CODING: Words stricken are deletions; words underlined are additions.





                                                   HOUSE AMENDMENT

                                      Bill No. CS/HB 149, 1st Eng.

    Amendment No.     (for drafter's use only)

                            CHAMBER ACTION
              Senate                               House
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 5                                           ORIGINAL STAMP BELOW

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10                                                                

11  Representative(s) Sobel and Frankel offered the following:

12

13         Amendment (with title amendment) 

14         On page 2, between lines 14-15 of the bill

15

16  insert:

17         Section 4.  Section 641.185, Florida Statutes, is

18  created to read:

19         641.185  Health maintenance organization subscriber

20  protections.--

21         (1)  With respect to the provisions of this part and

22  part III, the principles expressed in the following statements

23  shall serve as standards to be followed by the Department of

24  Insurance and the Agency for Health Care Administration in

25  exercising their powers and duties, in exercising

26  administrative discretion, in administrative interpretations

27  of the law, in enforcing its provisions, and in adopting

28  rules:

29         (a)  A health maintenance organization shall ensure

30  that the health care services provided to its subscribers

31  shall be rendered under reasonable standards of quality of

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    hmo0008                     07:45 am         00149-0100-452313




                                                   HOUSE AMENDMENT

                                      Bill No. CS/HB 149, 1st Eng.

    Amendment No.     (for drafter's use only)





 1  care which are at a minimum consistent with the prevailing

 2  standards of medical practice in the community pursuant to ss.

 3  641.495(1) and 641.51.

 4         (b)  A health maintenance organization subscriber shall

 5  receive quality health care from a broad panel of providers,

 6  including referrals, preventive care pursuant to s.

 7  641.402(1), emergency screening and services pursuant to ss.

 8  641.31(12) and 641.513, and second opinions pursuant to s.

 9  641.51.

10         (c)  A health maintenance organization subscriber shall

11  receive assurance that the health maintenance organization has

12  been independently accredited by a national review

13  organization pursuant to s. 641.512, and is financially secure

14  as determined by the state pursuant to ss. 641.221, 641.225,

15  and 641.228.

16         (d)  A health maintenance organization subscriber shall

17  receive continuity of health care, even after the provider is

18  no longer with the health maintenance organization pursuant to

19  s. 641.51(7).

20         (e)  A health maintenance organization subscriber shall

21  receive timely, concise information regarding the health

22  maintenance organization's reimbursement to providers and

23  services pursuant to ss. 641.31 and 641.31015.

24         (f)  A health maintenance organization subscriber shall

25  receive the flexibility to transfer to another Florida health

26  maintenance organization, regardless of health status,

27  pursuant to ss. 641.3104, 641.3107, 641.3111, 641.3921,

28  641.3922, and 641.228.

29         (g)  A health maintenance organization subscriber shall

30  be eligible for coverage without discrimination against

31  individual participants and beneficiaries of group plans based

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                                                   HOUSE AMENDMENT

                                      Bill No. CS/HB 149, 1st Eng.

    Amendment No.     (for drafter's use only)





 1  on health status pursuant to s. 641.31073.

 2         (h)  A health maintenance organization that issues a

 3  group health contract must: provide coverage for preexisting

 4  conditions pursuant to s. 641.31071; guarantee renewability of

 5  coverage pursuant to s. 641.31074; provide notice of

 6  cancellation pursuant to s. 641.3108; provide extension of

 7  benefits pursuant to s. 641.3111; provide for conversion on

 8  termination of eligibility pursuant to s. 641.3921; and

 9  provide for conversion contracts and conditions pursuant to s.

10  641.3922.

11         (i)  A health maintenance organization subscriber shall

12  receive timely, and, if necessary, urgent grievances and

13  appeals within the health maintenance organization pursuant to

14  ss. 641.228, 641.31(5), 641.47, and 641.511.

15         (j)  A health maintenance organization shall receive

16  timely and, if necessary, urgent review by an independent

17  state external review organization for unresolved grievances

18  and appeals pursuant to s. 408.7056.

19         (k)  A health maintenance organization subscriber shall

20  be given written notice at least 30 days in advance of a rate

21  change pursuant to s. 641.31(3)(b). In the case of a group

22  member, there may be a contractual agreement with the health

23  maintenance organization to have the employer provide the

24  required notice to the individual members of the group

25  pursuant to s. 641.31(3)(b).

26         (l)  A health maintenance organization subscriber shall

27  be given a copy of the applicable health maintenance contract,

28  certificate, or member handbook specifying: all the

29  provisions, disclosure, and limitations required pursuant to

30  s. 641.31(1) and (4); the covered services, including those

31  services, medical conditions, and provider types specified in

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                                                   HOUSE AMENDMENT

                                      Bill No. CS/HB 149, 1st Eng.

    Amendment No.     (for drafter's use only)





 1  ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(10), and

 2  641.513; and where and in what manner services may be obtained

 3  pursuant to s. 641.31(4).

 4         (m)  The subscriber's right under ss. 641.31 and

 5  641.513 to receive emergency services for emergency medical

 6  conditions without having to obtain prior authorization or

 7  face any other restriction prohibited by law.

 8         (n)  The subscriber's right under ss.641.19 and 641.51

 9  to see a gynecologist or obstetrician without first having to

10  get a referral from her primary care physician.

11         (o)  The subscriber's right under 641.441 to receive

12  from the health maintenance organization prompt decisions

13  about and treatment of life-threatening conditions.

14         (p)  The subscriber's right under ss.641.315 and

15  641.3903 to a physician who cannot be penalized by the health

16  maintenance organization for fully informing the subscriber

17  about all medical information that the physician thinks the

18  subscriber needs to know about his or her medical condition

19  and treatment options.

20         (q)  The subscriber's right under s. 641.31073 to be

21  free from discrimination in the determination as to the

22  subscriber's eligibility to participate in the plan.

23         (2)  Any health maintenance organization subscriber has

24  a cause of action against a health maintenance organization

25  that fails to comply with the subscriber protections set forth

26  in this section for damages resulting from all reasonably

27  foreseeable harm caused by the violation of said protections.

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29

30  ================ T I T L E   A M E N D M E N T ===============

31  And the title is amended as follows:

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                                                   HOUSE AMENDMENT

                                      Bill No. CS/HB 149, 1st Eng.

    Amendment No.     (for drafter's use only)





 1         On page 1, line 10

 2  Remove from the title:  all of said line

 3

 4  and insert in lieu thereof:

 5         creating s. 641.185, F.S.; providing health

 6         maintenance organization subscriber

 7         protections; specifying the principles to serve

 8         as standards for the Department of Insurance

 9         and the Agency for Health Care Administration

10         exercising their duties and responsibilities;

11         requiring that a health maintenance

12         organization observe certain standards in

13         providing health care for subscribers;

14         providing for subscribers to receive quality

15         care from a broad panel of providers,

16         referrals, preventive care, emergency screening

17         services, and second opinions; providing for

18         assurance of independent accreditation by a

19         national review organization and financial

20         security of the organization; providing for

21         continuity of health care; providing for

22         timely, concise information regarding

23         reimbursement to providers and services;

24         providing for flexibility to transfer to

25         another health maintenance organization within

26         the state; providing for eligibility without

27         discrimination based on health status;

28         providing requirements for health maintenance

29         organizations that issue group health contracts

30         relating to preexisting conditions, contract

31         renewability, cancellation, extension,

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                                                   HOUSE AMENDMENT

                                      Bill No. CS/HB 149, 1st Eng.

    Amendment No.     (for drafter's use only)





 1         termination, and conversion; providing for

 2         timely, urgent grievances and appeals within

 3         the organization; providing for timely and

 4         urgent review of grievances and appeals by an

 5         independent state external review agency;

 6         providing for notice of rate changes; providing

 7         for information regarding contract provisions,

 8         services, medical conditions, providers, and

 9         service delivery; providing for civil penalty;

10         providing an effective date.

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    hmo0008                     07:45 am         00149-0100-452313