Senate Bill 2472c1
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Florida Senate - 1999 CS for SB's 2472 & 1892
By the Committee on Health, Aging and Long-Term Care; and
Senators Clary and Saunders
317-1997B-99
1 A bill to be entitled
2 An act relating to managed health care;
3 amending s. 408.05, F.S., relating to the State
4 Center for Health Statistics; requiring the
5 Agency for Health Care Administration to
6 publish health maintenance organization report
7 cards; amending s. 408.7056, F.S.; excluding
8 certain additional grievances from
9 consideration by a statewide provider and
10 subscriber assistance panel; revising the
11 membership of the panel; amending s. 627.6471,
12 F.S.; requiring preferred provider organization
13 policies that require a referral for services
14 to conform to certain requirements imposed on
15 exclusive provider organization contracts;
16 amending s. 641.31, F.S., relating to health
17 maintenance contracts; providing for a
18 point-of-service benefit rider on a health
19 maintenance contract; providing requirements;
20 providing restrictions; authorizing reasonable
21 copayment and annual deductible; providing
22 exceptions relating to subscriber liability for
23 services received; amending s. 641.3155, F.S.,
24 relating to health maintenance organization
25 provider contracts and payment of claims;
26 requiring health maintenance organizations to
27 reconcile retroactive reductions of payment to
28 specific claims; requiring providers to
29 reconcile retroactive demands for underpayment
30 or nonpayment to specific claims; providing an
31 exception; providing for the contract to
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Florida Senate - 1999 CS for SB's 2472 & 1892
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1 specify the look-back period; providing for an
2 advisory group established in the Agency for
3 Health Care Administration; requiring a report;
4 amending s. 641.51, F.S.; requiring that health
5 maintenance organizations provide additional
6 information to the Agency for Health Care
7 Administration indicating quality of care;
8 removing a requirement that organizations
9 conduct customer satisfaction surveys; revising
10 requirements for preventive pediatric health
11 care provided by health maintenance
12 organizations; amending s. 641.58, F.S.;
13 providing for moneys in the Health Care Trust
14 Fund to be used for additional purposes;
15 providing an appropriation; providing an
16 effective date.
17
18 Be It Enacted by the Legislature of the State of Florida:
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20 Section 1. Paragraph (a) of subsection (5) of section
21 408.05, Florida Statutes, 1998 Supplement, is amended to read:
22 408.05 State Center for Health Statistics.--
23 (5) PUBLICATIONS; REPORTS; SPECIAL STUDIES.--The
24 center shall provide for the widespread dissemination of data
25 which it collects and analyzes. The center shall have the
26 following publication, reporting, and special study functions:
27 (a) The center shall publish and make available
28 periodically to agencies and individuals health statistics
29 publications of general interest, including HMO report cards;
30 publications providing health statistics on topical health
31 policy issues;, publications that which provide health status
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Florida Senate - 1999 CS for SB's 2472 & 1892
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1 profiles of the people in this state;, and other topical
2 health statistics publications.
3 Section 2. Subsections (2) and (11) of section
4 408.7056, Florida Statutes, 1998 Supplement, are amended to
5 read:
6 408.7056 Statewide Provider and Subscriber Assistance
7 Program.--
8 (2) The agency shall adopt and implement a program to
9 provide assistance to subscribers and providers, including
10 those whose grievances are not resolved by the managed care
11 entity to the satisfaction of the subscriber or provider. The
12 program shall consist of one or more panels that meet as often
13 as necessary to timely review, consider, and hear grievances
14 and recommend to the agency or the department any actions that
15 should be taken concerning individual cases heard by the
16 panel. The panel shall hear every grievance filed by
17 subscribers and providers on behalf of subscribers, unless the
18 grievance:
19 (a) Relates to a managed care entity's refusal to
20 accept a provider into its network of providers;
21 (b) Is part of an internal grievance in a Medicare
22 managed care entity or a reconsideration appeal through the
23 Medicare appeals process which does not involve a quality of
24 care issue;
25 (c) Is related to a health plan not regulated by the
26 state such as an administrative services organization,
27 third-party administrator, or federal employee health benefit
28 program;
29 (d) Is related to appeals by in-plan suppliers and
30 providers, unless related to quality of care provided by the
31 plan;
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Florida Senate - 1999 CS for SB's 2472 & 1892
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1 (e) Is part of a Medicaid fair hearing pursued under
2 42 C.F.R. ss. 431.220 et seq.;
3 (f) Is the basis for an action pending in state or
4 federal court;
5 (g) Is related to an appeal by nonparticipating
6 providers, unless related to the quality of care provided to a
7 subscriber by the managed care entity and the provider is
8 involved in the care provided to the subscriber;
9 (h) Was filed before the subscriber or provider
10 completed the entire internal grievance procedure of the
11 managed care entity, the managed care entity has complied with
12 its timeframes for completing the internal grievance
13 procedure, and the circumstances described in subsection (6)
14 do not apply;
15 (i) Has been resolved to the satisfaction of the
16 subscriber or provider who filed the grievance, unless the
17 managed care entity's initial action is egregious or may be
18 indicative of a pattern of inappropriate behavior;
19 (j) Is limited to seeking damages for pain and
20 suffering, lost wages, or other incidental expenses, including
21 accrued interest on unpaid balances, court costs, and
22 transportation costs associated with a grievance procedure;
23 (k) Is limited to issues involving conduct of a health
24 care provider or facility, staff member, or employee of a
25 managed care entity which constitute grounds for disciplinary
26 action by the appropriate professional licensing board and is
27 not indicative of a pattern of inappropriate behavior, and the
28 agency or department has reported these grievances to the
29 appropriate professional licensing board or to the health
30 facility regulation section of the agency for possible
31 investigation; or
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1 (l) Is withdrawn by the subscriber or provider.
2 Failure of the subscriber or the provider to attend the
3 hearing shall be considered a withdrawal of the grievance.
4 (11) The panel shall consist of members employed by
5 the agency and members employed by the department, chosen by
6 their respective agencies; a consumer appointed by the
7 Governor; a physician appointed by the Governor, as a standing
8 member; and physicians who have expertise relevant to the case
9 to be heard, on a rotating basis. The agency may contract with
10 a medical director and a primary care physician who shall
11 provide additional technical expertise to the panel. The
12 medical director shall be selected from a health maintenance
13 organization with a current certificate of authority to
14 operate in Florida.
15 Section 3. Present subsection (5) of section 627.6471,
16 Florida Statutes, is redesignated as subsection (6) and a new
17 subsection (5) is added to that section to read:
18 627.6471 Contracts for reduced rates of payment;
19 limitations; coinsurance and deductibles.--
20 (5) Any policy issued under this section which
21 requires an insured to obtain a referral prior to receiving
22 services must conform to the requirements of s. 627.6472(16).
23 Section 4. Subsection (36) is added to section 641.31,
24 Florida Statutes, 1998 Supplement, to read:
25 641.31 Health maintenance contracts.--
26 (36)(a) Notwithstanding any other provision of this
27 part, a health maintenance organization that meets the
28 requirements of paragraph (b) may, through a point-of-service
29 rider to its contract providing comprehensive health care
30 services, include a point-of-service benefit. Under such a
31 rider, a subscriber or other covered person of the health
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1 maintenance organization may choose, at the time of covered
2 service, a provider with whom the health maintenance
3 organization does not have a health maintenance organization
4 provider contract. The rider may not require a referral from
5 the health maintenance organization for the point-of-service
6 benefits.
7 (b) A health maintenance organization offering a
8 point-of-service rider under this subsection must have a valid
9 certificate of authority issued under the provisions of the
10 chapter, must have been licensed under this chapter for a
11 minimum of 3 years, and must at all times that it has riders
12 in effect maintain a minimum surplus of $5 million.
13 (c) Premiums paid in for the point-of-service riders
14 may not exceed 15 percent of total premiums for all health
15 plan products sold by the health maintenance organization
16 offering the rider. If the premiums paid for point-of-service
17 riders exceed 15 percent, the health maintenance organization
18 must notify the department and, once this fact is known, must
19 immediately cease offering such a rider until it is in
20 compliance with the rider premium cap.
21 (d) Notwithstanding the limitations of deductibles and
22 copayment provisions in this part, a point-of-service rider
23 may require the subscriber to pay a reasonable copayment for
24 each visit for services provided by a noncontracted provider
25 chosen at the time of the service. The copayment by the
26 subscriber may either be a specific dollar amount or a
27 percentage of the reimbursable provider charges covered by the
28 contract and must be paid by the subscriber to the
29 noncontracted provider upon receipt of covered services. The
30 point-of-service rider may require that a reasonable annual
31 deductible for the expenses associated with the
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1 point-of-service rider be met and may include a lifetime
2 maximum benefit amount. The rider must include the language
3 required by s. 627.6044 and must comply with copayment limits
4 described in s. 627.6471. Section 641.315(2) and (3) does not
5 apply to a point-of-service rider authorized under this
6 subsection.
7 (e) The term "point of service" may not be used by a
8 health maintenance organization except with riders permitted
9 under this section or with forms approved by the department in
10 which a point-of-service product is offered with an indemnity
11 carrier.
12 (f) A point-of-service rider must be filed and
13 approved under ss. 627.410 and 627.411.
14 Section 5. Subsection (4) is added to section
15 641.3155, Florida Statutes, 1998 Supplement, to read:
16 641.3155 Provider contracts; payment of claims.--
17 (4) Any retroactive reductions of payments or demands
18 for refund of previous overpayments which are due to
19 retroactive review-of-coverage decisions or payment levels
20 must be reconciled to specific claims unless the parties agree
21 to other reconciliation methods and terms. Any retroactive
22 demands by providers for payment due to underpayments or
23 nonpayments for covered services must be reconciled to
24 specific claims unless the parties agree to other
25 reconciliation methods and terms. The look-back period may be
26 specified by the terms of the contract.
27 Section 6. The Director of the Agency for Health Care
28 Administration shall establish an advisory group composed of
29 eight members, with three members from health maintenance
30 organizations licensed in Florida, one representative from a
31 not-for-profit hospital, one representative from a for-profit
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1 hospital, one representative who is a licensed physician, one
2 representative from the Office of the Insurance Commissioner,
3 and one representative from the Agency for Health Care
4 Administration. The advisory group shall study and make
5 recommendations concerning:
6 (1) Trends and issues relating to legislative,
7 regulatory, or private-sector solutions for timely and
8 accurate submission and payment of health claims.
9 (2) Development of electronic billing and claims
10 processing for providers and health care facilities that
11 provide for electronic processing of eligibility requests;
12 benefit verification; authorizations; precertifications;
13 business expensing of assets, including software, used for
14 electronic billing and claims processing; and claims status,
15 including use of models such as those compatible with federal
16 billing systems.
17 (3) The form and content of claims.
18 (4) Measures to reduce fraud and abuse relating to the
19 submission and payment of claims.
20
21 The advisory group shall be appointed and convened by July 1,
22 1999, and shall meet in Tallahassee. Members of the advisory
23 group shall not receive per diem or travel reimbursement. The
24 advisory group shall submit its recommendations in a report,
25 by January 1, 2000, to the President of the Senate and the
26 Speaker of the House of Representatives.
27 Section 7. Subsections (8), (9), and (10) of section
28 641.51, Florida Statutes, are amended to read:
29 641.51 Quality assurance program; second medical
30 opinion requirement.--
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1 (8) Each organization shall release to the agency data
2 that which are indicators of access and quality of care. The
3 agency shall develop rules specifying data-reporting
4 requirements for these indicators. The indicators shall
5 include the following characteristics:
6 (a) They must relate to access and quality of care
7 measures.
8 (b) They must be consistent with data collected
9 pursuant to accreditation activities and standards.
10 (c) They must be consistent with frequency
11 requirements under the accreditation process.
12 (d) They must include measures of the management of
13 chronic diseases.
14 (e) They must include preventive health care for
15 adults and children.
16 (f) They must include measures of prenatal care.
17 (g) They must include measures of health checkups for
18 children.
19
20 The agency shall develop by rule a uniform format for
21 publication of the data for the public which shall contain
22 explanations of the data collected and the relevance of such
23 data. The agency shall publish such data no less frequently
24 than every 2 years.
25 (9) Each organization shall conduct a standardized
26 customer satisfaction survey, as developed by the agency by
27 rule, of its membership at intervals specified by the agency.
28 The survey shall be consistent with surveys required by
29 accrediting organizations and may contain up to 10 additional
30 questions based on concerns specific to Florida. Survey data
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1 shall be submitted to the agency, which shall make comparative
2 findings available to the public.
3 (9)(10) Each organization shall adopt recommendations
4 for preventive pediatric health care which are consistent with
5 the early periodic screening, diagnosis, and treatment
6 requirements for health checkups for children developed for
7 the Medicaid program. Each organization shall establish goals
8 to achieve 80-percent compliance by July 1, 1998, and
9 90-percent compliance by July 1, 1999, for their enrolled
10 pediatric population.
11 Section 8. Subsection (4) of section 641.58, Florida
12 Statutes, is amended to read:
13 641.58 Regulatory assessment; levy and amount; use of
14 funds; tax returns; penalty for failure to pay.--
15 (4) The moneys so received and deposited into the
16 Health Care Trust Fund shall be used to defray the expenses of
17 the agency in the discharge of its administrative and
18 regulatory powers and duties under this part, including
19 conducting an annual survey of the satisfaction of members of
20 health maintenance organizations; contracting with physician
21 consultants for the Statewide Provider and Subscriber
22 Assistance Panel; the maintaining of offices and necessary
23 supplies, essential equipment, and other materials, salaries
24 and expenses of required personnel;, and discharging all other
25 legitimate expenses relating to the discharge of the
26 administrative and regulatory powers and duties imposed under
27 this such part.
28 Section 9. There is appropriated to the Agency for
29 Health Care Administration for fiscal year 1999-2000
30 $1,439,000 from the Health Care Trust Fund for 12 months of
31 funding for the purpose of implementing this act.
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1 Section 10. This act shall take effect upon becoming a
2 law.
3
4 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
5 SB's 2472 and 1892
6
7 Adds to the responsibilities of the State Center for Health
Statistics within AHCA publication of health maintenance
8 organization report cards.
9 Designates the Governor to appoint the consumer member and the
physician member added to the Statewide Provider and
10 Subscriber Assistance Panel.
11 Deletes a revision to current law that would have required the
Agency for Health Care Administration or the Department of
12 Insurance to adopt the recommendations of the Statewide
Provider and Subscriber Assistance Panel in a final order
13 rather than a proposed order.
14 Provides that preferred provider organization policies that
require a referral must conform to exclusive provider
15 organization policy requirements.
16 Authorizes health maintenance organizations to offer
point-of-service benefits through a point-of-service rider to
17 their comprehensive health care services contracts. Provides
restrictions and limitations on such riders. Requires $5
18 million surplus to cover riders and authorizes copayments and
deductibles for point-of-service benefit riders.
19
Requires that retroactive payment demands by a health
20 maintenance organization or a provider be reconciled to
specific claims, and provides for the contract to specify the
21 look-back period.
22 Directs the Director of the Agency for Health Care
Administration to establish an advisory group to study and
23 make recommendations relating to claims payment; deletes the
provisions establishing and providing for funding of the
24 Health Care Information Council; and provides an appropriation
of $1,439,000 from the Health Care Trust Fund to the Agency
25 for Health Care Administration for Fiscal Year 1999-2000.
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