House Bill 1927e1
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CS/HBs 1927 & 961, First Engrossed
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.
10 627.6471, F.S.; requiring preferred provider
11 organization policies which do not provide
12 direct patient access to a dermatologist to
13 conform to certain requirements imposed on
14 exclusive provider organization contracts;
15 amending s. 641.31, F.S.; providing for a
16 point-of-service benefit rider on a health
17 maintenance contract; providing requirements;
18 providing restrictions; authorizing reasonable
19 copayment and annual deductible; providing
20 exceptions relating to subscriber liability for
21 services received; amending s. 641.3155, F.S.;
22 providing a process for retroactive reduction
23 of payments of provider claims under certain
24 circumstances; amending s. 641.51, F.S.;
25 requiring that health maintenance organizations
26 provide additional information to the Agency
27 for Health Care Administration indicating
28 quality of care; removing a requirement that
29 organizations conduct customer satisfaction
30 surveys; revising requirements for preventive
31 pediatric health care provided by health
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CS/HBs 1927 & 961, First Engrossed
1 maintenance organizations; amending s. 641.58,
2 F.S.; providing for moneys in the Health Care
3 Trust Fund to be used for additional purposes;
4 directing the director of the Agency for Health
5 Care Administration to establish an advisory
6 group on the submission and payment of health
7 claims; providing membership and duties;
8 requiring a report; providing an appropriation;
9 providing effective dates.
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11 Be It Enacted by the Legislature of the State of Florida:
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13 Section 1. Paragraph (a) of subsection (5) of section
14 408.05, Florida Statutes, 1998 Supplement, is amended to read:
15 408.05 State Center for Health Statistics.--
16 (5) PUBLICATIONS; REPORTS; SPECIAL STUDIES.--The
17 center shall provide for the widespread dissemination of data
18 which it collects and analyzes. The center shall have the
19 following publication, reporting, and special study functions:
20 (a) The center shall publish and make available
21 periodically to agencies and individuals health statistics
22 publications of general interest, including health maintenance
23 organization report cards; publications providing health
24 statistics on topical health policy issues;, publications
25 which provide health status profiles of the people in this
26 state;, and other topical health statistics publications.
27 Section 2. Subsections (2) and (11) of section
28 408.7056, Florida Statutes, 1998 Supplement, are amended to
29 read:
30 408.7056 Statewide Provider and Subscriber Assistance
31 Program.--
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CS/HBs 1927 & 961, First Engrossed
1 (2) The agency shall adopt and implement a program to
2 provide assistance to subscribers and providers, including
3 those whose grievances are not resolved by the managed care
4 entity to the satisfaction of the subscriber or provider. The
5 program shall consist of one or more panels that meet as often
6 as necessary to timely review, consider, and hear grievances
7 and recommend to the agency or the department any actions that
8 should be taken concerning individual cases heard by the
9 panel. The panel shall hear every grievance filed by
10 subscribers and providers on behalf of subscribers, unless the
11 grievance:
12 (a) Relates to a managed care entity's refusal to
13 accept a provider into its network of providers;
14 (b) Is part of an internal grievance in a Medicare
15 managed care entity or a reconsideration appeal through the
16 Medicare appeals process which does not involve a quality of
17 care issue;
18 (c) Is related to a health plan not regulated by the
19 state such as an administrative services organization,
20 third-party administrator, or federal employee health benefit
21 program;
22 (d) Is related to appeals by in-plan suppliers and
23 providers, unless related to quality of care provided by the
24 plan;
25 (e) Is part of a Medicaid fair hearing pursued under
26 42 C.F.R. ss. 431.220 et seq.;
27 (f) Is the basis for an action pending in state or
28 federal court;
29 (g) Is related to an appeal by nonparticipating
30 providers, unless related to the quality of care provided to a
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CS/HBs 1927 & 961, First Engrossed
1 subscriber by the managed care entity and the provider is
2 involved in the care provided to the subscriber;
3 (h) Was filed before the subscriber or provider
4 completed the entire internal grievance procedure of the
5 managed care entity, the managed care entity has complied with
6 its timeframes for completing the internal grievance
7 procedure, and the circumstances described in subsection (6)
8 do not apply;
9 (i) Has been resolved to the satisfaction of the
10 subscriber or provider who filed the grievance, unless the
11 managed care entity's initial action is egregious or may be
12 indicative of a pattern of inappropriate behavior;
13 (j) Is limited to seeking damages for pain and
14 suffering, lost wages, or other incidental expenses, including
15 accrued interest on unpaid balances, court costs, and
16 transportation costs associated with grievance procedures;
17 (k) Is limited to issues involving conduct of a health
18 care provider or facility, staff member, or employee of a
19 managed care entity which constitute grounds for disciplinary
20 action by the appropriate professional licensing board and is
21 not indicative of a pattern of inappropriate behavior, and the
22 agency or department has reported these grievances to the
23 appropriate professional licensing board or to the health
24 facility regulation section of the agency for possible
25 investigation; or
26 (l) Is withdrawn by the subscriber or provider.
27 Failure of the subscriber or the provider to attend the
28 hearing shall be considered a withdrawal of the grievance.
29 (11) The panel shall consist of members employed by
30 the agency and members employed by the department, chosen by
31 their respective agencies; a consumer appointed by the
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CS/HBs 1927 & 961, First Engrossed
1 Governor; a physician appointed by the Governor, who shall
2 serve as a standing member; and physicians with expertise
3 relevant to the case to be heard, who shall serve on a
4 rotating basis. The agency may contract with a medical
5 director and a primary care physician who shall provide
6 additional technical expertise to the panel. The medical
7 director shall be selected from a health maintenance
8 organization with a current certificate of authority to
9 operate in Florida.
10 Section 3. Subsection (5) of section 627.6471, Florida
11 Statutes, is renumbered as subsection (6), and a new
12 subsection (5) is added to said section to read:
13 627.6471 Contracts for reduced rates of payment;
14 limitations; coinsurance and deductibles.--
15 (5) Any policy issued under this section which does
16 not provide direct patient access to a dermatologist must
17 conform to the requirements of s. 627.6472(16). Nothing in
18 this subsection shall affect the amount the insured or patient
19 must pay as a deductible or coinsurance amount authorized
20 under this section.
21 Section 4. Subsection (36) is added to section 641.31,
22 Florida Statutes, 1998 Supplement, to read:
23 641.31 Health maintenance contracts.--
24 (36)(a) Notwithstanding any other provision of this
25 part, a health maintenance organization which meets the
26 requirements of paragraph (b) may, through a point-of-service
27 rider to its contract providing comprehensive health care
28 services, include a point-of-service benefit. Under such a
29 rider, a subscriber or other covered person of the health
30 maintenance organization may choose, at the time of covered
31 service, a provider with whom the health maintenance
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CS/HBs 1927 & 961, First Engrossed
1 organization does not have a health maintenance organization
2 provider contract. The rider shall not require a referral from
3 the health maintenance organization for the point-of-service
4 benefits.
5 (b) A health maintenance organization offering a
6 point-of-service rider under this subsection must have a valid
7 certificate of authority issued under the provisions of the
8 chapter, must have been licensed under this chapter for a
9 minimum of 3 years, and must at all times that it has riders
10 in effect maintain a minimum surplus of $5 million, inclusive
11 of the surplus requirements in s. 641.225.
12 (c) Premiums paid for the point-of-service riders may
13 not exceed 15 percent of total premiums for all health plan
14 products sold by the health maintenance organization offering
15 the rider. If the premiums paid for point-of-service riders
16 exceed 15 percent, the health maintenance organization must
17 notify the department and must, immediately upon discovery
18 that the premium cap has been exceeded, cease offering such a
19 rider until compliance with the premium cap is restored.
20 (d) Notwithstanding the limitations of deductibles and
21 copayment provisions in this part, a point-of-service rider
22 may require the subscriber to pay a reasonable copayment per
23 visit for services provided by a noncontracted provider chosen
24 by the subscriber at the time of the service. The copayment
25 may either be a specific dollar amount or a percentage of the
26 reimbursable provider charges covered by the contract and must
27 be paid by the subscriber to the noncontracted provider upon
28 receipt of covered service. The point-of-service rider may
29 require that a reasonable annual deductible for the expenses
30 associated with the point-of-service rider be met and may
31 include a lifetime maximum benefit amount.
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CS/HBs 1927 & 961, First Engrossed
1 (e) The rider must include language as required in s.
2 627.6044 and must comply with copayment and deductible limits
3 described in s. 627.6471. The provisions of s. 641.315(2) and
4 (3) are inapplicable to a point-of-service rider authorized
5 under this subsection.
6 (f) The term "point of service" may not be used by a
7 health maintenance organization except with riders permitted
8 under this section or with forms approved by the department in
9 which a point-of-service product is offered with an indemnity
10 carrier.
11 (g) A point-of-service rider must be filed and
12 approved under ss. 627.410 and 627.411.
13 Section 5. Subsection (4) is added to section
14 641.3155, Florida Statutes, 1998 Supplement, to read:
15 641.3155 Provider contracts; payment of claims.--
16 (4) Any retroactive reductions of payments or demands
17 for refund of previous overpayments which are due to
18 retroactive review of coverage decisions or payment levels
19 must be reconciled to specific claims, unless the parties
20 agree to other reconciliation methods and terms. Any
21 retroactive demands by providers for payment due to
22 underpayments or nonpayments for covered services must be
23 reconciled to specific claims, unless the parties agree to
24 other reconciliation methods and terms. The look-back period
25 may be specified by the terms of the contract.
26 Section 6. Subsections (8), (9), and (10) of section
27 641.51, Florida Statutes, are amended to read:
28 641.51 Quality assurance program; second medical
29 opinion requirement.--
30 (8) Each organization shall release to the agency data
31 that which are indicators of access and quality of care. The
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CS/HBs 1927 & 961, First Engrossed
1 agency shall develop rules specifying data-reporting
2 requirements for these indicators. The indicators shall
3 include the following characteristics:
4 (a) They must relate to access and quality of care
5 measures.
6 (b) They must be consistent with data collected
7 pursuant to accreditation activities and standards.
8 (c) They must be consistent with frequency
9 requirements under the accreditation process.
10 (d) They must include chronic disease management
11 measures.
12 (e) They must relate to preventive health care for
13 adults and children.
14 (f) They must include prenatal care measures.
15 (g) They must include child health checkup measures.
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17 The agency shall develop by rule a uniform format for
18 publication of the data for the public which shall contain
19 explanations of the data collected and the relevance of such
20 data. The agency shall publish such data no less frequently
21 than every 2 years.
22 (9) Each organization shall conduct a standardized
23 customer satisfaction survey, as developed by the agency by
24 rule, of its membership at intervals specified by the agency.
25 The survey shall be consistent with surveys required by
26 accrediting organizations and may contain up to 10 additional
27 questions based on concerns specific to Florida. Survey data
28 shall be submitted to the agency, which shall make comparative
29 findings available to the public.
30 (9)(10) Each organization shall adopt recommendations
31 for preventive pediatric health care consistent with child
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1 health checkup early periodic screening, diagnosis, and
2 treatment requirements developed for the Medicaid program.
3 Each organization shall establish goals to achieve 80-percent
4 compliance by July 1, 1998, and 90-percent compliance by July
5 1, 1999, for their enrolled pediatric population.
6 Section 7. Subsection (4) of section 641.58, Florida
7 Statutes, is amended to read:
8 641.58 Regulatory assessment; levy and amount; use of
9 funds; tax returns; penalty for failure to pay.--
10 (4) The moneys so received and deposited into the
11 Health Care Trust Fund shall be used to defray the expenses of
12 the agency in the discharge of its administrative and
13 regulatory powers and duties under this part, including
14 conducting an annual health maintenance organization member
15 satisfaction survey, contracting with physician consultants
16 for the statewide provider and subscriber assistance panel;
17 the maintaining of offices and necessary supplies, essential
18 equipment, and other materials, and salaries and expenses of
19 required personnel;, and discharging all other legitimate
20 expenses relating to the discharge of the administrative and
21 regulatory powers and duties imposed under this such part.
22 Section 8. (1) The Agency for Health Care
23 Administration shall establish an advisory group on the
24 submission and payment of health claims.
25 (1) The advisory group shall be composed of eight
26 members, including three members from health maintenance
27 organizations licensed in Florida, one representative from a
28 not-for-profit hospital, one representative from a for-profit
29 hospital, one representative who is a licensed physician, one
30 representative from the Office of the Insurance Commissioner,
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1 and one representative from the Agency for Health Care
2 Administration.
3 (2) The advisory group shall study and make
4 recommendations on:
5 (a) Trends and issues relating to legislative,
6 regulatory, or private-sector solutions for timely and
7 accurate submission and payment of health claims.
8 (b) Development of electronic billing and claims
9 processing for providers and health care facilities that
10 provide for electronic processing of eligibility requests,
11 benefit verification, authorizations, precertifications, and
12 claims status, including use of models such as the Florida
13 Shared System.
14 (c) The form and content of claims.
15 (d) Measures to reduce fraud and abuse relating to the
16 submission and payment of claims.
17 (3) The advisory group shall be appointed and shall
18 convene its first meeting by July 1, 1999. All meetings of the
19 advisory group shall be in Tallahassee. Members of the
20 advisory group shall not receive per diem or travel
21 reimbursement. The advisory group shall submit its
22 recommendations in a report, by January 1, 2000, to the
23 President of the Senate and the Speaker of the House of
24 Representatives.
25 (2) This section shall take effect upon becoming a
26 law.
27 Section 9. There is appropriated to the Agency for
28 Health Care Administration for fiscal year 1999-2000 the sum
29 of $1,439,000 from the Health Care Trust Fund, for 12 months
30 of funding for the purpose of implementing this act.
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CS/HBs 1927 & 961, First Engrossed
1 Section 10. Except as otherwise provide herein, this
2 act shall take effect July 1, 1999.
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