Senate Bill 2472
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
By Senator Clary
7-1546-99
1 A bill to be entitled
2 An act relating to managed health care;
3 amending s. 408.7056, F.S.; excluding certain
4 additional grievances from consideration by a
5 statewide provider and subscriber assistance
6 panel; revising the membership of the panel;
7 providing for the Agency for Health Care
8 Administration or the Department of Insurance
9 to adopt the panel's recommendation in a final
10 order rather than in a proposed order;
11 providing that a final order is subject to
12 judicial review; amending s. 641.51, F.S.;
13 requiring that health maintenance organizations
14 provide additional information to the Agency
15 for Health Care Administration indicating
16 quality of care; removing a requirement that
17 organizations conduct customer satisfaction
18 surveys; revising requirements for preventive
19 pediatric health care provided by health
20 maintenance organizations; amending s. 641.58,
21 F.S.; providing for moneys in the Health Care
22 Trust Fund to be used for additional purposes;
23 creating the Health Care Information Council
24 within the Agency for Health Care
25 Administration; providing for the appointment
26 of members to the council; providing terms of
27 office; providing that the council members are
28 entitled for reimbursement for per diem and
29 travel expenses; authorizing the council to
30 employ an executive director and staff members;
31 requiring that the council advise the Governor
1
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 and Legislature on matters of health care
2 accountability and consumer information;
3 requiring that the council administer a
4 member-satisfaction survey of health
5 maintenance organizations; requiring that the
6 survey results be made public; providing an
7 effective date.
8
9 Be It Enacted by the Legislature of the State of Florida:
10
11 Section 1. Subsections (2), (9), (11), and (14) of
12 section 408.7056, Florida Statutes, 1998 Supplement, are
13 amended to read:
14 408.7056 Statewide Provider and Subscriber Assistance
15 Program.--
16 (2) The agency shall adopt and implement a program to
17 provide assistance to subscribers and providers, including
18 those whose grievances are not resolved by the managed care
19 entity to the satisfaction of the subscriber or provider. The
20 program shall consist of one or more panels that meet as often
21 as necessary to timely review, consider, and hear grievances
22 and recommend to the agency or the department any actions that
23 should be taken concerning individual cases heard by the
24 panel. The panel shall hear every grievance filed by
25 subscribers and providers on behalf of subscribers, unless the
26 grievance:
27 (a) Relates to a managed care entity's refusal to
28 accept a provider into its network of providers;
29 (b) Is part of an internal grievance in a managed care
30 entity or a reconsideration appeal through the Medicare
31
2
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 appeals process which does not involve a quality of care
2 issue;
3 (c) Is related to a health plan not regulated by the
4 state such as an administrative services organization,
5 third-party administrator, or federal employee health benefit
6 program;
7 (d) Is related to appeals by in-plan suppliers and
8 providers, unless related to quality of care provided by the
9 plan;
10 (e) Is part of a Medicaid fair hearing pursued under
11 42 C.F.R. ss. 431.220 et seq.;
12 (f) Is the basis for an action pending in state or
13 federal court;
14 (g) Is related to an appeal by nonparticipating
15 providers, unless related to the quality of care provided to a
16 subscriber by the managed care entity and the provider is
17 involved in the care provided to the subscriber;
18 (h) Was filed before the subscriber or provider
19 completed the entire internal grievance procedure of the
20 managed care entity, the managed care entity has complied with
21 its timeframes for completing the internal grievance
22 procedure, and the circumstances described in subsection (6)
23 do not apply;
24 (i) Has been resolved to the satisfaction of the
25 subscriber or provider who filed the grievance, unless the
26 managed care entity's initial action is egregious or may be
27 indicative of a pattern of inappropriate behavior;
28 (j) Is limited to seeking damages for pain and
29 suffering, lost wages, or other incidental expenses, including
30 accrued interest on unpaid balances, court costs, and
31 transportation costs associated with a grievance procedure;
3
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 (k) Is limited to issues involving conduct of a health
2 care provider or facility, staff member, or employee of a
3 managed care entity which constitute grounds for disciplinary
4 action by the appropriate professional licensing board and is
5 not indicative of a pattern of inappropriate behavior, and the
6 agency or department has reported these grievances to the
7 appropriate professional licensing board or to the health
8 facility regulation section of the agency for possible
9 investigation; or
10 (l) Is withdrawn by the subscriber or provider.
11 Failure of the subscriber or the provider to attend the
12 hearing shall be considered a withdrawal of the grievance.
13 (9) No later than 30 days after the issuance of the
14 panel's recommendation and, for an expedited grievance, no
15 later than 10 days after the issuance of the panel's
16 recommendation, the agency or the department may adopt the
17 panel's recommendation or findings of fact in a final proposed
18 order or an emergency order, as provided in chapter 120, which
19 it shall issue to the managed care entity. The agency or
20 department may issue a proposed order or an emergency order,
21 as provided in chapter 120, imposing fines or sanctions,
22 including those contained in ss. 641.25 and 641.52. The
23 agency or the department may reject all or part of the panel's
24 recommendation. All fines collected under this subsection must
25 be deposited into the Health Care Trust Fund.
26 (11) The panel shall consist of members employed by
27 the agency and members employed by the department, chosen by
28 their respective agencies; a consumer; a physician, as a
29 standing member; and physicians who have expertise relevant to
30 the case to be heard, on a rotating basis. The agency may
31 contract with a medical director and a primary care physician
4
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 who shall provide additional technical expertise to the panel.
2 The medical director shall be selected from a health
3 maintenance organization with a current certificate of
4 authority to operate in Florida.
5 (14) A final proposed order issued by the agency or
6 department which only requires the managed care entity to take
7 a specific action under subsection (7) is subject to judicial
8 review under s. 120.68 a summary hearing in accordance with s.
9 120.574, unless all of the parties agree otherwise. If the
10 managed care entity does not prevail at a judicial review the
11 hearing, the managed care entity must pay reasonable costs and
12 attorney's fees of the agency or the department incurred in
13 that proceeding.
14 Section 2. Subsections (8), (9), and (10) of section
15 641.51, Florida Statutes, are amended to read:
16 641.51 Quality assurance program; second medical
17 opinion requirement.--
18 (8) Each organization shall release to the agency data
19 that which are indicators of access and quality of care. The
20 agency shall develop rules specifying data-reporting
21 requirements for these indicators. The indicators shall
22 include the following characteristics:
23 (a) They must relate to access and quality of care
24 measures.
25 (b) They must be consistent with data collected
26 pursuant to accreditation activities and standards.
27 (c) They must be consistent with frequency
28 requirements under the accreditation process.
29 (d) They must include measures of the management of
30 chronic diseases.
31
5
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 (e) They must include preventative health care for
2 adults and children.
3 (f) They must include measures of prenatal care.
4 (g) They must include measures of health checkups for
5 children.
6
7 The agency shall develop by rule a uniform format for
8 publication of the data for the public which shall contain
9 explanations of the data collected and the relevance of such
10 data. The agency shall publish such data no less frequently
11 than every 2 years.
12 (9) Each organization shall conduct a standardized
13 customer satisfaction survey, as developed by the agency by
14 rule, of its membership at intervals specified by the agency.
15 The survey shall be consistent with surveys required by
16 accrediting organizations and may contain up to 10 additional
17 questions based on concerns specific to Florida. Survey data
18 shall be submitted to the agency, which shall make comparative
19 findings available to the public.
20 (9)(10) Each organization shall adopt recommendations
21 for preventive pediatric health care which are consistent with
22 the early periodic screening, diagnosis, and treatment
23 requirements for health checkups for children developed for
24 the Medicaid program. Each organization shall establish goals
25 to achieve 80-percent compliance by July 1, 1998, and
26 90-percent compliance by July 1, 1999, for their enrolled
27 pediatric population.
28 Section 3. Subsection (4) of section 641.58, Florida
29 Statutes, is amended to read:
30 641.58 Regulatory assessment; levy and amount; use of
31 funds; tax returns; penalty for failure to pay.--
6
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 (4) The moneys so received and deposited into the
2 Health Care Trust Fund shall be used to defray the expenses of
3 the agency in the discharge of its administrative and
4 regulatory powers and duties under this part, including
5 administering the Health Care Information Council; conducting
6 an annual survey of the satisfaction of members of health
7 maintenance organizations; contracting with physician
8 consultants for the Statewide Provider and Subscriber
9 Assistance Panel; the maintaining of offices and necessary
10 supplies, essential equipment, and other materials, salaries
11 and expenses of required personnel;, and discharging all other
12 legitimate expenses relating to the discharge of the
13 administrative and regulatory powers and duties imposed under
14 this such part.
15 Section 4. Health Care Information Council.--
16 (1) There is created a Health Care Information
17 Council. The council shall be located within the Agency for
18 Health Care Administration for administrative purposes, but
19 shall independently exercise the powers and duties specified
20 in this section.
21 (a) The council shall be composed of 11 members,
22 including the Director of the Agency for Health Care
23 Administration, or his or her designee; the Insurance
24 Commissioner, or his or her designee; three members appointed
25 by the Governor; three members appointed by the President of
26 the Senate; and three members appointed by the Speaker of the
27 House of Representatives. The appointments shall be made in
28 such a manner as to achieve a balance between managed care
29 organizations, health care providers, and consumers.
30 (b) Members shall be appointed for staggered terms of
31 not more than 2 years. An appointment to fill a vacancy shall
7
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 be for the remainder of the term. The Governor may remove any
2 member who, without cause, fails to attend two consecutive
3 meetings.
4 (c) The council shall annually select a chairperson
5 and vice chairperson from among its members. The council shall
6 meet at least quarterly, but shall also meet at the call of
7 its chairperson or at the request of a majority of its
8 members. A majority of the members of the council constitutes
9 a quorum.
10 (d) Membership on the council does not disqualify a
11 member from holding any other public office or from being
12 employed by a public entity, except that a member of the
13 Legislature may not serve on the council.
14 (e) Members of the council shall serve without
15 compensation, but are entitled to reimbursement for per diem
16 and travel expenses as provided in section 112.061, Florida
17 Statutes.
18 (2) The council shall employ an executive director and
19 necessary staff members, as provided by legislative
20 appropriation. The council may retain consultants as necessary
21 to accomplish its purposes. The executive director and any
22 consultant retained by the council may not be a current or
23 former contract vendor of the Department of Insurance or the
24 Agency for Health Care Administration.
25 (3) The Health Care Information Council shall act in
26 an advisory capacity to the Governor, the Legislature, the
27 Department of Insurance, and the Agency for Health Care
28 Administration on matters of health care accountability and
29 consumer information. The duties of the council include, but
30 are not limited to:
31
8
CODING: Words stricken are deletions; words underlined are additions.
Florida Senate - 1999 SB 2472
7-1546-99
1 (a) Contracting with an independent contractor to
2 administer an annual member-satisfaction survey for all health
3 maintenance organizations, including the Medicare and Medicaid
4 programs.
5 (b) Selecting the instrument and the sampling design
6 to meet the requirements for member-satisfaction surveys for
7 accreditation organizations of health maintenance
8 organizations.
9 (c) Producing a report card for health maintenance
10 organizations.
11 (d) Making comparative survey results available to
12 health maintenance organizations and the public.
13 (4) In addition to the results of the
14 member-satisfaction survey, the report card for health
15 maintenance organizations must include benefit availability,
16 physician qualifications, payment arrangements, copayment
17 requirements, and the quality indicators provided under
18 section 641.51(8)(d), (e), (f), and (g), Florida Statutes.
19 Section 5. This act shall take effect upon becoming a
20 law.
21
22 *****************************************
23 SENATE SUMMARY
24 Revises certain provisions of the grievance procedures
for subscribers of health maintenance organizations.
25 Provides for the provider and subscriber assistance panel
to include a consumer, a physician, and physicians who
26 have specific expertise. Requires that the Agency for
Health Care Administration or the Department of Insurance
27 adopt the panel's recommendation as a final order rather
than a proposed order. Provides that the final order is
28 subject to judicial review. Provides additional
requirements for health maintenance organizations in
29 providing pediatric health care. Creates the Health Care
Information Council to administer member-satisfaction
30 surveys of health maintenance organizations and advise
the Governor and Legislature on matters of health care
31 accountability and consumer information. (See bill for
details.)
9