House Bill 0961
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Florida House of Representatives - 1999 HB 961
By Representative Lacasa
1 A bill to be entitled
2 An act relating to health care services;
3 amending s. 408.7056, F.S.; requiring certain
4 physician members on Statewide Provider and
5 Subscriber Assistance Program panels; amending
6 ss. 408.706 and 627.419, F.S., and creating s.
7 641.3151, F.S.; providing for patient choice in
8 the selection of a physician under any plan
9 offered through a health maintenance
10 organization, managed care provider
11 organization, prepaid health plan, or
12 accountable health partnership, or under any
13 health insurance policy, plan, or contract,
14 offered in the state; prohibiting certain
15 denial of payment for physician services;
16 specifying terms of reimbursement for services;
17 providing liability of subscribers for certain
18 charges; providing penalties; deleting
19 provisions relating to community health
20 purchasing alliance district health care
21 provider participation; amending s. 641.315,
22 F.S.; conforming provisions relating to
23 liability of subscribers under a health
24 maintenance organization provider contract;
25 amending s. 641.495, F.S., relating to
26 requirements for issuance and maintenance of a
27 health maintenance organization certificate of
28 authority; requiring certain documentation of
29 adverse determinations; providing an effective
30 date.
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Florida House of Representatives - 1999 HB 961
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1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Subsection (11) of section 408.7056,
4 Florida Statutes, 1998 Supplement, is amended to read:
5 408.7056 Statewide Provider and Subscriber Assistance
6 Program.--
7 (11) The panel shall consist of members employed by
8 the agency and members employed by the department, chosen by
9 their respective agencies. At least one-third of the members
10 of the panel shall be physicians licensed under chapter 458 or
11 chapter 459. If the grievance involves an adverse
12 determination as defined in s. 641.47, at least one of the
13 physicians on the panel shall be in the same specialty as that
14 forming the subject of the grievance or have training and
15 experience in the procedure in question. The agency may
16 contract with a medical director and a primary care physician
17 who shall provide additional technical expertise to the panel.
18 The medical director shall be selected from a health
19 maintenance organization with a current certificate of
20 authority to operate in Florida.
21 Section 2. Subsection (11) of section 408.706, Florida
22 Statutes, is amended to read:
23 408.706 Community health purchasing alliances;
24 accountable health partnerships.--
25 (11) Notwithstanding any other provision of law to the
26 contrary, any subscriber to a health plan offered by or
27 through a health maintenance organization, managed care
28 provider organization, prepaid health plan, or accountable
29 health partnership is entitled, at all times, to free, full,
30 and absolute choice in the selection of a physician licensed
31 under chapter 458 or chapter 459. It is expressly forbidden
2
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Florida House of Representatives - 1999 HB 961
574-148-99
1 for any health plan to contain any provision which would
2 require or coerce a subscriber to the plan to use any
3 physician other than the physician selected by the subscriber.
4 The ability to recruit and retain alliance district health
5 care providers in its provider network. For provider networks
6 initially formed in an alliance district after July 1, 1993,
7 an accountable health partnership shall make offers as to
8 provider participation in its provider network to relevant
9 alliance district health care providers for at least 60
10 percent of the available provider positions. A provider who is
11 made an offer may participate in an accountable health
12 partnership as long as the provider abides by the terms and
13 conditions of the provider network contract, provides services
14 at a rate or price equal to the rate or price negotiated by
15 the accountable health partnership, and meets all of the
16 accountable health partnership's qualifications for
17 participation in its provider networks including, but not
18 limited to, network adequacy criteria. For purposes of this
19 subsection, "alliance district health care provider" means a
20 health care provider who is licensed under chapter 458,
21 chapter 459, chapter 460, chapter 461, chapter 464, or chapter
22 465 who has practiced in Florida for more than 1 year within
23 the alliance district served by the accountable health
24 partnership.
25 (a) A health maintenance organization, managed care
26 provider organization, prepaid health plan, or accountable
27 health partnership may not deny payment to a physician
28 licensed under chapter 458 or chapter 459 who has rendered
29 covered services to a subscriber, based solely on the fact
30 that the physician has not entered into a provider contract
31 with the organization, plan, or partnership, as long as:
3
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Florida House of Representatives - 1999 HB 961
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1 1. That physician meets the health maintenance
2 organization, managed care provider organization, prepaid
3 health plan, or accountable health partnership's eligibility
4 criteria; and
5 2. Under accepted medical standards, the covered
6 services provided by the physician were medically necessary
7 such that the organization, plan, or partnership would be
8 required to pay for the services had they been performed by a
9 contracted provider.
10 (b) Reimbursement by a health maintenance
11 organization, managed care provider organization, prepaid
12 health plan, or accountable health partnership for services by
13 a physician who does not have a contract with the
14 organization, plan, or partnership shall be the lesser of:
15 1. Eighty percent of the physician's charges;
16 2. Eighty percent of the highest rate paid by the
17 organization, plan, or partnership to contracted physicians
18 for the procedure performed; or
19 3. The charge mutually agreed to by the organization,
20 plan, or partnership and the physician within 30 days after
21 the submittal of the claim.
22
23 The subscriber shall be liable for all physician charges not
24 covered by the health maintenance organization, managed care
25 provider organization, prepaid health plan, or accountable
26 health partnership pursuant to this paragraph.
27 (c) A health maintenance organization, managed care
28 provider organization, prepaid health plan, or accountable
29 health partnership that violates the provisions of this
30 section is subject to a civil fine in the amount of:
31 1. Up to $25,000 for each violation; or
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1 2. If the Director of Health Care Administration
2 determines that the entity has engaged in a pattern of
3 violations of this subsection, up to $100,000 for each
4 violation.
5 Section 3. Subsection (9) is added to section 627.419,
6 Florida Statutes, 1998 Supplement, to read:
7 627.419 Construction of policies.--
8 (9)(a) Notwithstanding any other provision of law to
9 the contrary, any person covered under any health insurance
10 policy, health care services plan, or other contract which
11 provides for payment for medical expense benefits or
12 procedures is entitled, at all times, to free, full, and
13 absolute choice in the selection of a physician licensed under
14 chapter 458 or chapter 459. It is expressly forbidden for any
15 health plan to contain any provision which would require or
16 coerce a person covered by the plan to use any provider other
17 than the provider selected by the subscriber. A health plan
18 may not deny payment to a physician licensed under chapter 458
19 or chapter 459 who has rendered covered services to an
20 insured, based solely on the fact that the physician has not
21 entered into a provider contract with the plan, as long as:
22 1. That physician meets the plan's eligibility
23 criteria; and
24 2. Under accepted medical standards, the covered
25 services provided by the physician were medically necessary
26 such that the organization would be required to pay for the
27 services had they been performed by a contracted physician.
28 (b) Reimbursement for services pursuant to this
29 subsection by a physician who does not have a contract with
30 the health plan shall be the lesser of:
31 1. Eighty percent of the physician's charges;
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1 2. Eighty percent of the highest rate paid by the
2 organization to contracted physicians for the procedure
3 performed; or
4 3. The charge mutually agreed to by the organization
5 and the physician within 30 days after the submittal of the
6 claim.
7
8 The subscriber shall be liable for all physician charges not
9 covered by the health plan pursuant to this paragraph.
10 (c) The provider of any health insurance policy,
11 health care services plan, or other contract that violates the
12 provisions of this subsection is subject to a civil fine in
13 the amount of:
14 1. Up to $25,000 for each violation; or
15 2. If the Director of Health Care Administration
16 determines that the entity has engaged in a pattern of
17 violations of this subsection, up to $100,000 for each
18 violation.
19 Section 4. Subsections (2) and (3) of section 641.315,
20 Florida Statutes, are amended to read:
21 641.315 Provider contracts.--
22 (2) No subscriber of an HMO shall be liable to any
23 provider of health care services who is a contracted provider
24 of that HMO for any services covered by the HMO.
25 (3) No provider of services who is a contracted
26 provider of an HMO, or any representative of such provider,
27 shall collect or attempt to collect from an HMO subscriber any
28 money for services covered by an HMO and no contracted
29 provider or representative of such provider may maintain any
30 action at law against a subscriber of an HMO to collect money
31 owed to such provider by an HMO.
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1 Section 5. Section 641.3151, Florida Statutes, is
2 created to read:
3 641.3151 Subscriber freedom of choice.--
4 (1) Notwithstanding any other provision of law to the
5 contrary, any subscriber to a health plan offered by or
6 through a health maintenance organization or managed care
7 provider organization is entitled, at all times, to free,
8 full, and absolute choice in the selection of a physician
9 licensed under chapter 458 or chapter 459. It is expressly
10 forbidden for any health plan to contain any provision which
11 would require or coerce a subscriber to the plan to use any
12 physician other than the physician selected by the subscriber.
13 A health maintenance organization or managed care provider
14 organization may not deny payment to a physician licensed
15 under chapter 458 or chapter 459 who has rendered covered
16 services to a subscriber, based solely on the fact that the
17 physician has not entered into a provider contract with the
18 organization, as long as:
19 (a) That physician meets the organization's
20 eligibility criteria; and
21 (b) Under accepted medical standards, the covered
22 services provided by the physician were medically necessary
23 such that the organization would be required to pay for the
24 services had they been performed by a contracted physician.
25 (2) Reimbursement for services pursuant to this
26 section by a physician who does not have a contract with the
27 health maintenance organization or managed care provider
28 organization shall be the lesser of:
29 (a) Eighty percent of the physician's charges;
30
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Florida House of Representatives - 1999 HB 961
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1 (b) Eighty percent of the highest rate paid by the
2 organization to contracted physicians for the procedure
3 performed; or
4 (c) The charge mutually agreed to by the organization
5 and the physician within 30 days after the submittal of the
6 claim.
7
8 The subscriber shall be liable for all physician charges not
9 covered by the health maintenance organization or managed care
10 provider organization pursuant to this subsection.
11 (3) A health maintenance organization or managed care
12 provider organization that violates the provisions of this
13 section is subject to a civil fine in the amount of:
14 (a) Up to $25,000 for each violation; or
15 (b) If the Director of Health Care Administration
16 determines that the entity has engaged in a pattern of
17 violations of this section, up to $100,000 for each violation.
18 Section 6. Subsection (11) of section 641.495, Florida
19 Statutes, 1998 Supplement, is amended to read:
20 641.495 Requirements for issuance and maintenance of
21 certificate.--
22 (11) The organization shall designate a medical
23 director who is a physician licensed under chapter 458 or
24 chapter 459. For every adverse determination made by the
25 organization regarding any subscriber, the medical director is
26 required to document and sign the subscriber's medical records
27 setting forth the facts regarding the organization's adverse
28 determination and the rationale for such decision. The
29 rendering of an adverse determination by a medical director
30 shall constitute the practice of medicine as defined in s.
31 458.305.
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1 Section 7. This act shall take effect October 1, 1999.
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4 HOUSE SUMMARY
5
Requires at least one-third of Statewide Provider and
6 Subscriber Assistance Program panel members to be
licensed physicians. Requires at least one physician
7 member to have training and experience in the subject
area of a grievance involving an adverse determination.
8 Provides for patient choice in the selection of a
physician under any plan offered through a health
9 maintenance organization, management care provider
organization, prepaid health plan, or accountable health
10 partnership, or under any health insurance policy, plan,
or contract, offered in the state. Prohibits denial of
11 payment for physician services based solely on the fact
that the physician has not entered into a provider
12 contract with the organization, plan, or partnership.
Specifies terms for reimbursement for services. Provides
13 the subscriber's liability for noncovered physician
charges. Provides for fines of up to $25,000 per
14 violation, or up to $100,000 per violation where a
pattern of violations is involved as determined by the
15 Agency for Health Care Administration. Requires certain
documentation of adverse determinations as a condition
16 for issuance and maintenance of a health maintenance
organization's certificate of authority.
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