House Bill 0783

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    Florida House of Representatives - 1999                 HB 783

        By Representative Murman






  1                      A bill to be entitled

  2         An act relating to provider contracts; creating

  3         s. 626.8812, F.S.; requiring an insurance

  4         administrator to pay certain contract provider

  5         claims under certain circumstances; providing

  6         requirements for administrators in denying

  7         claims; requiring contract providers to provide

  8         certain information under certain

  9         circumstances; specifying conditions of payment

10         of claims; providing for interest on overdue

11         claim payments; requiring payment of claims

12         within a time certain; amending s. 641.31,

13         F.S.; authorizing a subscriber to terminate a

14         health maintenance contract under certain

15         circumstances; limiting certain activities by a

16         health maintenance organization between open

17         enrollment periods; authorizing a health

18         maintenance organization to amend a contract

19         under certain circumstances; amending s.

20         641.315, F.S.; prohibiting certain provisions

21         in contracts between health care providers and

22         health maintenance organizations; providing

23         application; amending s. 641.3155, F.S.;

24         providing application to fiscal intermediary

25         services organizations; providing an effective

26         date.

27

28  Be It Enacted by the Legislature of the State of Florida:

29

30         Section 1.  Section 626.8812, Florida Statutes, is

31  created to read:

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    Florida House of Representatives - 1999                 HB 783

    583-145-99






  1         626.8812  Provider contracts; payment of claims.--

  2         (1)(a)  An administrator shall pay any claim or any

  3  portion of a claim made by a contract provider for services or

  4  goods provided under a contract with the administrator which

  5  the administrator does not contest or deny within 35 days

  6  after receipt of the claim by the administrator which is

  7  mailed or electronically transferred by the provider.

  8         (b)  An administrator that denies or contests a

  9  provider's claim, or any portion of such claim, shall notify

10  the contract provider, in writing, within 35 days after

11  receipt of the claim by the administrator that the claim is

12  contested or denied.  The notice that the claim is denied or

13  contested must identify the contested portion of the claim and

14  the specific reason for contesting or denying the claim, and

15  may include a request for additional information.  If the

16  administrator requests additional information, the provider

17  shall, within 35 days after receipt of such request, mail or

18  electronically transfer the information to the administrator.

19  The administrator shall pay or deny the claim or portion of

20  the claim within 45 days after receipt of the information.

21         (2)  Payment of a claim is considered made on the date

22  the payment was received or electronically transferred or

23  otherwise delivered.  An overdue payment of a claim bears

24  simple interest at the rate of 10 percent per year.

25         (3)  An administrator shall pay or deny any claim no

26  later than 120 days after receiving the claim.

27         Section 2.  Paragraph (a) of subsection (3) and

28  subsection (22) of section 641.31, Florida Statutes, 1998

29  Supplement, are amended, to read:

30         641.31  Health maintenance contracts.--

31

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    Florida House of Representatives - 1999                 HB 783

    583-145-99






  1         (3)(a)  If a health maintenance organization desires to

  2  amend any contract with its subscribers or any certificate or

  3  member handbook, or desires to change any rate charged for the

  4  contract or to change any basic health maintenance contract,

  5  certificate, grievance procedure, or member handbook form, or

  6  application form where written application is required and is

  7  to be made a part of the contract, or printed amendment,

  8  addendum, rider, or endorsement form or form of renewal

  9  certificate, it may do so, upon filing with the department the

10  proposed change, amendment, or change in rates.  Any proposed

11  change shall be effective immediately, subject to disapproval

12  by the department.  Following receipt of notice of such

13  disapproval or withdrawal of approval, no health maintenance

14  organization shall issue or use any form or rate disapproved

15  by the department or as to which the department has withdrawn

16  approval. Any change in the rate requires at least 30 days'

17  advance written notice to the subscriber.  In the case of a

18  group member, there may be a contractual agreement with the

19  health maintenance organization to have the employer provide

20  the required notice to the individual members of the group. A

21  subscriber may terminate his or her contract 30 days after

22  providing advance written notice to the health maintenance

23  organization after receiving a written notice from the health

24  maintenance organization of a material change in member

25  benefits, including, but not limited to:

26         1.  Termination by the health maintenance organization

27  of the provider contract of the subscriber's primary care

28  physician.

29         2.  Termination of the provider contract of any

30  specialist physician with whom the subscriber has an active

31  physician-patient relationship.

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    Florida House of Representatives - 1999                 HB 783

    583-145-99






  1         3.  The deletion from the approved formulary of any

  2  prescription drug currently prescribed to the subscriber.

  3         (22)  Each health maintenance organization that offers

  4  a group plan within this state must have at least one open

  5  enrollment period of not less than 30 days every 18 months.

  6  Such open enrollment periods are required for as long as the

  7  group exists unless the health maintenance organization and

  8  the employer mutually agree to a shorter period of time than

  9  18 months.  Between open enrollment periods, the health

10  maintenance organization may not delete, amend, limit, or

11  increase the copayment for any of the services to which a

12  subscriber is entitled under the group contract.  Upon written

13  notice to the subscriber at least 30 days in advance of the

14  next open enrollment period, the health maintenance

15  organization may amend the contract with its group

16  subscribers, subject to the provisions of subsection (3), with

17  such amendment being effective immediately upon the expiration

18  of the open enrollment period.

19         Section 3.  (1)  Subsection (9) is added to section

20  641.315, Florida Statutes, to read:

21         641.315  Provider contracts.--

22         (9)  A contract between a health maintenance

23  organization and a provider of health care services shall not

24  contain any provision which prohibits or restricts:

25         (a)  The health care provider from entering into

26  contract with any other health maintenance organization; or

27         (b)  The health maintenance organization from entering

28  into contract with any other health care provider.

29         (2)  The amendment to s. 641.315, Florida Statutes, by

30  this act shall apply to contracts renewed or entered into on

31  or after July 1, 1999.

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    Florida House of Representatives - 1999                 HB 783

    583-145-99






  1         Section 4.  Subsection (4) is added to section

  2  641.3155, Florida Statutes, 1998 Supplement, to read:

  3         641.3155  Provider contracts; payment of claims.--

  4         (4)  This section applies to fiscal intermediary

  5  services organizations as defined in s. 641.316.

  6         Section 5.  This act shall take effect July 1, 1999.

  7

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  9                          HOUSE SUMMARY

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      Provides conditions and requirements for payment of
11    claims under provider contracts.  Authorizes a subscriber
      to terminate a health maintenance contract after a health
12    maintenance organization makes material changes to member
      benefits. Limits activities by a health maintenance
13    organization between open enrollment periods. Authorizes
      a health maintenance organization to amend a contract
14    after advance notice. Prohibits provisions in contracts
      between health care providers and health maintenance
15    organizations that prohibit or restrict the health care
      provider from entering into contract with any other
16    health maintenance organization or the health maintenance
      organization from entering into contract with any other
17    health care provider.  Applies provider contract claim
      payment requirements to fiscal intermediary services
18    organization.

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