House Bill 1927c1
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Florida House of Representatives - 1999 CS/HBs 1927 & 961
By the Committee on Health Care Services and
Representatives Eggelletion, Lacasa, Levine, Kyle, Garcia,
Villalobos, Merchant, Greenstein and Betancourt
1 A bill to be entitled
2 An act relating to managed health care;
3 amending s. 408.05, F.S.; requiring the State
4 Center for Health Statistics to publish health
5 maintenance organization report cards; amending
6 s. 408.7056, F.S.; excluding certain additional
7 grievances from consideration by a statewide
8 provider and subscriber assistance panel;
9 revising panel membership; amending s. 641.31,
10 F.S.; providing for a point-of-service benefit
11 rider on a health maintenance contract;
12 providing requirements; providing restrictions;
13 authorizing reasonable copayment and annual
14 deductible; providing exceptions relating to
15 subscriber liability for services received;
16 amending s. 641.3155, F.S.; providing a process
17 for retroactive reduction of payments of
18 provider claims under certain circumstances;
19 amending s. 641.51, F.S.; requiring that health
20 maintenance organizations provide additional
21 information to the Agency for Health Care
22 Administration indicating quality of care;
23 removing a requirement that organizations
24 conduct customer satisfaction surveys; revising
25 requirements for preventive pediatric health
26 care provided by health maintenance
27 organizations; amending s. 641.58, F.S.;
28 providing for moneys in the Health Care Trust
29 Fund to be used for additional purposes;
30 directing the director of the Agency for Health
31 Care Administration to establish an advisory
1
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1 group on the submission and payment of health
2 claims; providing membership and duties;
3 requiring a report; providing an appropriation;
4 providing effective dates.
5
6 Be It Enacted by the Legislature of the State of Florida:
7
8 Section 1. Paragraph (a) of subsection (5) of section
9 408.05, Florida Statutes, 1998 Supplement, is amended to read:
10 408.05 State Center for Health Statistics.--
11 (5) PUBLICATIONS; REPORTS; SPECIAL STUDIES.--The
12 center shall provide for the widespread dissemination of data
13 which it collects and analyzes. The center shall have the
14 following publication, reporting, and special study functions:
15 (a) The center shall publish and make available
16 periodically to agencies and individuals health statistics
17 publications of general interest, including health maintenance
18 organization report cards; publications providing health
19 statistics on topical health policy issues;, publications
20 which provide health status profiles of the people in this
21 state;, and other topical health statistics publications.
22 Section 2. Subsections (2) and (11) of section
23 408.7056, Florida Statutes, 1998 Supplement, are amended to
24 read:
25 408.7056 Statewide Provider and Subscriber Assistance
26 Program.--
27 (2) The agency shall adopt and implement a program to
28 provide assistance to subscribers and providers, including
29 those whose grievances are not resolved by the managed care
30 entity to the satisfaction of the subscriber or provider. The
31 program shall consist of one or more panels that meet as often
2
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Florida House of Representatives - 1999 CS/HBs 1927 & 961
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1 as necessary to timely review, consider, and hear grievances
2 and recommend to the agency or the department any actions that
3 should be taken concerning individual cases heard by the
4 panel. The panel shall hear every grievance filed by
5 subscribers and providers on behalf of subscribers, unless the
6 grievance:
7 (a) Relates to a managed care entity's refusal to
8 accept a provider into its network of providers;
9 (b) Is part of an internal grievance in a Medicare
10 managed care entity or a reconsideration appeal through the
11 Medicare appeals process which does not involve a quality of
12 care issue;
13 (c) Is related to a health plan not regulated by the
14 state such as an administrative services organization,
15 third-party administrator, or federal employee health benefit
16 program;
17 (d) Is related to appeals by in-plan suppliers and
18 providers, unless related to quality of care provided by the
19 plan;
20 (e) Is part of a Medicaid fair hearing pursued under
21 42 C.F.R. ss. 431.220 et seq.;
22 (f) Is the basis for an action pending in state or
23 federal court;
24 (g) Is related to an appeal by nonparticipating
25 providers, unless related to the quality of care provided to a
26 subscriber by the managed care entity and the provider is
27 involved in the care provided to the subscriber;
28 (h) Was filed before the subscriber or provider
29 completed the entire internal grievance procedure of the
30 managed care entity, the managed care entity has complied with
31 its timeframes for completing the internal grievance
3
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1 procedure, and the circumstances described in subsection (6)
2 do not apply;
3 (i) Has been resolved to the satisfaction of the
4 subscriber or provider who filed the grievance, unless the
5 managed care entity's initial action is egregious or may be
6 indicative of a pattern of inappropriate behavior;
7 (j) Is limited to seeking damages for pain and
8 suffering, lost wages, or other incidental expenses, including
9 accrued interest on unpaid balances, court costs, and
10 transportation costs associated with grievance procedures;
11 (k) Is limited to issues involving conduct of a health
12 care provider or facility, staff member, or employee of a
13 managed care entity which constitute grounds for disciplinary
14 action by the appropriate professional licensing board and is
15 not indicative of a pattern of inappropriate behavior, and the
16 agency or department has reported these grievances to the
17 appropriate professional licensing board or to the health
18 facility regulation section of the agency for possible
19 investigation; or
20 (l) Is withdrawn by the subscriber or provider.
21 Failure of the subscriber or the provider to attend the
22 hearing shall be considered a withdrawal of the grievance.
23 (11) The panel shall consist of members employed by
24 the agency and members employed by the department, chosen by
25 their respective agencies; a consumer appointed by the
26 Governor; a physician appointed by the Governor, who shall
27 serve as a standing member; and physicians with expertise
28 relevant to the case to be heard, who shall serve on a
29 rotating basis. The agency may contract with a medical
30 director and a primary care physician who shall provide
31 additional technical expertise to the panel. The medical
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1 director shall be selected from a health maintenance
2 organization with a current certificate of authority to
3 operate in Florida.
4 Section 3. Subsection (36) is added to section 641.31,
5 Florida Statutes, 1998 Supplement, to read:
6 641.31 Health maintenance contracts.--
7 (36)(a) Notwithstanding any other provision of this
8 part, a health maintenance organization which meets the
9 requirements of paragraph (b) may, through a point-of-service
10 rider to its contract providing comprehensive health care
11 services, include a point-of-service benefit. Under such a
12 rider, a subscriber or other covered person of the health
13 maintenance organization may choose, at the time of covered
14 service, a provider with whom the health maintenance
15 organization does not have a health maintenance organization
16 provider contract. The rider shall not require a referral from
17 the health maintenance organization for the point-of-service
18 benefits.
19 (b) A health maintenance organization offering a
20 point-of-service rider under this subsection must have a valid
21 certificate of authority issued under the provisions of the
22 chapter, must have been licensed under this chapter for a
23 minimum of 3 years, and must at all times that it has riders
24 in effect maintain a minimum surplus of $5 million, inclusive
25 of the surplus requirements in s. 641.225.
26 (c) Premiums paid for the point-of-service riders may
27 not exceed 15 percent of total premiums for all health plan
28 products sold by the health maintenance organization offering
29 the rider. If the premiums paid for point-of-service riders
30 exceed 15 percent, the health maintenance organization must
31 notify the department and must, immediately upon discovery
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1 that the premium cap has been exceeded, cease offering such a
2 rider until compliance with the premium cap is restored.
3 (d) Notwithstanding the limitations of deductibles and
4 copayment provisions in this part, a point-of-service rider
5 may require the subscriber to pay a reasonable copayment per
6 visit for services provided by a noncontracted provider chosen
7 by the subscriber at the time of the service. The copayment
8 may either be a specific dollar amount or a percentage of the
9 reimbursable provider charges covered by the contract and must
10 be paid by the subscriber to the noncontracted provider upon
11 receipt of covered service. The point-of-service rider may
12 require that a reasonable annual deductible for the expenses
13 associated with the point-of-service rider be met and may
14 include a lifetime maximum benefit amount.
15 (e) The rider must include language as required in s.
16 627.6044 and must comply with copayment and deductible limits
17 described in s. 627.6471. The provisions of s. 641.315(2) and
18 (3) are inapplicable to a point-of-service rider authorized
19 under this subsection.
20 (f) The term "point of service" may not be used except
21 with riders permitted under this section.
22 (g) A point-of-service rider must be filed and
23 approved under ss. 627.410 and 627.411.
24 Section 4. Subsection (4) is added to section
25 641.3155, Florida Statutes, 1998 Supplement, to read:
26 641.3155 Provider contracts; payment of claims.--
27 (4) Any retroactive reductions of payments or demands
28 for refund of previous overpayments which are due to
29 retroactive review of coverage decisions or payment levels
30 must be reconciled to specific claims, unless the parties
31 agree to other reconciliation methods and terms. Any
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1 retroactive demands by providers for payment due to
2 underpayments or nonpayments for covered services must be
3 reconciled to specific claims, unless the parties agree to
4 other reconciliation methods and terms. The look-back period
5 may be specified by the terms of the contract.
6 Section 5. Subsections (8), (9), and (10) of section
7 641.51, Florida Statutes, are amended to read:
8 641.51 Quality assurance program; second medical
9 opinion requirement.--
10 (8) Each organization shall release to the agency data
11 that which are indicators of access and quality of care. The
12 agency shall develop rules specifying data-reporting
13 requirements for these indicators. The indicators shall
14 include the following characteristics:
15 (a) They must relate to access and quality of care
16 measures.
17 (b) They must be consistent with data collected
18 pursuant to accreditation activities and standards.
19 (c) They must be consistent with frequency
20 requirements under the accreditation process.
21 (d) They must include chronic disease management
22 measures.
23 (e) They must relate to preventive health care for
24 adults and children.
25 (f) They must include prenatal care measures.
26 (g) They must include child health checkup measures.
27
28 The agency shall develop by rule a uniform format for
29 publication of the data for the public which shall contain
30 explanations of the data collected and the relevance of such
31
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1 data. The agency shall publish such data no less frequently
2 than every 2 years.
3 (9) Each organization shall conduct a standardized
4 customer satisfaction survey, as developed by the agency by
5 rule, of its membership at intervals specified by the agency.
6 The survey shall be consistent with surveys required by
7 accrediting organizations and may contain up to 10 additional
8 questions based on concerns specific to Florida. Survey data
9 shall be submitted to the agency, which shall make comparative
10 findings available to the public.
11 (9)(10) Each organization shall adopt recommendations
12 for preventive pediatric health care consistent with child
13 health checkup early periodic screening, diagnosis, and
14 treatment requirements developed for the Medicaid program.
15 Each organization shall establish goals to achieve 80-percent
16 compliance by July 1, 1998, and 90-percent compliance by July
17 1, 1999, for their enrolled pediatric population.
18 Section 6. Subsection (4) of section 641.58, Florida
19 Statutes, is amended to read:
20 641.58 Regulatory assessment; levy and amount; use of
21 funds; tax returns; penalty for failure to pay.--
22 (4) The moneys so received and deposited into the
23 Health Care Trust Fund shall be used to defray the expenses of
24 the agency in the discharge of its administrative and
25 regulatory powers and duties under this part, including
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, and salaries and expenses of
31 required personnel;, and discharging all other legitimate
8
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1 expenses relating to the discharge of the administrative and
2 regulatory powers and duties imposed under this such part.
3 Section 7. (1) The Agency for Health Care
4 Administration shall establish an advisory group on the
5 submission and payment of health claims.
6 (1) The advisory group shall be composed of eight
7 members, including three members from health maintenance
8 organizations licensed in Florida, one representative from a
9 not-for-profit hospital, one representative from a for-profit
10 hospital, one representative who is a licensed physician, one
11 representative from the Office of the Insurance Commissioner,
12 and one representative from the Agency for Health Care
13 Administration.
14 (2) The advisory group shall study and make
15 recommendations on:
16 (a) Trends and issues relating to legislative,
17 regulatory, or private-sector solutions for timely and
18 accurate submission and payment of health claims.
19 (b) Development of electronic billing and claims
20 processing for providers and health care facilities that
21 provide for electronic processing of eligibility requests,
22 benefit verification, authorizations, precertifications, and
23 claims status, including use of models such as the Florida
24 Shared System.
25 (c) The form and content of claims.
26 (d) Measures to reduce fraud and abuse relating to the
27 submission and payment of claims.
28 (3) The advisory group shall be appointed and shall
29 convene its first meeting by July 1, 1999. All meetings of the
30 advisory group shall be in Tallahassee. Members of the
31 advisory group shall not receive per diem or travel
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1 reimbursement. The advisory group shall submit its
2 recommendations in a report, by January 1, 2000, to the
3 President of the Senate and the Speaker of the House of
4 Representatives.
5 (2) This section shall take effect upon becoming a
6 law.
7 Section 8. There is appropriated to the Agency for
8 Health Care Administration for fiscal year 1999-2000 the sum
9 of $1,439,000 from the Health Care Trust Fund, for 12 months
10 of funding for the purpose of implementing this act.
11 Section 9. Except as otherwise provide herein, this
12 act shall take effect July 1, 1999.
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