CODING: Words stricken are deletions; words underlined are additions.
HOUSE AMENDMENT
Bill No. HB 1625, 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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11 Representative(s) Bucher and Sobel offered the following:
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13 Amendment (with title amendment)
14 On page 69, line 1 of the bill
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16 insert:
17 Section 41. 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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HOUSE AMENDMENT
Bill No. HB 1625, 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. HB 1625, 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. HB 1625, 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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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. HB 1625, 1st Eng.
Amendment No. (for drafter's use only)
1 On page 5, line 10-11
2 Remove from the title: all of said lines
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4 and insert in lieu thereof:
5 Alzheimer's Disease Day; creating s. 641.185,
6 F.S.; providing health maintenance organization
7 subscriber protections; specifying the
8 principles to serve as standards for the
9 Department of Insurance and the Agency for
10 Health Care Administration exercising their
11 duties and responsibilities; requiring that a
12 health maintenance organization observe certain
13 standards in providing health care for
14 subscribers; providing for subscribers to
15 receive quality care from a broad panel of
16 providers, referrals, preventive care,
17 emergency screening services, and second
18 opinions; providing for assurance of
19 independent accreditation by a national review
20 organization and financial security of the
21 organization; providing for continuity of
22 health care; providing for timely, concise
23 information regarding reimbursement to
24 providers and services; providing for
25 flexibility to transfer to another health
26 maintenance organization within the state;
27 providing for eligibility without
28 discrimination based on health status;
29 providing requirements for health maintenance
30 organizations that issue group health contracts
31 relating to preexisting conditions, contract
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HOUSE AMENDMENT
Bill No. HB 1625, 1st Eng.
Amendment No. (for drafter's use only)
1 renewability, cancellation, extension,
2 termination, and conversion; providing for
3 timely, urgent grievances and appeals within
4 the organization; providing for timely and
5 urgent review of grievances and appeals by an
6 independent state external review agency;
7 providing for notice of rate changes; providing
8 for information regarding contract provisions,
9 services, medical conditions, providers, and
10 service delivery; providing for civil penalty;
11 providing an effective date.
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