Senate Bill 2230
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
By Senator Klein
28-1166-99
1 A bill to be entitled
2 An act relating to insurance; creating s.
3 627.64726, F.S.; authorizing point of service
4 policies under arrangements between health
5 insurers and health maintenance organizations;
6 providing criteria; providing standards;
7 creating s. 627.64727, F.S.; prohibiting the
8 use of certain words; amending s. 627.662,
9 F.S.; prohibiting the use of certain words;
10 creating s. 627.6693, F.S.; mandating that
11 group policies providing coverage pursuant to a
12 point of service agreement shall comply with s.
13 627.64726, F.S.; creating s. 641.191, F.S.;
14 establishing a subscriber's bill of rights to
15 serve as standards for certain purposes;
16 creating s. 641.2019, F.S.; prohibiting a
17 health maintenance organization from excluding
18 a covered service if the subscriber is
19 receiving noncovered service in conjunction
20 therewith; amending s. 641.30, F.S.; making the
21 provisions of s. 627.64726, F.S., applicable to
22 health maintenance organizations; amending s.
23 641.31, F.S.; providing for return of excessive
24 premiums received; providing for continuation
25 of care under certain circumstances; amending
26 s. 641.3108, F.S.; prohibiting retroactive
27 cancellation and requiring certain notice to
28 group member subscribers prior to the effective
29 date of cancellation; amending s. 641.315,
30 F.S.; providing for notice to the department of
31 cancellation of a provider contract; creating
1
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 s. 641.34, F.S.; prohibiting the use of certain
2 words; amending s. 641.51, F.S.; extending the
3 period in which a subscriber may receive
4 covered services from a terminated provider;
5 amending s. 641.511, F.S.; requiring a health
6 maintenance organization to respond to an
7 initial complaint within a specified time;
8 requiring a grievance manager to provide
9 written determination of grievance panel
10 review; requiring that the grievance process
11 permit subscribers to appear and be heard,
12 bring representation, be accompanied by their
13 provider, and be permitted to document the
14 hearing by certain methods; providing an
15 effective date.
16
17 Be It Enacted by the Legislature of the State of Florida:
18
19 Section 1. Section 627.64726, Florida Statutes, is
20 created to read:
21 627.64726 Point of service policies; purpose;
22 definition; authority; standards; reporting; application of
23 other laws.--
24 (1) PURPOSE.--It is the purpose of this section to
25 encourage the issuance of coverage to persons which provides
26 an option, at the time medical services are secured, of
27 accessing benefits provided by a licensed health maintenance
28 organization or accessing benefits provided by a licensed
29 health insurer. By authorizing the issuance of that coverage,
30 the Legislature intends to maximize health care options for
31 consumers of health care policies.
2
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 (2) SCOPE.--Point of service coverage may be issued on
2 an individual or group basis.
3 (3) DEFINITION.--As used in this section:
4 (a) "Point of service agreement" is the contractual
5 means by which a health insurer and health maintenance
6 organization offer point of service coverage.
7 (b) "Point of service policy" is a policy providing
8 comprehensive health benefits under which an insured has:
9 1. Both a health insurance policy issued by an
10 authorized health insurer and a health maintenance contract
11 issued by a licensed health maintenance organization, whereby
12 the insured may choose at each time of service whether to
13 access indemnity benefits under the health insurance policy or
14 benefits under the health maintenance contract, but not both;
15 or
16 2. A single contract issued by a health maintenance
17 organization or a single policy issued by a health insurer,
18 pursuant to a point of service agreement between the health
19 insurer and the health maintenance organization, whereby the
20 insured may choose at each time of service whether to access
21 indemnity benefits under the health insurance portion of the
22 policy or benefits under the health maintenance portion of the
23 policy, buy not both.
24 (c) "Insured" is the policyholder or subscriber of an
25 individual point of service policy, or the subscriber or
26 certificateholder under a group point of service policy.
27 (4) AUTHORITY TO ISSUE.--
28 (a) Subject to the requirements contained in this
29 section, nothing in the Florida Insurance Code including
30 chapter 641, and rules adopted thereunder, shall prohibit an
31 authorized health insurer and a licensed health maintenance
3
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 organization in conjunction, from soliciting, offering, or
2 providing point of service coverage either in a separate
3 policy issued by the health insurer and a separate health
4 maintenance contract issued by the health maintenance
5 organization or in a single contract issued by the health
6 maintenance organization or by a single policy by the health
7 insurer.
8 (b) Except as provided in this section, no insurer or
9 health maintenance organization shall solicit, offer, or
10 provide a point of service policy.
11 (5) PROVISIONS OF POINT OF SERVICE POLICIES.--Each
12 point of service policy shall contain the following provisions
13 in addition to all others required under the Florida Insurance
14 Code, chapter 641, and rules adopted thereunder:
15 (a) A provision clearly identifying both the health
16 insurer and the health maintenance organization and, in the
17 instance of a group policy, a provision in the member handbook
18 or certificate of coverage clearly identifying the same.
19 (b) A provision stating that an insured covered under
20 a point of service policy must elect either indemnity benefits
21 or health maintenance organization coverage for a given
22 medical treatment.
23 (c) A provision stating that when coverage has been
24 paid or provided with respect to a given medical treatment by
25 either the health insurer or the health maintenance
26 organization pursuant to a filed and approved point of service
27 policy, the provisions of s. 627.4235 do not apply with
28 respect to the point of service policy, but do apply as to
29 other policies, plans, or contracts of the insured.
30 (d) A provision stating that 60 days prior to the
31 termination of a point of service agreement, the terminating
4
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 company must provide each insured who has a policy under the
2 agreement notice in writing of the termination.
3 (e) A provision that, in the event a point of service
4 agreement is terminated, the policyholder in an individual
5 contract or the contractholder in a group contract may, within
6 60 days after receiving notice of the termination, elect to
7 continue coverage with either the health maintenance
8 organization or the health insurer that was a party to the
9 point of service agreement for the remainder of the contract
10 period.
11 (f) A provision that, in the event the insured is
12 entitled to a conversion plan, for reasons provided in s.
13 627.646, s. 627.6675, or s. 641.3922, the insured is entitled
14 to a choice of either an indemnity plan from the health
15 insurer or a health maintenance organization contract, without
16 prejudice.
17 (6) FILING AND REPORTING REQUIREMENTS.--
18 (a) All point of service policy forms and rate filings
19 must be made jointly by a health insurer and a health
20 maintenance organization whether or not separate or combined
21 forms are used.
22 (b) The point of service policy form and rate filing
23 must include all forms and rates required by this section. If
24 a health insurer and a health maintenance organization use
25 forms and rates previously approved to satisfy the required
26 separate health benefit policies and the conversion policies
27 to be used in conjunction with this point of service policy,
28 it is sufficient to identify the form number and date of
29 approval of these forms and related rates.
30 (c) The point of service policy form and rate filing
31 must contain certification from an officer of the health
5
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 insurer and an officer of the health maintenance organization
2 that each company agrees, as a condition precedent to
3 termination of the point of service agreement, to provide the
4 department notice of its intention to terminate the point of
5 service arrangement no less than 90 days prior to the
6 effective date of termination. Further, each company agrees to
7 notify the department within 48 hours in the event of a
8 material breach by either company.
9 (d) All point of service policy filings must contain
10 an authorization from the health insurer and the health
11 maintenance organization, either as joint signatories, or in
12 an original letter of authorization from each company to the
13 other, to make the combined filing when a single policy will
14 be used and that both parties will be responsible for the
15 accuracy of the information contained in the combined filing.
16 (e) All point of service policy forms and rates must
17 be filed and approved prior to use. All form and rate changes
18 to such policy must be filed and approved prior to use.
19 (f) The health insurer and the health maintenance
20 organization shall each file and have approved a policy form
21 and rate to be made available to the insured when the point of
22 service agreement is terminated during an existing contract
23 period. The filing shall:
24 1. Contain levels of indemnity benefits or other
25 health benefit coverage no less than that provided under the
26 point of service policy;
27 2. Comply in all respects with the requirements of the
28 Florida Insurance Code or chapter 641 as related to the
29 product being filed; and
30
31
6
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 3. Clearly identify in the filing that this policy is
2 intended for use in conjunction with a point of service
3 policy.
4 (g) The health insurer and the health maintenance
5 organization shall each have filed and approved a conversion
6 policy, with corresponding rates, to be made available to the
7 insured when the right to conversion is required.
8 (h) The health insurer or the health maintenance
9 organization shall make, at a minimum, an annual rate filing
10 for each point of service policy form offered in this state.
11 Annual periodic rate adjustments must be made to reflect the
12 actual premium split based on experience and compared with the
13 assumed split at the beginning of the contract. Except as so
14 described, no other experience adjustments may be made on a
15 retrospective basis without approval by the department.
16 (i) All rate filings for a point of service policy
17 must contain the following terms and conditions, in addition
18 to all others required under statute or rule:
19 1. The health insurer and the health maintenance
20 organization shall each perform its own pricing on a net claim
21 basis.
22 2. The health insurer and the health maintenance
23 organization shall each calculate its own expenses and profit
24 margins.
25 3. Expenses are to be itemized and must clearly
26 identify which entity is performing which duty relative to
27 each expense item noted.
28 4. Minimum loss ratios, as defined in the Florida
29 Insurance Code or in any applicable rule adopted thereunder,
30 must be met by each company.
31
7
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 (j) The health insurer and the health maintenance
2 organization shall each maintain separate records relating to
3 any point of service policy. On each financial report made to
4 the department, which must be made on a form adopted by the
5 department, each company shall provide the following
6 information:
7 1. Total point of service earned premium.
8 2. Total number of point of service policyholders,
9 certificate holders, and subscribers by market (individual,
10 small group, large group).
11 3. Loss ratios for point of service policies.
12 4. Expenses.
13 5. Any other information required by the department in
14 carrying out its duties under this section.
15 (k) Each company shall disclose in its audited
16 financial statement, at a minimum in a footnote to such
17 report, the combined earned premium and total losses incurred
18 including expenses incurred but not reported for this product.
19 The annual actuarial certification must also contain a
20 specific actuarial certification that the rates charged for
21 this product are not inadequate, excessive, or discriminatory.
22 (7) APPLICABILITY.--
23 (a) Any health insurer entering into a point of
24 service arrangement pursuant to this section, in addition to
25 the requirements of this section, is subject to all provisions
26 of the Florida Insurance Code and other statutes and rules
27 adopted thereunder applicable to health insurers generally.
28 (b) Any health maintenance organization entering into
29 a point of service arrangement under this section, in addition
30 to the requirements of this section, is subject to chapter 641
31 and rules adopted thereunder and to all other provisions of
8
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 the Florida Insurance Code and other statutes and rules
2 adopted thereunder applicable to health maintenance
3 organizations generally.
4 (c) The health insurance portion of a point of service
5 arrangement policy is subject to the provisions of part III of
6 chapter 631. The health maintenance portion of a point of
7 service arrangement is subject to part IV of chapter 631.
8 (d) Any health maintenance organization entering into
9 a point of service arrangement under this section is not
10 subject to part VII of chapter 626 when administering a point
11 of service policy.
12 (8) RULEMAKING.--The department may adopt rules
13 necessary to implement this section. In adopting these rules
14 the department shall consider requirements to assure that
15 experience adjustments and other adjustments are reasonable,
16 fair, and equitable; that point of service policies,
17 advertisements, solicitation materials, and other statements
18 or documents related thereto are clear and understandable;
19 that point of service policies are provided to the
20 insurance-buying public in a fashion that meets the purposes
21 of this section and are provided in a fair and equitable
22 fashion; and that point of service policies provide for a
23 proper triggering of the conversion plan policies.
24 Section 2. Section 627.64727, Florida Statutes, is
25 created to read:
26 627.64727 Use of certain words prohibited.--A health
27 insurer or a health maintenance organization may not use in
28 its contracts or literature, including any form of
29 advertising, the phrase "point of service" or "POS" unless it
30 relates to a policy that has been filed and approved by the
31 department under s. 627.64726.
9
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 Section 3. Subsection (11) is added to section
2 627.662, Florida Statutes, to read:
3 627.662 Other provisions applicable.--The following
4 provisions apply to group health insurance, blanket health
5 insurance, and franchise health insurance:
6 (11) Section 627.64727, relating to prohibition of the
7 use of the term "point of service."
8 Section 4. Section 627.6693, Florida Statutes, is
9 created to read:
10 627.6693 Point of service.--Any group health insurance
11 policy that provides coverage to a resident of this state
12 pursuant to a point of service agreement as defined in s.
13 627.64726 must comply with the requirements of that section.
14 Section 5. Section 641.191, Florida Statutes, is
15 created to read:
16 641.191 Health maintenance organization subscriber's
17 bill of rights.--
18 (1) With respect to the provisions of this part, and
19 consistent with the scope of covered conditions and treatments
20 under the contract, the principles expressed in the following
21 statements serve as standards to be followed by the department
22 and the agency in exercising their powers and duties, in
23 exercising administrative discretion, in dispensing
24 administrative interpretations of the law, in enforcing the
25 law, and in adopting rules:
26 (a) A subscriber has the right to receive quality,
27 medically necessary, and appropriate health care services that
28 are available and accessible in a timely manner.
29 (b) A subscriber has the right to the provision of
30 medical care by the health maintenance organization with the
31 goal of maintaining the subscriber's good health in a cost
10
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 effective fashion and to treat the subscriber's medical
2 conditions as may be necessary and appropriate.
3 (c) A subscriber has the right to accurate and easily
4 understood information with which to make informed decisions
5 about health plans, professionals, and facilities.
6 (d) A subscriber has the right to compassionate,
7 sympathetic, and respectful care from all health maintenance
8 organization providers and employees.
9 (e) A subscriber has the right to simple, fair,
10 timely, and impartial procedures for resolving coverage
11 disputes.
12 (f) The subscriber has a right to a timely referral
13 with payment preauthorization for covered treatment outside
14 the health maintenance organization's provider network when a
15 health maintenance organization does not have a provider
16 specializing in or experienced with respect to the medical
17 care or course of treatment appropriate to the subscriber's
18 medical condition.
19 (g) A subscriber has a right to expedited treatment of
20 any covered condition that would jeopardize the life or health
21 of a subscriber or would jeopardize the subscriber's ability
22 to regain maximum function.
23 (h) A subscriber has a right to a quality assurance
24 program with respect to health maintenance organization
25 providers to provide medically necessary care and treatment
26 and to avoid unnecessary, inappropriate, or improper medical
27 care or services.
28 (2) This section may not be construed as creating a
29 civil cause of action by any subscriber against any health
30 maintenance organization.
31
11
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 Section 6. Section 641.2019, Florida Statutes, is
2 created to read:
3 641.2019 Simultaneous delivery of covered and
4 noncovered medical treatment.--A health maintenance
5 organization may not prohibit a subscriber from receiving
6 noncovered medically necessary treatment simultaneously with
7 covered treatment if a provider determines the simultaneous
8 treatment is not contrary to the best interests of the
9 subscriber. A health maintenance organization may not exclude
10 coverage for a covered procedure if the subscriber elects to
11 have a noncovered medically necessary procedure performed
12 simultaneously or in conjunction with a covered procedure. The
13 health maintenance organization must not reduce the level of
14 reimbursement to the provider performing the covered service
15 in conjunction with the noncovered service.
16 Section 7. Subsection (6) is added to section 641.30,
17 Florida Statutes, to read:
18 641.30 Construction and relationship to other laws.--
19 (6) Each health maintenance organization entering into
20 a point of service agreement must comply with s. 627.64726.
21 Section 8. Paragraph (b) of subsection (3) of section
22 641.31, Florida Statutes, 1998 Supplement, is amended and
23 subsection (36) is added to that section to read:
24 641.31 Health maintenance contracts.--
25 (3)
26 (b) The department shall disapprove any form filed
27 under this subsection, or withdraw any previous approval
28 thereof, if the form:
29 1. Is in any respect in violation of, or does not
30 comply with, any provision of this part or rule adopted
31 thereunder.
12
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 2. Contains or incorporates by reference, where such
2 incorporation is otherwise permissible, any inconsistent,
3 ambiguous, or misleading clauses or exceptions and conditions
4 which deceptively affect the risk purported to be assumed in
5 the general coverage of the contract.
6 3. Has any title, heading, or other indication of its
7 provisions which is misleading.
8 4. Is printed or otherwise reproduced in such a manner
9 as to render any material provision of the form substantially
10 illegible.
11 5. Contains provisions which are unfair, inequitable,
12 or contrary to the public policy of this state or which
13 encourage misrepresentation.
14 6. Charges rates that are determined by the department
15 to be inadequate, excessive, or unfairly discriminatory, or
16 the rating methodology followed by the health maintenance
17 organization is determined by the department to be
18 inconsistent, indeterminate, ambiguous, or encouraging
19 misrepresentation or misunderstanding. When the department
20 finds that a rate or rate change is excessive, inadequate, or
21 unfairly discriminatory, the department shall, in addition to
22 disapproving the form, specify that a new rate or rate
23 schedule, which responds to the findings of the department, be
24 filed by the health maintenance organization. The department
25 shall further require that premiums charged each
26 contractholder constituting the portion of the rate above that
27 which was approved be returned to such contractholder in the
28 form of a credit or refund. Use of the rating methodology must
29 be discontinued immediately upon disapproval unless the health
30 maintenance organization seeks administrative relief. The
31 refund or credit amount due shall be calculated from the date
13
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 of the original disapproval. When the department finds that a
2 health maintenance organization's rate or rate change is
3 inadequate, the new rate or rate schedule filed with the
4 department in response to such a finding If a new rating
5 methodology is filed with the department, the premiums
6 determined by such newly filed rating methodology may apply
7 prospectively only to new or renewal business written on or
8 after the effective date of the responsive filing made by the
9 health maintenance organization.
10 7. Excludes coverage for human immunodeficiency virus
11 infection or acquired immune deficiency syndrome or contains
12 limitations in the benefits payable, or in the terms or
13 conditions of such contract, for human immunodeficiency virus
14 infection or acquired immune deficiency syndrome which are
15 different than those which apply to any other sickness or
16 medical condition.
17 (36) A health maintenance organization contract must
18 include the provisions of s. 641.51(7).
19 Section 9. Section 641.3108, Florida Statutes, is
20 amended to read:
21 641.3108 Notice of cancellation of contract.--
22 (1) Except for nonpayment of premium or termination of
23 eligibility, no health maintenance organization may cancel or
24 otherwise terminate or fail to renew a health maintenance
25 contract without giving each the subscriber covered by the
26 contract at least 45 days' notice in writing of the
27 cancellation, termination, or nonrenewal of the contract. The
28 written notice shall state the reason or reasons for the
29 cancellation, termination, or nonrenewal. All health
30 maintenance contracts shall contain a clause which requires
31 that this notice be given. In the case of a health
14
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 maintenance contract issued to an employer or person holding
2 the contract on behalf of the subscriber group, the health
3 maintenance organization may make the notification through the
4 employer or group contract holder, and, if the health
5 maintenance organization elects to take this action through
6 the employer or group contract holder, the organization shall
7 be deemed to have complied with the provisions of this section
8 upon notifying the employer or group contract holder of the
9 requirements of this section and requesting the employer or
10 group contract holder to forward to all subscribers the notice
11 required herein.
12 (2) No health maintenance organization may cancel or
13 otherwise terminate or fail to renew a group health
14 maintenance contract for nonpayment of premium or termination
15 of eligibility without giving each subscriber covered by the
16 contract at least 30 days' notice in writing of the
17 cancellation, termination, or nonrenewal of the contract. The
18 written notice shall state the reason or reasons for the
19 cancellation, termination, or nonrenewal. All group health
20 maintenance contracts shall contain a clause that requires
21 that this notice be given.
22 Section 10. Subsection (6) of section 641.315, Florida
23 Statutes, is amended to read:
24 641.315 Provider contracts.--
25 (6)(a) For all provider contracts executed after
26 October 1, 1999 1991, and within 180 days after October 1,
27 1991, for contracts in existence as of October 1, 1991:
28 1. The contracts must provide that the provider shall
29 provide 60 days' advance written notice to the health
30 maintenance organization and the department before canceling
31
15
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 the contract with the health maintenance organization for any
2 reason; and
3 2. The contract must also provide that nonpayment for
4 goods or services rendered by the provider to the health
5 maintenance organization shall not be a valid reason for
6 avoiding the 60-day advance notice of cancellation; and.
7 3. The contract must also provide that the health
8 maintenance organization shall, within 72 hours after receipt
9 of the notice required in subparagraph 1., notify the
10 department of the provider's intent to cancel its contract
11 with the health maintenance organization.
12 (b) For all provider contracts executed after October
13 1, 1999 1996, and within 180 days after October 1, 1996, for
14 contracts in existence as of October 1, 1996, the contracts
15 must provide that the health maintenance organization will
16 provide 60 days' advance written notice to the provider and
17 the department before canceling, without cause, the contract
18 with the provider, except in a case in which a patient's
19 health is subject to imminent danger or a physician's ability
20 to practice medicine is effectively impaired by an action by
21 the Board of Medicine or other governmental agency.
22 Section 11. Section 641.34, Florida Statutes, is
23 created to read:
24 641.34 Use of certain words prohibited.--A health
25 maintenance organization may not use in its contracts or
26 literature, including any form of advertising, the phrase
27 "point of service" or "POS" unless it relates to a policy that
28 has been filed and approved by the department pursuant to s.
29 627.64726.
30 Section 12. Subsection (7) of section 641.51, Florida
31 Statutes, is amended to read:
16
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 641.51 Quality assurance program; second medical
2 opinion requirement.--
3 (7) Each organization shall allow subscribers to
4 continue care for 90 60 days with a terminated treating
5 provider when medically necessary, provided the subscriber has
6 a life-threatening condition or a disabling and degenerative
7 condition. Each organization shall allow a subscriber who is
8 in the third trimester of pregnancy to continue care with a
9 terminated treating provider until completion of postpartum
10 care. The organization and the provider shall continue to be
11 bound by the terms of the contract for such continued care.
12 This subsection shall not apply to treating providers who have
13 been terminated by the organization for cause.
14 Section 13. Subsections (2) and (4) of section
15 641.511, Florida Statutes, 1998 Supplement, are amended to
16 read:
17 641.511 Subscriber grievance reporting and resolution
18 requirements.--
19 (2) When an organization receives an initial complaint
20 from a subscriber, the organization must respond to the
21 complaint within a reasonable time after its submission, not
22 to exceed 15 days. At the time of receipt of the initial
23 complaint, the organization shall inform the subscriber that
24 the subscriber has a right to file a written grievance at any
25 time and that assistance in preparing the written grievance
26 shall be provided by the organization.
27 (4)(a) With respect to a grievance concerning an
28 adverse determination, an organization shall make available to
29 the subscriber a review of the grievance by an internal review
30 panel; such review must be requested within 30 days after the
31 organization's transmittal of the final decision in writing by
17
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 the grievance manager pursuant to paragraph (3)(f)
2 determination notice of an adverse determination. A majority
3 of the panel shall be persons who previously were not involved
4 in the initial adverse determination. A person who previously
5 was involved in the adverse determination may appear before
6 the panel to present information or answer questions. The
7 panel shall have the authority to bind the organization to the
8 panel's decision.
9 (b) An organization shall ensure that a majority of
10 the persons reviewing a grievance involving an adverse
11 determination are providers who have appropriate expertise.
12 An organization shall issue a copy of the written decision of
13 the review panel to the subscriber and to the provider, if
14 any, who submits a grievance on behalf of a subscriber. In
15 cases where there has been a denial of coverage of service,
16 the reviewing provider shall not be a provider previously
17 involved with the adverse determination.
18 (c) An organization shall establish written procedures
19 for a review of an adverse determination. Review procedures
20 shall be available to the subscriber and to a provider acting
21 on behalf of a subscriber.
22 (d) Each organization's grievance procedures for the
23 review panel as required under this subsection must include as
24 a minimum the following:
25 1. A hearing must be held at which the subscriber may
26 appear, be heard, and submit documentation regarding the
27 grievance;
28 2. The subscriber may be represented at the hearing by
29 a person of his or her choice including legal counsel;
30
31
18
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2230
28-1166-99
1 3. The subscriber may be accompanied by the provider
2 who ordered the disputed treatment or service, who shall be
3 allowed to speak on the subscriber's behalf; and
4 4. The subscriber must be allowed to document the
5 hearing by transcription or by video or audio recording.
6 (e)(d) In any case when the review process does not
7 resolve a difference of opinion between the organization and
8 the subscriber or the provider acting on behalf of the
9 subscriber, the subscriber or the provider acting on behalf of
10 the subscriber may submit a written grievance to the Statewide
11 Provider and Subscriber Assistance Program.
12 Section 14. This act shall take effect on October 1,
13 1999, and shall apply to policies and contracts issued or
14 renewed on or after that date.
15
16 *****************************************
17 SENATE SUMMARY
18 Authorizes point of service policies under arrangements
between health insurers and health maintenance
19 organizations. Provides criteria and standards.
Establishes a subscriber's bill of rights. Prohibits
20 health maintenance organizations from excluding a covered
service if a subscriber is receiving a noncovered service
21 in conjunction with the covered service. Provides for the
return of excessive premiums and for continuation of care
22 under certain circumstances. Prohibits retroactive
cancellation and requires notice prior to cancellation.
23 Requires that the Department of Insurance be given notice
of the cancellation of a provider contract. Prohibits the
24 use of certain words on forms, contracts, and advertising
material. Extends time for receiving covered services
25 from a terminated provider. Requires an HMO to respond to
an initial complaint within 45 days. Specifies certain
26 grievance procedures and rights. (See bill for details.)
27
28
29
30
31
19