelines for expending
14 moneys from the Health Care Trust Fund. Creates the
Health Care Information Council within the Agency for
15 Health Care Administration. Provides for council
membership, terms of office, and election of officers.
16 Provides for reimbursement for travel and per diem
expenses. Provides for an executive director, staff, and
17 consultants. Provides duties of the council.
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