Senate Bill 2126
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
By Senator Saunders
25-1161-99
1 A bill to be entitled
2 An act relating to health care; amending ss.
3 408.706, F.S., 627.419, F.S., and creating s.
4 641.3151, F.S.; allowing subscribers to certain
5 health plans to select their physician;
6 prohibiting the denial of payment to such
7 health care providers selected; providing
8 reimbursement criteria; providing penalties;
9 amending s. 641.315, F.S.; limiting the
10 liability for payment for HMO subscribers;
11 amending s. 408.7056, F.S.; revising the
12 membership of a statewide provider and
13 subscriber assistance panel; amending s.
14 641.495, F.S.; providing responsibilities for
15 health maintenance organization medical
16 directors regarding adverse determinations with
17 respect to subscribers; providing an effective
18 date.
19
20 Be It Enacted by the Legislature of the State of Florida:
21
22 Section 1. Subsection (11) of section 408.706, Florida
23 Statutes, is amended to read:
24 408.706 Community health purchasing alliances;
25 accountable health partnerships.--
26 (11) Notwithstanding any other provision of law to the
27 contrary, any subscriber to a health plan offered by or
28 through a health maintenance organization, managed care
29 organization, prepaid health plan, or accountable health
30 partnership may select a physician of his or her choice who is
31 licensed under chapter 458 or chapter 459. A health plan may
1
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
25-1161-99
1 not contain any provision that requires or coerces a
2 subscriber to use any physician other than one selected by the
3 subscriber.
4 (a) A health maintenance organization, managed care
5 organization, prepaid health plan, or accountable health
6 partnership may not deny payment to a physician who has
7 rendered covered services to a subscriber, based solely on the
8 fact that the physician has not entered into a provider
9 contract with the organization, plan, or partnership, if:
10 1. The physician meets the eligibility criteria of the
11 organization, plan, or partnership; and
12 2. Under accepted medical standards, the services were
13 medically necessary so that the organization, plan, or
14 partnership would be required to pay for the services had they
15 been performed by a contracted provider.
16 (b) Reimbursement for services by a physician who does
17 not have a contract with the organization, plan, or
18 partnership must be the lesser of:
19 1. Eighty percent of the physician's charges;
20 2. Eighty percent of the highest rate paid by the
21 organization, plan, or partnership to contracted physicians
22 for the procedure; or
23 3. The charge agreed to by the organization, plan, or
24 partnership and the physician within 30 days after submittal
25 of the claim.
26
27 The subscriber is liable for all physician charges not covered
28 by the health maintenance organization under this paragraph.
29 (c) A health maintenance organization, managed care
30 provider organization, prepaid health plan, or accountable
31
2
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
25-1161-99
1 health partnership that violates this subsection is subject to
2 a civil fine in the amount of:
3 1. Up to $25,000 for each violation; or
4 2. If the Director of the Agency for Health Care
5 Administration determines that the entity has engaged in a
6 pattern of violations, up to $100,000 for each violation. The
7 ability to recruit and retain alliance district health care
8 providers in its provider network. For provider networks
9 initially formed in an alliance district after July 1, 1993,
10 an accountable health partnership shall make offers as to
11 provider participation in its provider network to relevant
12 alliance district health care providers for at least 60
13 percent of the available provider positions. A provider who is
14 made an offer may participate in an accountable health
15 partnership as long as the provider abides by the terms and
16 conditions of the provider network contract, provides services
17 at a rate or price equal to the rate or price negotiated by
18 the accountable health partnership, and meets all of the
19 accountable health partnership's qualifications for
20 participation in its provider networks including, but not
21 limited to, network adequacy criteria. For purposes of this
22 subsection, "alliance district health care provider" means a
23 health care provider who is licensed under chapter 458,
24 chapter 459, chapter 460, chapter 461, chapter 464, or chapter
25 465 who has practiced in Florida for more than 1 year within
26 the alliance district served by the accountable health
27 partnership.
28 Section 2. Subsection (9) is added to section 627.419,
29 Florida Statutes, 1998 Supplement, to read:
30 627.419 Construction of policies.--
31
3
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
25-1161-99
1 (9)(a) Notwithstanding any other provision of law to
2 the contrary, any person covered under any health insurance
3 policy, health care services plan, or other contract that
4 provides for payment for medical expense benefits or
5 procedures may select a physician of his or her choice who is
6 licensed under chapter 458 or chapter 459. A health plan may
7 not contain any provision that requires or coerces a person
8 covered by the plan to use any provider other than one
9 selected by the subscriber. A health plan may not deny payment
10 to a physician who has rendered covered services to an
11 insured, based solely on the fact that the physician has not
12 entered into a provider contract with the plan, if:
13 1. The physician meets the plan's eligibility
14 criteria; and
15 2. Under accepted medical standards, the services were
16 medically necessary so that the organization would be required
17 to pay for the services had they been performed by a
18 contracted physician.
19 (b) Reimbursement for services by a physician who does
20 not have a contract with the health plan must be the lesser
21 of:
22 1. Eighty percent of the physician's charges;
23 2. Eighty percent of the highest rate paid by the
24 organization to contracted physicians for the procedure; or
25 3. The charge agreed to by the organization within 30
26 days after submittal of the claim.
27
28 The subscriber shall be liable for all physician charges not
29 covered by the health plan under this paragraph.
30
31
4
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
25-1161-99
1 (c) The provider of any health insurance policy,
2 health care services plan, or other contract that violates
3 this subsection is subject to a civil fine in the amount of:
4 1. Up to $25,000 for each violation; or
5 2. If the Director of the Agency for Health Care
6 Administration determines that the entity has engaged in a
7 pattern of violations, up to $100,000 for each violation.
8 Section 3. Section 641.3151, Florida Statutes, is
9 created to read:
10 641.3151 Subscriber freedom of choice.--
11 (1) Notwithstanding any other provision of law to the
12 contrary, any subscriber to a health plan offered by or
13 through a health maintenance organization or managed care
14 organization may select a physician of his or her choice who
15 is licensed under chapter 458 or chapter 459. A health plan
16 may not contain any provision that requires or coerces a
17 subscriber to use any physician other than one selected by the
18 subscriber. A health maintenance organization or managed care
19 organization may not deny payment to a physician who has
20 rendered covered services to a subscriber, based solely on the
21 fact that the physician has not entered into a provider
22 contract with the organization, if:
23 (a) The physician meets the organization's eligibility
24 criteria; and
25 (b) Under accepted medical standards, the services
26 were medically necessary so that the organization would be
27 required to pay for the services had they been performed by a
28 contracted physician.
29 (2) Reimbursement for services by a physician who does
30 not have a contract with the health maintenance organization
31 or managed care organization must be the lesser of:
5
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
25-1161-99
1 (a) Eighty percent of the physician's charges;
2 (b) Eighty percent of the highest rate paid by the
3 organization to contracted physicians for the procedure; or
4 (c) The charge agreed to by the organization within 30
5 days after submittal of the claim.
6
7 The subscriber shall be liable for all physician charges not
8 covered by the health maintenance organization under this
9 subsection.
10 (3) A health maintenance organization or managed care
11 provider organization that violates this section is subject to
12 a civil fine in the amount of:
13 (a) Up to $25,000 for each violation; or
14 (b) If the Director of the Agency for Health Care
15 Administration determines that the entity has engaged in a
16 pattern of violations, up to $100,000 for each violation.
17 Section 4. Subsections (2) and (3) of section 641.315,
18 Florida Statutes, are amended to read:
19 641.315 Provider contracts.--
20 (2) No subscriber of an HMO shall be liable to any
21 contracted provider of health care services of that HMO for
22 any services covered by the HMO.
23 (3) No contracted provider of services of an HMO or
24 any representative of such provider shall collect or attempt
25 to collect from an HMO subscriber any money for services
26 covered by an HMO and no contracted provider or representative
27 of such provider may maintain any action at law against a
28 subscriber of an HMO to collect money owed to such provider by
29 an HMO.
30 Section 5. Subsection (11) of section 408.7056,
31 Florida Statutes, 1998 Supplement, is amended to read:
6
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
25-1161-99
1 408.7056 Statewide Provider and Subscriber Assistance
2 Program.--
3 (11) The panel shall consist of members employed by
4 the agency and members employed by the department, chosen by
5 their respective agencies. In addition, at least one-third of
6 the panel must be comprised of physicians licensed under
7 chapter 458 or chapter 459. If the grievance involves an
8 adverse determination, as defined in s. 641.47, at least one
9 of the physicians on the panel must be in the same specialty
10 as that forming the subject of the grievance or must have
11 training and experience in the procedure in question. The
12 agency may contract with a medical director and a primary care
13 physician who shall provide additional technical expertise to
14 the panel. The medical director shall be selected from a
15 health maintenance organization with a current certificate of
16 authority to operate in Florida.
17 Section 6. Subsection (11) of section 641.495, Florida
18 Statutes, 1998 Supplement, is amended to read:
19 641.495 Requirements for issuance and maintenance of
20 certificate.--
21 (11) The organization shall designate a medical
22 director who is a physician licensed under chapter 458 or
23 chapter 459. For every adverse determination made by the HMO
24 regarding any subscriber, the medical director must document
25 and sign the subscriber's medical records setting forth the
26 facts regarding the HMO's adverse determination and the
27 rationale for that determination. The rendering of an adverse
28 determination by a medical director constitutes the practice
29 of medicine as defined in s. 458.305.
30 Section 7. This act shall take effect July 1, 1999.
31
7
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2126
25-1161-99
1 *****************************************
2 SENATE SUMMARY
3 Revises provisions related to health services plans.
Allows subscribers to select their physicians. Prohibits
4 the denial of payment to such providers and provides
criteria for reimbursement. Provides penalties. Limits
5 the liability of HMO subscribers for payments to
providers. Revises the membership of the statewide
6 provider and assistance panels. Provides responsibilities
for HMO medical directors regarding adverse
7 determinations. (See bill for details.)
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
8