Senate Bill 2154c3
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Florida Senate - 2000 CS for CS for CS for SB 2154, CS for SB
1900 & SB 282
By the Committees on Fiscal Policy; Health, Aging and
Long-Term Care; Banking and Insurance; and Senators Latvala,
Brown-Waite, Silver, Geller, Campbell, Kurth, Mitchell, Dawson
and Klein
309-2227A-00
1 A bill to be entitled
2 An act relating to health care; providing a
3 short title; amending s. 395.701, F.S.;
4 reducing an assessment against hospitals for
5 outpatient services; amending s. 395.7015,
6 F.S.; reducing an assessment against certain
7 health care entities; amending s. 408.904,
8 F.S.; increasing benefits for certain persons
9 who receive hospital outpatient services;
10 amending s. 408.905, F.S.; increasing benefits
11 furnished by Medicaid providers to recipients
12 of hospital outpatient services; amending s.
13 905.908, F.S.; increasing reimbursement to
14 hospitals for outpatient care; amending s.
15 409.912, F.S.; providing for a contract with
16 and reimbursement of an entity in Pasco or
17 Pinellas County that provides in-home physician
18 services to Medicaid recipients with
19 degenerative neurological diseases; providing
20 for future repeal; providing appropriations;
21 amending s. 400.471, F.S.; deleting the
22 certificate-of-need requirement for licensure
23 of Medicare-certified home health agencies;
24 amending s. 408.032, F.S.; adding definitions
25 of "exemption" and "mental health services";
26 revising the term "health service"; deleting
27 the definitions of "home health agency,"
28 "institutional health service," "intermediate
29 care facility," "multifacility project," and
30 "respite care"; amending s. 408.033, F.S.;
31 deleting references to the state health plan;
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Florida Senate - 2000 CS for CS for CS for SB 2154, CS for SB
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1 amending s. 408.034, F.S.; deleting a reference
2 to licensing of home health agencies by the
3 Agency for Health Care Administration; amending
4 s. 408.035, F.S.; deleting obsolete
5 certificate-of-need review criteria and
6 revising other criteria; amending s. 408.036,
7 F.S.; revising provisions relating to projects
8 subject to review; deleting references to
9 Medicare-certified home health agencies;
10 deleting the review of certain acquisitions;
11 specifying the types of bed increases subject
12 to review; deleting cost overruns from review;
13 deleting review of combinations or division of
14 nursing home certificates of need; providing
15 for expedited review of certain conversions of
16 licensed hospital beds; deleting the
17 requirement for an exemption for initiation or
18 expansion of obstetric services, provision of
19 respite care services, establishment of a
20 Medicare-certified home health agency, or
21 provision of a health service exclusively on an
22 outpatient basis; providing exemptions for
23 combinations or divisions of nursing home
24 certificates of need and additions of certain
25 hospital beds and nursing home beds within
26 specified limitations; requiring a fee for each
27 request for exemption; amending s. 408.037,
28 F.S.; deleting reference to the state health
29 plan; amending ss. 408.038, 408.039, 408.044,
30 and 408.045, F.S.; replacing "department" with
31 "agency"; clarifying the opportunity to
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1 challenge an intended award of a certificate of
2 need; amending s. 408.040, F.S.; deleting an
3 obsolete reference; revising the format of
4 conditions related to Medicaid; creating a
5 certificate-of-need workgroup within the Agency
6 for Health Care Administration; providing for
7 expenses; providing membership, duties, and
8 meetings; providing for termination; amending
9 s. 651.118, F.S.; excluding a specified number
10 of beds from a time limit imposed on extension
11 of authorization for continuing care
12 residential community providers to use
13 sheltered beds for nonresidents; requiring a
14 facility to report such use after the
15 expiration of the extension; repealing s.
16 400.464(3), F.S., relating to home health
17 agency licenses provided to certificate-of-need
18 exempt entities; providing applicability;
19 reducing the allocation of funds and positions
20 from the Health Care Trust Fund in the Agency
21 for Health Care Administration; amending s.
22 216.136, F.S.; creating the Mandated Health
23 Insurance Benefits and Providers Estimating
24 Conference; providing for membership and duties
25 of the conference; providing duties of
26 legislative committees that have jurisdiction
27 over health insurance matters; amending s.
28 624.215, F.S.; providing that certain
29 legislative proposals must be submitted to and
30 assessed by the conference, rather than the
31 Agency for Health Care Administration; amending
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1 guidelines for assessing the impact of a
2 proposal to legislatively mandate certain
3 health coverage; providing prerequisites to
4 legislative consideration of such proposals;
5 requiring physicians and hospitals to post a
6 sign and provide a statement informing patients
7 about the toll-free health care hotline;
8 amending s. 408.7056, F.S.; providing
9 additional definitions for the Statewide
10 Provider and Subscriber Assistance Program;
11 amending s. 627.654, F.S.; providing for
12 insuring small employers under policies issued
13 to small employer health alliances; providing
14 requirements for participation; providing
15 limitations; providing for insuring spouses and
16 dependent children; allowing a single master
17 policy to include alternative health plans;
18 amending s. 627.6571, F.S.; including small
19 employer health alliances within policy
20 nonrenewal or discontinuance, coverage
21 modification, and application provisions;
22 amending s. 627.6699, F.S.; revising
23 restrictions relating to premium rates to
24 authorize small employer carriers to modify
25 rates under certain circumstances and to
26 authorize carriers to issue group health
27 insurance policies to small employer health
28 alliances under certain circumstances;
29 requiring carriers issuing a policy to an
30 alliance to allow appointed agents to sell such
31 a policy; amending ss. 240.2995, 240.2996,
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1 240.512, 381.0406, 395.3035, and 627.4301,
2 F.S.; conforming cross-references; defining the
3 term "managed care"; repealing ss. 408.70(3),
4 408.701, 408.702, 408.703, 408.704, 408.7041,
5 408.7042, 408.7045, 408.7055, and 408.706,
6 F.S., relating to community health purchasing
7 alliances; amending s. 627.6699, F.S.;
8 modifying definitions; requiring small employer
9 carriers to begin to offer and issue all small
10 employer benefit plans on a specified date;
11 deleting the requirement that basic and
12 standard small employer health benefit plans be
13 issued; providing additional requirements for
14 determining premium rates for benefit plans;
15 providing for applicability of the act to plans
16 provided by small employer carriers that are
17 insurers or health maintenance organizations
18 notwithstanding the provisions of certain other
19 specified statutes under specified conditions;
20 amending s. 641.201, F.S.; clarifying
21 applicability of the Florida Insurance Code to
22 health maintenance organizations; amending s.
23 641.234, F.S.; providing conditions under which
24 the Department of Insurance may order a health
25 maintenance organization to cancel a contract;
26 amending s. 641.27, F.S.; providing for payment
27 by a health maintenance organization of fees to
28 outside examiners appointed by the Department
29 of Insurance; creating s. 641.226, F.S.;
30 providing for application of federal solvency
31 requirements to provider-sponsored
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1 organizations; creating s. 641.39, F.S.;
2 prohibiting the solicitation or acceptance of
3 contracts by insolvent or impaired health
4 maintenance organizations; providing a criminal
5 penalty; creating s. 641.2011, F.S.; providing
6 that part IV of chapter 628, F.S., applies to
7 health maintenance organizations; creating s.
8 641.275, F.S.; providing legislative intent
9 that the rights of subscribers who are covered
10 under health maintenance organization contracts
11 be recognized and summarized; requiring health
12 maintenance organizations to operate in
13 conformity with such rights; requiring
14 organizations to provide subscribers with a
15 copy of their rights; listing specified
16 requirements for organizations that are
17 currently required by other statutes;
18 authorizing administrative penalties for
19 enforcing the rights specified in s. 641.275,
20 F.S.; amending s. 641.28, F.S.; revising award
21 of attorney's fees in civil actions under
22 certain circumstances; amending s. 641.3917,
23 F.S.; authorizing civil actions against health
24 maintenance organizations by certain persons
25 under certain circumstances; providing
26 requirements and procedures; providing for
27 liability for damages and attorney's fees;
28 prohibiting punitive damages under certain
29 circumstances; requiring the advance posting of
30 discovery costs; amending s. 440.11, F.S.;
31 establishing exclusive liability of health
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Florida Senate - 2000 CS for CS for CS for SB 2154, CS for SB
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1 maintenance organizations; providing
2 application; providing a legislative
3 declaration; providing an appropriation;
4 amending ss. 641.31, 641.315, 641.3155, F.S.;
5 prohibiting a health maintenance organization
6 from restricting a provider's ability to
7 provide in-patient hospital services to a
8 subscriber; requiring payment for medically
9 necessary in-patient hospital services;
10 amending s. 641.51, F.S., relating to quality
11 assurance program requirements for certain
12 managed-care organizations; allowing the
13 rendering of adverse determinations by
14 physicians licensed in Florida or states with
15 similar requirements; requiring the submission
16 of facts and documentation pertaining to
17 rendered adverse determinations; providing
18 timeframe for organizations to submit facts and
19 documentation to providers and subscribers in
20 writing; requiring an authorized representative
21 to sign the notification; providing effective
22 dates.
23
24 Be It Enacted by the Legislature of the State of Florida:
25
26 Section 1. This act may be cited as the "Health Care
27 Protection Act of 2000."
28 Section 2. Subsection (2) of section 395.701, Florida
29 Statutes, is amended to read:
30
31
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Florida Senate - 2000 CS for CS for CS for SB 2154, CS for SB
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1 395.701 Annual assessments on net operating revenues
2 to fund public medical assistance; administrative fines for
3 failure to pay assessments when due; exemption.--
4 (2) There is imposed upon each hospital an assessment
5 in an amount equal to 1.5 percent of the annual net operating
6 revenue for inpatient services and an assessment in an amount
7 equal to 1 percent of the annual net operating revenue for
8 outpatient services for each hospital, such revenue to be
9 determined by the agency, based on the actual experience of
10 the hospital as reported to the agency. Within 6 months after
11 the end of each hospital fiscal year, the agency shall certify
12 the amount of the assessment for each hospital. The
13 assessment shall be payable to and collected by the agency in
14 equal quarterly amounts, on or before the first day of each
15 calendar quarter, beginning with the first full calendar
16 quarter that occurs after the agency certifies the amount of
17 the assessment for each hospital. All moneys collected
18 pursuant to this subsection shall be deposited into the Public
19 Medical Assistance Trust Fund.
20 Section 3. Subsection (2) of section 395.7015, Florida
21 Statutes, is amended to read:
22 395.7015 Annual assessment on health care entities.--
23 (2) There is imposed an annual assessment against
24 certain health care entities as described in this section:
25 (a) The assessment shall be equal to 1 1.5 percent of
26 the annual net operating revenues of health care entities. The
27 assessment shall be payable to and collected by the agency.
28 Assessments shall be based on annual net operating revenues
29 for the entity's most recently completed fiscal year as
30 provided in subsection (3).
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1 (b) For the purpose of this section, "health care
2 entities" include the following:
3 1. Ambulatory surgical centers and mobile surgical
4 facilities licensed under s. 395.003. This subsection shall
5 only apply to mobile surgical facilities operating under
6 contracts entered into on or after July 1, 1998.
7 2. Clinical laboratories licensed under s. 483.091,
8 excluding any hospital laboratory defined under s. 483.041(5),
9 any clinical laboratory operated by the state or a political
10 subdivision of the state, any clinical laboratory which
11 qualifies as an exempt organization under s. 501(c)(3) of the
12 Internal Revenue Code of 1986, as amended, and which receives
13 70 percent or more of its gross revenues from services to
14 charity patients or Medicaid patients, and any blood, plasma,
15 or tissue bank procuring, storing, or distributing blood,
16 plasma, or tissue either for future manufacture or research or
17 distributed on a nonprofit basis, and further excluding any
18 clinical laboratory which is wholly owned and operated by 6 or
19 fewer physicians who are licensed pursuant to chapter 458 or
20 chapter 459 and who practice in the same group practice, and
21 at which no clinical laboratory work is performed for patients
22 referred by any health care provider who is not a member of
23 the same group.
24 3. Diagnostic-imaging centers that are freestanding
25 outpatient facilities that provide specialized services for
26 the identification or determination of a disease through
27 examination and also provide sophisticated radiological
28 services, and in which services are rendered by a physician
29 licensed by the Board of Medicine under s. 458.311, s.
30 458.313, or s. 458.317, or by an osteopathic physician
31 licensed by the Board of Osteopathic Medicine under s.
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1 459.006, s. 459.007, or s. 459.0075. For purposes of this
2 paragraph, "sophisticated radiological services" means the
3 following: magnetic resonance imaging; nuclear medicine;
4 angiography; arteriography; computed tomography; positron
5 emission tomography; digital vascular imaging; bronchography;
6 lymphangiography; splenography; ultrasound, excluding
7 ultrasound providers that are part of a private physician's
8 office practice or when ultrasound is provided by two or more
9 physicians licensed under chapter 458 or chapter 459 who are
10 members of the same professional association and who practice
11 in the same medical specialties; and such other sophisticated
12 radiological services, excluding mammography, as adopted in
13 rule by the board.
14 Section 4. Paragraph (c) of subsection (2) of section
15 408.904, Florida Statutes, is amended to read:
16 408.904 Benefits.--
17 (2) Covered health services include:
18 (c) Hospital outpatient services. Those services
19 provided to a member in the outpatient portion of a hospital
20 licensed under part I of chapter 395, up to a limit of $1,500
21 $1,000 per calendar year per member, that are preventive,
22 diagnostic, therapeutic, or palliative.
23 Section 5. Subsection (6) of section 409.905, Florida
24 Statutes, is amended to read:
25 409.905 Mandatory Medicaid services.--The agency may
26 make payments for the following services, which are required
27 of the state by Title XIX of the Social Security Act,
28 furnished by Medicaid providers to recipients who are
29 determined to be eligible on the dates on which the services
30 were provided. Any service under this section shall be
31 provided only when medically necessary and in accordance with
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1 state and federal law. Nothing in this section shall be
2 construed to prevent or limit the agency from adjusting fees,
3 reimbursement rates, lengths of stay, number of visits, number
4 of services, or any other adjustments necessary to comply with
5 the availability of moneys and any limitations or directions
6 provided for in the General Appropriations Act or chapter 216.
7 (6) HOSPITAL OUTPATIENT SERVICES.--The agency shall
8 pay for preventive, diagnostic, therapeutic, or palliative
9 care and other services provided to a recipient in the
10 outpatient portion of a hospital licensed under part I of
11 chapter 395, and provided under the direction of a licensed
12 physician or licensed dentist, except that payment for such
13 care and services is limited to $1,500 $1,000 per state fiscal
14 year per recipient, unless an exception has been made by the
15 agency, and with the exception of a Medicaid recipient under
16 age 21, in which case the only limitation is medical
17 necessity.
18 Section 6. Paragraph (a) of subsection (1) of section
19 409.908, Florida Statutes, is amended to read:
20 409.908 Reimbursement of Medicaid providers.--Subject
21 to specific appropriations, the agency shall reimburse
22 Medicaid providers, in accordance with state and federal law,
23 according to methodologies set forth in the rules of the
24 agency and in policy manuals and handbooks incorporated by
25 reference therein. These methodologies may include fee
26 schedules, reimbursement methods based on cost reporting,
27 negotiated fees, competitive bidding pursuant to s. 287.057,
28 and other mechanisms the agency considers efficient and
29 effective for purchasing services or goods on behalf of
30 recipients. Payment for Medicaid compensable services made on
31 behalf of Medicaid eligible persons is subject to the
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1 availability of moneys and any limitations or directions
2 provided for in the General Appropriations Act or chapter 216.
3 Further, nothing in this section shall be construed to prevent
4 or limit the agency from adjusting fees, reimbursement rates,
5 lengths of stay, number of visits, or number of services, or
6 making any other adjustments necessary to comply with the
7 availability of moneys and any limitations or directions
8 provided for in the General Appropriations Act, provided the
9 adjustment is consistent with legislative intent.
10 (1) Reimbursement to hospitals licensed under part I
11 of chapter 395 must be made prospectively or on the basis of
12 negotiation.
13 (a) Reimbursement for inpatient care is limited as
14 provided for in s. 409.905(5). Reimbursement for hospital
15 outpatient care is limited to $1,500 $1,000 per state fiscal
16 year per recipient, except for:
17 1. Such care provided to a Medicaid recipient under
18 age 21, in which case the only limitation is medical
19 necessity;
20 2. Renal dialysis services; and
21 3. Other exceptions made by the agency.
22 Section 7. Paragraph (e) is added to subsection (3) of
23 section 409.912, Florida Statutes, to read:
24 409.912 Cost-effective purchasing of health care.--The
25 agency shall purchase goods and services for Medicaid
26 recipients in the most cost-effective manner consistent with
27 the delivery of quality medical care. The agency shall
28 maximize the use of prepaid per capita and prepaid aggregate
29 fixed-sum basis services when appropriate and other
30 alternative service delivery and reimbursement methodologies,
31 including competitive bidding pursuant to s. 287.057, designed
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1 to facilitate the cost-effective purchase of a case-managed
2 continuum of care. The agency shall also require providers to
3 minimize the exposure of recipients to the need for acute
4 inpatient, custodial, and other institutional care and the
5 inappropriate or unnecessary use of high-cost services.
6 (3) The agency may contract with:
7 (e) An entity in Pasco County or Pinellas County that
8 provides in-home physician services to Medicaid recipients
9 having degenerative neurological diseases in order to test the
10 cost-effectiveness of enhanced home-based medical care. The
11 entity providing the services shall be reimbursed on a
12 fee-for-service basis at a rate not less than comparable
13 Medicare reimbursement rates. The agency may apply for waivers
14 of federal regulations necessary to implement such program.
15 This paragraph expires July 1, 2002.
16 Section 8. The Legislature shall appropriate each
17 fiscal year from the General Revenue Fund to the Public
18 Medical Assistance Trust Fund an amount sufficient to replace
19 the funds lost due to the reduction by this act of the
20 assessment on other health care entities under section
21 395.7015, Florida Statutes, and the reduction by this act in
22 the assessment on hospitals under section 395.701, Florida
23 Statutes, and to maintain federal approval of the reduced
24 amount of funds deposited into the Public Medical Assistance
25 Trust Fund under section 395.701, Florida Statutes, as state
26 matching funds for the state's Medicaid program.
27 Section 9. The sum of $28.3 million is appropriated
28 from the General Revenue Fund to the Agency for Health Care
29 Administration for the purpose of implementing this act.
30 However, such appropriation shall be reduced by an amount
31 equal to any similar appropriation for the same purpose which
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1 is contained in other legislation adopted during the 2000
2 legislative session and which becomes a law.
3 Section 10. Subsections (2) and (11) of section
4 400.471, Florida Statutes, are amended to read:
5 400.471 Application for license; fee; provisional
6 license; temporary permit.--
7 (2) The applicant must file with the application
8 satisfactory proof that the home health agency is in
9 compliance with this part and applicable rules, including:
10 (a) A listing of services to be provided, either
11 directly by the applicant or through contractual arrangements
12 with existing providers;
13 (b) The number and discipline of professional staff to
14 be employed; and
15 (c) Proof of financial ability to operate.
16
17 If the applicant has applied for a certificate of need under
18 ss. 408.0331-408.045 within the preceding 12 months, the
19 applicant may submit the proof required during the
20 certificate-of-need process along with an attestation that
21 there has been no substantial change in the facts and
22 circumstances underlying the original submission.
23 (11) The agency may not issue a license designated as
24 certified to a home health agency that fails to receive a
25 certificate of need under ss. 408.031-408.045 or that fails to
26 satisfy the requirements of a Medicare certification survey
27 from the agency.
28 Section 11. Section 408.032, Florida Statutes, is
29 amended to read:
30 408.032 Definitions.--As used in ss. 408.031-408.045,
31 the term:
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1 (1) "Agency" means the Agency for Health Care
2 Administration.
3 (2) "Capital expenditure" means an expenditure,
4 including an expenditure for a construction project undertaken
5 by a health care facility as its own contractor, which, under
6 generally accepted accounting principles, is not properly
7 chargeable as an expense of operation and maintenance, which
8 is made to change the bed capacity of the facility, or
9 substantially change the services or service area of the
10 health care facility, health service provider, or hospice, and
11 which includes the cost of the studies, surveys, designs,
12 plans, working drawings, specifications, initial financing
13 costs, and other activities essential to acquisition,
14 improvement, expansion, or replacement of the plant and
15 equipment.
16 (3) "Certificate of need" means a written statement
17 issued by the agency evidencing community need for a new,
18 converted, expanded, or otherwise significantly modified
19 health care facility, health service, or hospice.
20 (4) "Commenced construction" means initiation of and
21 continuous activities beyond site preparation associated with
22 erecting or modifying a health care facility, including
23 procurement of a building permit applying the use of
24 agency-approved construction documents, proof of an executed
25 owner/contractor agreement or an irrevocable or binding forced
26 account, and actual undertaking of foundation forming with
27 steel installation and concrete placing.
28 (5) "District" means a health service planning
29 district composed of the following counties:
30 District 1.--Escambia, Santa Rosa, Okaloosa, and Walton
31 Counties.
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1 District 2.--Holmes, Washington, Bay, Jackson,
2 Franklin, Gulf, Gadsden, Liberty, Calhoun, Leon, Wakulla,
3 Jefferson, Madison, and Taylor Counties.
4 District 3.--Hamilton, Suwannee, Lafayette, Dixie,
5 Columbia, Gilchrist, Levy, Union, Bradford, Putnam, Alachua,
6 Marion, Citrus, Hernando, Sumter, and Lake Counties.
7 District 4.--Baker, Nassau, Duval, Clay, St. Johns,
8 Flagler, and Volusia Counties.
9 District 5.--Pasco and Pinellas Counties.
10 District 6.--Hillsborough, Manatee, Polk, Hardee, and
11 Highlands Counties.
12 District 7.--Seminole, Orange, Osceola, and Brevard
13 Counties.
14 District 8.--Sarasota, DeSoto, Charlotte, Lee, Glades,
15 Hendry, and Collier Counties.
16 District 9.--Indian River, Okeechobee, St. Lucie,
17 Martin, and Palm Beach Counties.
18 District 10.--Broward County.
19 District 11.--Dade and Monroe Counties.
20 (6) "Exemption" means the process by which a proposal
21 that would otherwise require a certificate of need may proceed
22 without a certificate of need.
23 (7)(6) "Expedited review" means the process by which
24 certain types of applications are not subject to the review
25 cycle requirements contained in s. 408.039(1), and the letter
26 of intent requirements contained in s. 408.039(2).
27 (8)(7) "Health care facility" means a hospital,
28 long-term care hospital, skilled nursing facility, hospice,
29 intermediate care facility, or intermediate care facility for
30 the developmentally disabled. A facility relying solely on
31
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1 spiritual means through prayer for healing is not included as
2 a health care facility.
3 (9)(8) "Health services" means diagnostic, curative,
4 or rehabilitative services and includes alcohol treatment,
5 drug abuse treatment, and mental health services. Obstetric
6 services are not health services for purposes of ss.
7 408.031-408.045.
8 (9) "Home health agency" means an organization, as
9 defined in s. 400.462(4), that is certified or seeks
10 certification as a Medicare home health service provider.
11 (10) "Hospice" or "hospice program" means a hospice as
12 defined in part VI of chapter 400.
13 (11) "Hospital" means a health care facility licensed
14 under chapter 395.
15 (12) "Institutional health service" means a health
16 service which is provided by or through a health care facility
17 and which entails an annual operating cost of $500,000 or
18 more. The agency shall, by rule, adjust the annual operating
19 cost threshold annually using an appropriate inflation index.
20 (13) "Intermediate care facility" means an institution
21 which provides, on a regular basis, health-related care and
22 services to individuals who do not require the degree of care
23 and treatment which a hospital or skilled nursing facility is
24 designed to provide, but who, because of their mental or
25 physical condition, require health-related care and services
26 above the level of room and board.
27 (12)(14) "Intermediate care facility for the
28 developmentally disabled" means a residential facility
29 licensed under chapter 393 and certified by the Federal
30 Government pursuant to the Social Security Act as a provider
31
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1 of Medicaid services to persons who are mentally retarded or
2 who have a related condition.
3 (13)(15) "Long-term care hospital" means a hospital
4 licensed under chapter 395 which meets the requirements of 42
5 C.F.R. s. 412.23(e) and seeks exclusion from the Medicare
6 prospective payment system for inpatient hospital services.
7 (14) "Mental health services" means inpatient services
8 provided in a hospital licensed under chapter 395 and listed
9 on the hospital license as psychiatric beds for adults;
10 psychiatric beds for children and adolescents; intensive
11 residential treatment beds for children and adolescents;
12 substance abuse beds for adults; or substance abuse beds for
13 children and adolescents.
14 (16) "Multifacility project" means an integrated
15 residential and health care facility consisting of independent
16 living units, assisted living facility units, and nursing home
17 beds certificated on or after January 1, 1987, where:
18 (a) The aggregate total number of independent living
19 units and assisted living facility units exceeds the number of
20 nursing home beds.
21 (b) The developer of the project has expended the sum
22 of $500,000 or more on the certificated and noncertificated
23 elements of the project combined, exclusive of land costs, by
24 the conclusion of the 18th month of the life of the
25 certificate of need.
26 (c) The total aggregate cost of construction of the
27 certificated element of the project, when combined with other,
28 noncertificated elements, is $10 million or more.
29 (d) All elements of the project are contiguous or
30 immediately adjacent to each other and construction of all
31 elements will be continuous.
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1 (15)(17) "Nursing home geographically underserved
2 area" means:
3 (a) A county in which there is no existing or approved
4 nursing home;
5 (b) An area with a radius of at least 20 miles in
6 which there is no existing or approved nursing home; or
7 (c) An area with a radius of at least 20 miles in
8 which all existing nursing homes have maintained at least a 95
9 percent occupancy rate for the most recent 6 months or a 90
10 percent occupancy rate for the most recent 12 months.
11 (18) "Respite care" means short-term care in a
12 licensed health care facility which is personal or custodial
13 and is provided for chronic illness, physical infirmity, or
14 advanced age for the purpose of temporarily relieving family
15 members of the burden of providing care and attendance.
16 (16)(19) "Skilled nursing facility" means an
17 institution, or a distinct part of an institution, which is
18 primarily engaged in providing, to inpatients, skilled nursing
19 care and related services for patients who require medical or
20 nursing care, or rehabilitation services for the
21 rehabilitation of injured, disabled, or sick persons.
22 (17)(20) "Tertiary health service" means a health
23 service which, due to its high level of intensity, complexity,
24 specialized or limited applicability, and cost, should be
25 limited to, and concentrated in, a limited number of hospitals
26 to ensure the quality, availability, and cost-effectiveness of
27 such service. Examples of such service include, but are not
28 limited to, organ transplantation, specialty burn units,
29 neonatal intensive care units, comprehensive rehabilitation,
30 and medical or surgical services which are experimental or
31 developmental in nature to the extent that the provision of
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1 such services is not yet contemplated within the commonly
2 accepted course of diagnosis or treatment for the condition
3 addressed by a given service. The agency shall establish by
4 rule a list of all tertiary health services.
5 (18)(21) "Regional area" means any of those regional
6 health planning areas established by the agency to which local
7 and district health planning funds are directed to local
8 health councils through the General Appropriations Act.
9 Section 12. Paragraph (b) of subsection (1) and
10 paragraph (a) of subsection (3) of section 408.033, Florida
11 Statutes, are amended to read:
12 408.033 Local and state health planning.--
13 (1) LOCAL HEALTH COUNCILS.--
14 (b) Each local health council may:
15 1. Develop a district or regional area health plan
16 that permits is consistent with the objectives and strategies
17 in the state health plan, but that shall permit each local
18 health council to develop strategies and set priorities for
19 implementation based on its unique local health needs. The
20 district or regional area health plan must contain preferences
21 for the development of health services and facilities, which
22 may be considered by the agency in its review of
23 certificate-of-need applications. The district health plan
24 shall be submitted to the agency and updated periodically. The
25 district health plans shall use a uniform format and be
26 submitted to the agency according to a schedule developed by
27 the agency in conjunction with the local health councils. The
28 schedule must provide for coordination between the development
29 of the state health plan and the district health plans and for
30 the development of district health plans by major sections
31 over a multiyear period. The elements of a district plan
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1 which are necessary to the review of certificate-of-need
2 applications for proposed projects within the district may be
3 adopted by the agency as a part of its rules.
4 2. Advise the agency on health care issues and
5 resource allocations.
6 3. Promote public awareness of community health needs,
7 emphasizing health promotion and cost-effective health service
8 selection.
9 4. Collect data and conduct analyses and studies
10 related to health care needs of the district, including the
11 needs of medically indigent persons, and assist the agency and
12 other state agencies in carrying out data collection
13 activities that relate to the functions in this subsection.
14 5. Monitor the onsite construction progress, if any,
15 of certificate-of-need approved projects and report council
16 findings to the agency on forms provided by the agency.
17 6. Advise and assist any regional planning councils
18 within each district that have elected to address health
19 issues in their strategic regional policy plans with the
20 development of the health element of the plans to address the
21 health goals and policies in the State Comprehensive Plan.
22 7. Advise and assist local governments within each
23 district on the development of an optional health plan element
24 of the comprehensive plan provided in chapter 163, to assure
25 compatibility with the health goals and policies in the State
26 Comprehensive Plan and district health plan. To facilitate
27 the implementation of this section, the local health council
28 shall annually provide the local governments in its service
29 area, upon request, with:
30 a. A copy and appropriate updates of the district
31 health plan;
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1 b. A report of hospital and nursing home utilization
2 statistics for facilities within the local government
3 jurisdiction; and
4 c. Applicable agency rules and calculated need
5 methodologies for health facilities and services regulated
6 under s. 408.034 for the district served by the local health
7 council.
8 8. Monitor and evaluate the adequacy, appropriateness,
9 and effectiveness, within the district, of local, state,
10 federal, and private funds distributed to meet the needs of
11 the medically indigent and other underserved population
12 groups.
13 9. In conjunction with the Agency for Health Care
14 Administration, plan for services at the local level for
15 persons infected with the human immunodeficiency virus.
16 10. Provide technical assistance to encourage and
17 support activities by providers, purchasers, consumers, and
18 local, regional, and state agencies in meeting the health care
19 goals, objectives, and policies adopted by the local health
20 council.
21 11. Provide the agency with data required by rule for
22 the review of certificate-of-need applications and the
23 projection of need for health services and facilities in the
24 district.
25 (3) DUTIES AND RESPONSIBILITIES OF THE AGENCY.--
26 (a) The agency, in conjunction with the local health
27 councils, is responsible for the coordinated planning of all
28 health care services in the state and for the preparation of
29 the state health plan.
30 Section 13. Subsection (2) of section 408.034, Florida
31 Statutes, is amended to read:
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1 408.034 Duties and responsibilities of agency;
2 rules.--
3 (2) In the exercise of its authority to issue licenses
4 to health care facilities and health service providers, as
5 provided under chapters 393, 395, and parts II, IV, and VI of
6 chapter 400, the agency may not issue a license to any health
7 care facility, health service provider, hospice, or part of a
8 health care facility which fails to receive a certificate of
9 need or an exemption for the licensed facility or service.
10 Section 14. Section 408.035, Florida Statutes, is
11 amended to read:
12 408.035 Review criteria.--
13 (1) The agency shall determine the reviewability of
14 applications and shall review applications for
15 certificate-of-need determinations for health care facilities
16 and health services in context with the following criteria:
17 (1)(a) The need for the health care facilities and
18 health services being proposed in relation to the applicable
19 district health plan, except in emergency circumstances that
20 pose a threat to the public health.
21 (2)(b) The availability, quality of care, efficiency,
22 appropriateness, accessibility, and extent of utilization of,
23 and adequacy of like and existing health care facilities and
24 health services in the service district of the applicant.
25 (3)(c) The ability of the applicant to provide quality
26 of care and the applicant's record of providing quality of
27 care.
28 (d) The availability and adequacy of other health care
29 facilities and health services in the service district of the
30 applicant, such as outpatient care and ambulatory or home care
31 services, which may serve as alternatives for the health care
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1 facilities and health services to be provided by the
2 applicant.
3 (e) Probable economies and improvements in service
4 which may be derived from operation of joint, cooperative, or
5 shared health care resources.
6 (4)(f) The need in the service district of the
7 applicant for special health care equipment and services that
8 are not reasonably and economically accessible in adjoining
9 areas.
10 (5)(g) The needs of need for research and educational
11 facilities, including, but not limited to, facilities with
12 institutional training programs and community training
13 programs for health care practitioners and for doctors of
14 osteopathic medicine and medicine at the student, internship,
15 and residency training levels.
16 (6)(h) The availability of resources, including health
17 personnel, management personnel, and funds for capital and
18 operating expenditures, for project accomplishment and
19 operation.; the effects the project will have on clinical
20 needs of health professional training programs in the service
21 district; the extent to which the services will be accessible
22 to schools for health professions in the service district for
23 training purposes if such services are available in a limited
24 number of facilities; the availability of alternative uses of
25 such resources for the provision of other health services; and
26 (7) The extent to which the proposed services will
27 enhance access to health care for be accessible to all
28 residents of the service district.
29 (8)(i) The immediate and long-term financial
30 feasibility of the proposal.
31
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1 (j) The special needs and circumstances of health
2 maintenance organizations.
3 (k) The needs and circumstances of those entities that
4 provide a substantial portion of their services or resources,
5 or both, to individuals not residing in the service district
6 in which the entities are located or in adjacent service
7 districts. Such entities may include medical and other health
8 professions, schools, multidisciplinary clinics, and specialty
9 services such as open-heart surgery, radiation therapy, and
10 renal transplantation.
11 (9)(l) The extent to which the proposal will foster
12 competition that promotes quality and cost-effectiveness. The
13 probable impact of the proposed project on the costs of
14 providing health services proposed by the applicant, upon
15 consideration of factors including, but not limited to, the
16 effects of competition on the supply of health services being
17 proposed and the improvements or innovations in the financing
18 and delivery of health services which foster competition and
19 service to promote quality assurance and cost-effectiveness.
20 (10)(m) The costs and methods of the proposed
21 construction, including the costs and methods of energy
22 provision and the availability of alternative, less costly, or
23 more effective methods of construction.
24 (11)(n) The applicant's past and proposed provision of
25 health care services to Medicaid patients and the medically
26 indigent.
27 (o) The applicant's past and proposed provision of
28 services that promote a continuum of care in a multilevel
29 health care system, which may include, but are not limited to,
30 acute care, skilled nursing care, home health care, and
31 assisted living facilities.
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1 (12)(p) The applicant's designation as a Gold Seal
2 Program nursing facility pursuant to s. 400.235, when the
3 applicant is requesting additional nursing home beds at that
4 facility.
5 (2) In cases of capital expenditure proposals for the
6 provision of new health services to inpatients, the agency
7 shall also reference each of the following in its findings of
8 fact:
9 (a) That less costly, more efficient, or more
10 appropriate alternatives to such inpatient services are not
11 available and the development of such alternatives has been
12 studied and found not practicable.
13 (b) That existing inpatient facilities providing
14 inpatient services similar to those proposed are being used in
15 an appropriate and efficient manner.
16 (c) In the case of new construction or replacement
17 construction, that alternatives to the construction, for
18 example, modernization or sharing arrangements, have been
19 considered and have been implemented to the maximum extent
20 practicable.
21 (d) That patients will experience serious problems in
22 obtaining inpatient care of the type proposed, in the absence
23 of the proposed new service.
24 (e) In the case of a proposal for the addition of beds
25 for the provision of skilled nursing or intermediate care
26 services, that the addition will be consistent with the plans
27 of other agencies of the state responsible for the provision
28 and financing of long-term care, including home health
29 services.
30 Section 15. Section 408.036, Florida Statutes, is
31 amended to read:
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1 408.036 Projects subject to review.--
2 (1) APPLICABILITY.--Unless exempt under subsection
3 (3), all health-care-related projects, as described in
4 paragraphs (a)-(h)(k), are subject to review and must file an
5 application for a certificate of need with the agency. The
6 agency is exclusively responsible for determining whether a
7 health-care-related project is subject to review under ss.
8 408.031-408.045.
9 (a) The addition of beds by new construction or
10 alteration.
11 (b) The new construction or establishment of
12 additional health care facilities, including a replacement
13 health care facility when the proposed project site is not
14 located on the same site as the existing health care facility.
15 (c) The conversion from one type of health care
16 facility to another, including the conversion from one level
17 of care to another, in a skilled or intermediate nursing
18 facility, if the conversion effects a change in the level of
19 care of 10 beds or 10 percent of total bed capacity of the
20 skilled or intermediate nursing facility within a 2-year
21 period. If the nursing facility is certified for both skilled
22 and intermediate nursing care, the provisions of this
23 paragraph do not apply.
24 (d) An Any increase in the total licensed bed capacity
25 of a health care facility.
26 (e) Subject to the provisions of paragraph (3)(i), The
27 establishment of a Medicare-certified home health agency, the
28 establishment of a hospice or hospice inpatient facility,
29 except as provided in s. 408.043 or the direct provision of
30 such services by a health care facility or health maintenance
31 organization for those other than the subscribers of the
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1 health maintenance organization; except that this paragraph
2 does not apply to the establishment of a Medicare-certified
3 home health agency by a facility described in paragraph
4 (3)(h).
5 (f) An acquisition by or on behalf of a health care
6 facility or health maintenance organization, by any means,
7 which acquisition would have required review if the
8 acquisition had been by purchase.
9 (f)(g) The establishment of inpatient institutional
10 health services by a health care facility, or a substantial
11 change in such services.
12 (h) The acquisition by any means of an existing health
13 care facility by any person, unless the person provides the
14 agency with at least 30 days' written notice of the proposed
15 acquisition, which notice is to include the services to be
16 offered and the bed capacity of the facility, and unless the
17 agency does not determine, within 30 days after receipt of
18 such notice, that the services to be provided and the bed
19 capacity of the facility will be changed.
20 (i) An increase in the cost of a project for which a
21 certificate of need has been issued when the increase in cost
22 exceeds 20 percent of the originally approved cost of the
23 project, except that a cost overrun review is not necessary
24 when the cost overrun is less than $20,000.
25 (g)(j) An increase in the number of beds for acute
26 care, nursing home care beds, specialty burn units, neonatal
27 intensive care units, comprehensive rehabilitation, mental
28 health services, or hospital-based distinct part skilled
29 nursing units, or at a long-term care hospital psychiatric or
30 rehabilitation beds.
31 (h)(k) The establishment of tertiary health services.
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1 (2) PROJECTS SUBJECT TO EXPEDITED REVIEW.--Unless
2 exempt pursuant to subsection (3), projects subject to an
3 expedited review shall include, but not be limited to:
4 (a) Cost overruns, as defined in paragraph (1)(i).
5 (a)(b) Research, education, and training programs.
6 (b)(c) Shared services contracts or projects.
7 (c)(d) A transfer of a certificate of need.
8 (d)(e) A 50-percent increase in nursing home beds for
9 a facility incorporated and operating in this state for at
10 least 60 years on or before July 1, 1988, which has a licensed
11 nursing home facility located on a campus providing a variety
12 of residential settings and supportive services. The
13 increased nursing home beds shall be for the exclusive use of
14 the campus residents. Any application on behalf of an
15 applicant meeting this requirement shall be subject to the
16 base fee of $5,000 provided in s. 408.038.
17 (f) Combination within one nursing home facility of
18 the beds or services authorized by two or more certificates of
19 need issued in the same planning subdistrict.
20 (g) Division into two or more nursing home facilities
21 of beds or services authorized by one certificate of need
22 issued in the same planning subdistrict. Such division shall
23 not be approved if it would adversely affect the original
24 certificate's approved cost.
25 (e)(h) Replacement of a health care facility when the
26 proposed project site is located in the same district and
27 within a 1-mile radius of the replaced health care facility.
28 (f) The conversion of mental health services beds
29 licensed under chapter 395 or hospital-based distinct part
30 skilled nursing unit beds to general acute care beds; the
31 conversion of mental health services beds between or among the
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1 licensed bed categories defined as beds for mental health
2 services; or the conversion of general acute care beds to beds
3 for mental health services.
4 1. Conversion under this paragraph shall not establish
5 a new licensed bed category at the hospital but shall apply
6 only to categories of beds licensed at that hospital.
7 2. Beds converted under this paragraph must be
8 licensed and operational for at least 12 months before the
9 hospital may apply for additional conversion affecting beds of
10 the same type.
11
12 The agency shall develop rules to implement the provisions for
13 expedited review, including time schedule, application content
14 which may be reduced from the full requirements of s.
15 408.037(1), and application processing.
16 (3) EXEMPTIONS.--Upon request, the following projects
17 are subject to supported by such documentation as the agency
18 requires, the agency shall grant an exemption from the
19 provisions of subsection (1):
20 (a) For the initiation or expansion of obstetric
21 services.
22 (a)(b) For replacement of any expenditure to replace
23 or renovate any part of a licensed health care facility on the
24 same site, provided that the number of licensed beds in each
25 licensed bed category will not increase and, in the case of a
26 replacement facility, the project site is the same as the
27 facility being replaced.
28 (c) For providing respite care services. An individual
29 may be admitted to a respite care program in a hospital
30 without regard to inpatient requirements relating to admitting
31 order and attendance of a member of a medical staff.
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1 (b)(d) For hospice services or home health services
2 provided by a rural hospital, as defined in s. 395.602, or for
3 swing beds in a such rural hospital, as defined in s. 395.602,
4 in a number that does not exceed one-half of its licensed
5 beds.
6 (c)(e) For the conversion of licensed acute care
7 hospital beds to Medicare and Medicaid certified skilled
8 nursing beds in a rural hospital, as defined in s. 395.602, so
9 long as the conversion of the beds does not involve the
10 construction of new facilities. The total number of skilled
11 nursing beds, including swing beds, may not exceed one-half of
12 the total number of licensed beds in the rural hospital as of
13 July 1, 1993. Certified skilled nursing beds designated under
14 this paragraph, excluding swing beds, shall be included in the
15 community nursing home bed inventory. A rural hospital which
16 subsequently decertifies any acute care beds exempted under
17 this paragraph shall notify the agency of the decertification,
18 and the agency shall adjust the community nursing home bed
19 inventory accordingly.
20 (d)(f) For the addition of nursing home beds at a
21 skilled nursing facility that is part of a retirement
22 community that provides a variety of residential settings and
23 supportive services and that has been incorporated and
24 operated in this state for at least 65 years on or before July
25 1, 1994. All nursing home beds must not be available to the
26 public but must be for the exclusive use of the community
27 residents.
28 (e)(g) For an increase in the bed capacity of a
29 nursing facility licensed for at least 50 beds as of January
30 1, 1994, under part II of chapter 400 which is not part of a
31 continuing care facility if, after the increase, the total
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1 licensed bed capacity of that facility is not more than 60
2 beds and if the facility has been continuously licensed since
3 1950 and has received a superior rating on each of its two
4 most recent licensure surveys.
5 (h) For the establishment of a Medicare-certified home
6 health agency by a facility certified under chapter 651; a
7 retirement community, as defined in s. 400.404(2)(g); or a
8 residential facility that serves only retired military
9 personnel, their dependents, and the surviving dependents of
10 deceased military personnel. Medicare-reimbursed home health
11 services provided through such agency shall be offered
12 exclusively to residents of the facility or retirement
13 community or to residents of facilities or retirement
14 communities owned, operated, or managed by the same corporate
15 entity. Each visit made to deliver Medicare-reimbursable home
16 health services to a home health patient who, at the time of
17 service, is not a resident of the facility or retirement
18 community shall be a deceptive and unfair trade practice and
19 constitutes a violation of ss. 501.201-501.213.
20 (i) For the establishment of a Medicare-certified home
21 health agency. This paragraph shall take effect 90 days after
22 the adjournment sine die of the next regular session of the
23 Legislature occurring after the legislative session in which
24 the Legislature receives a report from the Director of Health
25 Care Administration certifying that the federal Health Care
26 Financing Administration has implemented a per-episode
27 prospective pay system for Medicare-certified home health
28 agencies.
29 (f)(j) For an inmate health care facility built by or
30 for the exclusive use of the Department of Corrections as
31
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1 provided in chapter 945. This exemption expires when such
2 facility is converted to other uses.
3 (k) For an expenditure by or on behalf of a health
4 care facility to provide a health service exclusively on an
5 outpatient basis.
6 (g)(l) For the termination of an inpatient a health
7 care service.
8 (h)(m) For the delicensure of beds. A request for
9 exemption An application submitted under this paragraph must
10 identify the number, the category of beds classification, and
11 the name of the facility in which the beds to be delicensed
12 are located.
13 (i)(n) For the provision of adult inpatient diagnostic
14 cardiac catheterization services in a hospital.
15 1. In addition to any other documentation otherwise
16 required by the agency, a request for an exemption submitted
17 under this paragraph must comply with the following criteria:
18 a. The applicant must certify it will not provide
19 therapeutic cardiac catheterization pursuant to the grant of
20 the exemption.
21 b. The applicant must certify it will meet and
22 continuously maintain the minimum licensure requirements
23 adopted by the agency governing such programs pursuant to
24 subparagraph 2.
25 c. The applicant must certify it will provide a
26 minimum of 2 percent of its services to charity and Medicaid
27 patients.
28 2. The agency shall adopt licensure requirements by
29 rule which govern the operation of adult inpatient diagnostic
30 cardiac catheterization programs established pursuant to the
31
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1 exemption provided in this paragraph. The rules shall ensure
2 that such programs:
3 a. Perform only adult inpatient diagnostic cardiac
4 catheterization services authorized by the exemption and will
5 not provide therapeutic cardiac catheterization or any other
6 services not authorized by the exemption.
7 b. Maintain sufficient appropriate equipment and
8 health personnel to ensure quality and safety.
9 c. Maintain appropriate times of operation and
10 protocols to ensure availability and appropriate referrals in
11 the event of emergencies.
12 d. Maintain appropriate program volumes to ensure
13 quality and safety.
14 e. Provide a minimum of 2 percent of its services to
15 charity and Medicaid patients each year.
16 3.a. The exemption provided by this paragraph shall
17 not apply unless the agency determines that the program is in
18 compliance with the requirements of subparagraph 1. and that
19 the program will, after beginning operation, continuously
20 comply with the rules adopted pursuant to subparagraph 2. The
21 agency shall monitor such programs to ensure compliance with
22 the requirements of subparagraph 2.
23 b.(I) The exemption for a program shall expire
24 immediately when the program fails to comply with the rules
25 adopted pursuant to sub-subparagraphs 2.a., b., and c.
26 (II) Beginning 18 months after a program first begins
27 treating patients, the exemption for a program shall expire
28 when the program fails to comply with the rules adopted
29 pursuant to sub-subparagraphs 2.d. and e.
30 (III) If the exemption for a program expires pursuant
31 to sub-sub-subparagraph (I) or sub-sub-subparagraph (II), the
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1 agency shall not grant an exemption pursuant to this paragraph
2 for an adult inpatient diagnostic cardiac catheterization
3 program located at the same hospital until 2 years following
4 the date of the determination by the agency that the program
5 failed to comply with the rules adopted pursuant to
6 subparagraph 2.
7 4. The agency shall not grant any exemption under this
8 paragraph until the adoption of the rules required under this
9 paragraph, or until March 1, 1998, whichever comes first.
10 However, if final rules have not been adopted by March 1,
11 1998, the proposed rules governing the exemptions shall be
12 used by the agency to grant exemptions under the provisions of
13 this paragraph until final rules become effective.
14 (j)(o) For any expenditure to provide mobile surgical
15 facilities and related health care services provided under
16 contract with the Department of Corrections or a private
17 correctional facility operating pursuant to chapter 957.
18 (k)(p) For state veterans' nursing homes operated by
19 or on behalf of the Florida Department of Veterans' Affairs in
20 accordance with part II of chapter 296 for which at least 50
21 percent of the construction cost is federally funded and for
22 which the Federal Government pays a per diem rate not to
23 exceed one-half of the cost of the veterans' care in such
24 state nursing homes. These beds shall not be included in the
25 nursing home bed inventory.
26 (l) For combination within one nursing home facility
27 of the beds or services authorized by two or more certificates
28 of need issued in the same planning subdistrict. An exemption
29 granted under this paragraph shall extend the validity period
30 of the certificates of need to be consolidated by the length
31 of the period beginning upon submission of the exemption
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1 request and ending with issuance of the exemption. The
2 longest validity period among the certificates shall be
3 applicable to each of the combined certificates.
4 (m) For division into two or more nursing home
5 facilities of beds or services authorized by one certificate
6 of need issued in the same planning subdistrict. An exemption
7 granted under this paragraph shall extend the validity period
8 of the certificate of need to be divided by the length of the
9 period beginning upon submission of the exemption request and
10 ending with issuance of the exemption.
11 (n) For the addition of hospital beds licensed under
12 chapter 395 for acute care, mental health services, or a
13 hospital-based distinct part skilled nursing unit in a number
14 that may not exceed 10 total beds or 10 percent of the
15 licensed capacity of the bed category being expanded,
16 whichever is greater. Beds for specialty burn units, neonatal
17 intensive care units, or comprehensive rehabilitation, or at a
18 long-term care hospital, may not be increased under this
19 paragraph.
20 1. In addition to any other documentation otherwise
21 required by the agency, a request for exemption submitted
22 under this paragraph must:
23 a. Certify that the prior 12-month average occupancy
24 rate for the category of licensed beds being expanded at the
25 facility meets or exceeds 80 percent or, for a hospital-based
26 distinct part skilled nursing unit, the prior 12-month average
27 occupancy rate meets or exceeds 96 percent.
28 b. Certify that any beds of the same type authorized
29 for the facility under this paragraph before the date of the
30 current request for an exemption have been licensed and
31 operational for at least 12 months.
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1 2. The timeframes and monitoring process specified in
2 s. 408.040(2)(a)-(c) apply to any exemption issued under this
3 paragraph.
4 3. The agency shall count beds authorized under this
5 paragraph as approved beds in the published inventory of
6 hospital beds until the beds are licensed.
7 (o) For the addition of acute care beds, as authorized
8 by rule consistent with s. 395.003(4), in a number that may
9 not exceed 10 total beds or 10 percent of licensed bed
10 capacity, whichever is greater, for temporary beds in a
11 hospital that has experienced high seasonal occupancy within
12 the prior 12-month period or in a hospital that must respond
13 to emergency circumstances.
14 (p) For the addition of nursing home beds licensed
15 under chapter 400 in a number not exceeding 10 total beds or
16 10 percent of the number of beds licensed in the facility
17 being expanded, whichever is greater.
18 1. In addition to any other documentation required by
19 the agency, a request for exemption submitted under this
20 paragraph must:
21 a. Effective until June 30, 2001, certify that the
22 facility has not had any class I or class II deficiencies
23 within the 30 months preceding the request for addition.
24 b. Effective on July 1, 2001, certify that the
25 facility has been designated as a Gold Seal nursing home under
26 s. 400.235.
27 c. Certify that the prior 12-month average occupancy
28 rate for the nursing home beds at the facility meets or
29 exceeds 96 percent.
30 d. Certify that any beds authorized for the facility
31 under this paragraph before the date of the current request
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1 for an exemption have been licensed and operational for at
2 least 12 months.
3 2. The timeframes and monitoring process specified in
4 s. 408.040(2)(a)-(c) apply to any exemption issued under this
5 paragraph.
6 3. The agency shall count beds authorized under this
7 paragraph as approved beds in the published inventory of
8 nursing home beds until the beds are licensed.
9 (4) A request for exemption under this subsection (3)
10 may be made at any time and is not subject to the batching
11 requirements of this section. The request shall be supported
12 by such documentation as the agency requires by rule. The
13 agency shall assess a fee of $250 for each request for
14 exemption submitted under subsection (3).
15 Section 16. Paragraph (a) of subsection (1) of section
16 408.037, Florida Statutes, is amended to read:
17 408.037 Application content.--
18 (1) An application for a certificate of need must
19 contain:
20 (a) A detailed description of the proposed project and
21 statement of its purpose and need in relation to the local
22 health plan and the state health plan.
23 Section 17. Section 408.038, Florida Statutes, is
24 amended to read:
25 408.038 Fees.--The agency department shall assess fees
26 on certificate-of-need applications. Such fees shall be for
27 the purpose of funding the functions of the local health
28 councils and the activities of the agency department and shall
29 be allocated as provided in s. 408.033. The fee shall be
30 determined as follows:
31 (1) A minimum base fee of $5,000.
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1 (2) In addition to the base fee of $5,000, 0.015 of
2 each dollar of proposed expenditure, except that a fee may not
3 exceed $22,000.
4 Section 18. Subsections (3) and (4) and paragraphs (a)
5 and (b) of subsection (6) of section 408.039, Florida
6 Statutes, are amended to read:
7 408.039 Review process.--The review process for
8 certificates of need shall be as follows:
9 (3) APPLICATION PROCESSING.--
10 (a) An applicant shall file an application with the
11 agency department, and shall furnish a copy of the application
12 to the local health council and the agency department. Within
13 15 days after the applicable application filing deadline
14 established by agency department rule, the staff of the agency
15 department shall determine if the application is complete. If
16 the application is incomplete, the staff shall request
17 specific information from the applicant necessary for the
18 application to be complete; however, the staff may make only
19 one such request. If the requested information is not filed
20 with the agency department within 21 days of the receipt of
21 the staff's request, the application shall be deemed
22 incomplete and deemed withdrawn from consideration.
23 (b) Upon the request of any applicant or substantially
24 affected person within 14 days after notice that an
25 application has been filed, a public hearing may be held at
26 the agency's department's discretion if the agency department
27 determines that a proposed project involves issues of great
28 local public interest. The public hearing shall allow
29 applicants and other interested parties reasonable time to
30 present their positions and to present rebuttal information. A
31 recorded verbatim record of the hearing shall be maintained.
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1 The public hearing shall be held at the local level within 21
2 days after the application is deemed complete.
3 (4) STAFF RECOMMENDATIONS.--
4 (a) The agency's department's review of and final
5 agency action on applications shall be in accordance with the
6 district health plan, and statutory criteria, and the
7 implementing administrative rules. In the application review
8 process, the agency department shall give a preference, as
9 defined by rule of the agency department, to an applicant
10 which proposes to develop a nursing home in a nursing home
11 geographically underserved area.
12 (b) Within 60 days after all the applications in a
13 review cycle are determined to be complete, the agency
14 department shall issue its State Agency Action Report and
15 Notice of Intent to grant a certificate of need for the
16 project in its entirety, to grant a certificate of need for
17 identifiable portions of the project, or to deny a certificate
18 of need. The State Agency Action Report shall set forth in
19 writing its findings of fact and determinations upon which its
20 decision is based. If a finding of fact or determination by
21 the agency department is counter to the district health plan
22 of the local health council, the agency department shall
23 provide in writing its reason for its findings, item by item,
24 to the local health council. If the agency department intends
25 to grant a certificate of need, the State Agency Action Report
26 or the Notice of Intent shall also include any conditions
27 which the agency department intends to attach to the
28 certificate of need. The agency department shall designate by
29 rule a senior staff person, other than the person who issues
30 the final order, to issue State Agency Action Reports and
31 Notices of Intent.
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1 (c) The agency department shall publish its proposed
2 decision set forth in the Notice of Intent in the Florida
3 Administrative Weekly within 14 days after the Notice of
4 Intent is issued.
5 (d) If no administrative hearing is requested pursuant
6 to subsection (5), the State Agency Action Report and the
7 Notice of Intent shall become the final order of the agency
8 department. The agency department shall provide a copy of the
9 final order to the appropriate local health council.
10 (6) JUDICIAL REVIEW.--
11 (a) A party to an administrative hearing for an
12 application for a certificate of need has the right, within
13 not more than 30 days after the date of the final order, to
14 seek judicial review in the District Court of Appeal pursuant
15 to s. 120.68. The agency department shall be a party in any
16 such proceeding.
17 (b) In such judicial review, the court shall affirm
18 the final order of the agency department, unless the decision
19 is arbitrary, capricious, or not in compliance with ss.
20 408.031-408.045.
21 Section 19. Subsections (1) and (2) of section
22 408.040, Florida Statutes, are amended to read:
23 408.040 Conditions and monitoring.--
24 (1)(a) The agency may issue a certificate of need
25 predicated upon statements of intent expressed by an applicant
26 in the application for a certificate of need. Any conditions
27 imposed on a certificate of need based on such statements of
28 intent shall be stated on the face of the certificate of need.
29 1. Any certificate of need issued for construction of
30 a new hospital or for the addition of beds to an existing
31 hospital shall include a statement of the number of beds
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1 approved by category of service, including rehabilitation or
2 psychiatric service, for which the agency has adopted by rule
3 a specialty-bed-need methodology. All beds that are approved,
4 but are not covered by any specialty-bed-need methodology,
5 shall be designated as general.
6 (b)2. The agency may consider, in addition to the
7 other criteria specified in s. 408.035, a statement of intent
8 by the applicant that a specified to designate a percentage of
9 the annual patient days at beds of the facility will be
10 utilized for use by patients eligible for care under Title XIX
11 of the Social Security Act. Any certificate of need issued to
12 a nursing home in reliance upon an applicant's statements that
13 to provide a specified percentage number of annual patient
14 days will be utilized beds for use by residents eligible for
15 care under Title XIX of the Social Security Act must include a
16 statement that such certification is a condition of issuance
17 of the certificate of need. The certificate-of-need program
18 shall notify the Medicaid program office and the Department of
19 Elderly Affairs when it imposes conditions as authorized in
20 this paragraph subparagraph in an area in which a community
21 diversion pilot project is implemented.
22 (c)(b) A certificateholder may apply to the agency for
23 a modification of conditions imposed under paragraph (a) or
24 paragraph (b). If the holder of a certificate of need
25 demonstrates good cause why the certificate should be
26 modified, the agency shall reissue the certificate of need
27 with such modifications as may be appropriate. The agency
28 shall by rule define the factors constituting good cause for
29 modification.
30 (d)(c) If the holder of a certificate of need fails to
31 comply with a condition upon which the issuance of the
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1 certificate was predicated, the agency may assess an
2 administrative fine against the certificateholder in an amount
3 not to exceed $1,000 per failure per day. In assessing the
4 penalty, the agency shall take into account as mitigation the
5 relative lack of severity of a particular failure. Proceeds
6 of such penalties shall be deposited in the Public Medical
7 Assistance Trust Fund.
8 (2)(a) Unless the applicant has commenced
9 construction, if the project provides for construction, unless
10 the applicant has incurred an enforceable capital expenditure
11 commitment for a project, if the project does not provide for
12 construction, or unless subject to paragraph (b), a
13 certificate of need shall terminate 18 months after the date
14 of issuance, except in the case of a multifacility project, as
15 defined in s. 408.032, where the certificate of need shall
16 terminate 2 years after the date of issuance. The agency shall
17 monitor the progress of the holder of the certificate of need
18 in meeting the timetable for project development specified in
19 the application with the assistance of the local health
20 council as specified in s. 408.033(1)(b)5., and may revoke the
21 certificate of need, if the holder of the certificate is not
22 meeting such timetable and is not making a good-faith good
23 faith effort, as defined by rule, to meet it.
24 (b) A certificate of need issued to an applicant
25 holding a provisional certificate of authority under chapter
26 651 shall terminate 1 year after the applicant receives a
27 valid certificate of authority from the Department of
28 Insurance.
29 (c) The certificate-of-need validity period for a
30 project shall be extended by the agency, to the extent that
31 the applicant demonstrates to the satisfaction of the agency
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1 that good-faith good faith commencement of the project is
2 being delayed by litigation or by governmental action or
3 inaction with respect to regulations or permitting precluding
4 commencement of the project.
5 (d) If an application is filed to consolidate two or
6 more certificates as authorized by s. 408.036(2)(f) or to
7 divide a certificate of need into two or more facilities as
8 authorized by s. 408.036(2)(g), the validity period of the
9 certificate or certificates of need to be consolidated or
10 divided shall be extended for the period beginning upon
11 submission of the application and ending when final agency
12 action and any appeal from such action has been concluded.
13 However, no such suspension shall be effected if the
14 application is withdrawn by the applicant.
15 Section 20. Section 408.044, Florida Statutes, is
16 amended to read:
17 408.044 Injunction.--Notwithstanding the existence or
18 pursuit of any other remedy, the agency department may
19 maintain an action in the name of the state for injunction or
20 other process against any person to restrain or prevent the
21 pursuit of a project subject to review under ss.
22 408.031-408.045, in the absence of a valid certificate of
23 need.
24 Section 21. Section 408.045, Florida Statutes, is
25 amended to read:
26 408.045 Certificate of need; competitive sealed
27 proposals.--
28 (1) The application, review, and issuance procedures
29 for a certificate of need for an intermediate care facility
30 for the developmentally disabled may be made by the agency
31 department by competitive sealed proposals.
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1 (2) The agency department shall make a decision
2 regarding the issuance of the certificate of need in
3 accordance with the provisions of s. 287.057(15), rules
4 adopted by the agency department relating to intermediate care
5 facilities for the developmentally disabled, and the criteria
6 in s. 408.035, as further defined by rule.
7 (3) Notification of the decision shall be issued to
8 all applicants not later than 28 calendar days after the date
9 responses to a request for proposal are due.
10 (4) The procedures provided for under this section are
11 exempt from the batching cycle requirements and the public
12 hearing requirement of s. 408.039.
13 (5) The agency department may use the competitive
14 sealed proposal procedure for determining a certificate of
15 need for other types of health care facilities and services if
16 the agency department identifies an unmet health care need and
17 when funding in whole or in part for such health care
18 facilities or services is authorized by the Legislature.
19 Section 22. (1)(a) There is created a
20 certificate-of-need workgroup staffed by the Agency for Health
21 Care Administration.
22 (b) Workgroup participants shall be responsible for
23 only the expenses that they generate individually through
24 workgroup participation. The agency shall be responsible for
25 expenses incidental to the production of any required data or
26 reports.
27 (2) The workgroup shall consist of 30 members, 10
28 appointed by the Governor, 10 appointed by the President of
29 the Senate, and 10 appointed by the Speaker of the House of
30 Representatives. The workgroup chairperson shall be selected
31 by majority vote of a quorum present. Sixteen members shall
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1 constitute a quorum. The membership shall include, but not be
2 limited to, representatives from health care provider
3 organizations, health care facilities, individual health care
4 practitioners, local health councils, and consumer
5 organizations, and persons with health care market expertise
6 as a private-sector consultant.
7 (3) Appointment to the workgroup shall be as follows:
8 (a) The Governor shall appoint one representative each
9 from the hospital industry; nursing home industry; hospice
10 industry; local health councils; a consumer organization; and
11 three health care market consultants, one of whom is a
12 recognized expert on hospital markets, one of whom is a
13 recognized expert on nursing home or long-term-care markets,
14 and one of whom is a recognized expert on hospice markets; one
15 representative from the Medicaid program; and one
16 representative from a health care facility that provides a
17 tertiary service.
18 (b) The President of the Senate shall appoint a
19 representative of a for-profit hospital, a representative of a
20 not-for-profit hospital, a representative of a public
21 hospital, two representatives of the nursing home industry,
22 two representatives of the hospice industry, a representative
23 of a consumer organization, a representative from the
24 Department of Elderly Affairs involved with the implementation
25 of a long-term-care community diversion program, and a health
26 care market consultant with expertise in health care
27 economics.
28 (c) The Speaker of the House of Representatives shall
29 appoint a representative from the Florida Hospital
30 Association, a representative of the Association of Community
31 Hospitals and Health Systems of Florida, a representative of
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1 the Florida League of Health Systems, a representative of the
2 Florida Health Care Association, a representative of the
3 Florida Association of Homes for the Aging, three
4 representatives of Florida Hospices and Palliative Care, one
5 representative of local health councils, and one
6 representative of a consumer organization.
7 (4) The workgroup shall study issues pertaining to the
8 certificate-of-need program, including the impact of trends in
9 health care delivery and financing. The workgroup shall study
10 issues relating to implementation of the certificate-of-need
11 program.
12 (5) The workgroup shall meet at least annually, at the
13 request of the chairperson. The workgroup shall submit an
14 interim report by December 31, 2001, and a final report by
15 December 31, 2002. The workgroup is abolished effective July
16 1, 2003.
17 Section 23. Subsection (7) of section 651.118, Florida
18 Statutes, is amended to read:
19 651.118 Agency for Health Care Administration;
20 certificates of need; sheltered beds; community beds.--
21 (7) Notwithstanding the provisions of subsection (2),
22 at the discretion of the continuing care provider, sheltered
23 nursing home beds may be used for persons who are not
24 residents of the facility and who are not parties to a
25 continuing care contract for a period of up to 5 years after
26 the date of issuance of the initial nursing home license. A
27 provider whose 5-year period has expired or is expiring may
28 request the Agency for Health Care Administration for an
29 extension, not to exceed 30 percent of the total sheltered
30 nursing home beds, if the utilization by residents of the
31 facility in the sheltered beds will not generate sufficient
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1 income to cover facility expenses, as evidenced by one of the
2 following:
3 (a) The facility has a net loss for the most recent
4 fiscal year as determined under generally accepted accounting
5 principles, excluding the effects of extraordinary or unusual
6 items, as demonstrated in the most recently audited financial
7 statement; or
8 (b) The facility would have had a pro forma loss for
9 the most recent fiscal year, excluding the effects of
10 extraordinary or unusual items, if revenues were reduced by
11 the amount of revenues from persons in sheltered beds who were
12 not residents, as reported on by a certified public
13 accountant.
14
15 The agency shall be authorized to grant an extension to the
16 provider based on the evidence required in this subsection.
17 The agency may request a facility to use up to 25 percent of
18 the patient days generated by new admissions of nonresidents
19 during the extension period to serve Medicaid recipients for
20 those beds authorized for extended use if there is a
21 demonstrated need in the respective service area and if funds
22 are available. A provider who obtains an extension is
23 prohibited from applying for additional sheltered beds under
24 the provision of subsection (2), unless additional residential
25 units are built or the provider can demonstrate need by
26 facility residents to the Agency for Health Care
27 Administration. The 5-year limit does not apply to up to five
28 sheltered beds designated for inpatient hospice care as part
29 of a contractual arrangement with a hospice licensed under
30 part VI of chapter 400. A facility that uses such beds after
31 the 5-year period shall report such use to the Agency for
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1 Health Care Administration. For purposes of this subsection,
2 "resident" means a person who, upon admission to the facility,
3 initially resides in a part of the facility not licensed under
4 part II of chapter 400.
5 Section 24. Subsection (3) of section 400.464, Florida
6 Statutes, is repealed.
7 Section 25. Applications for certificates of need
8 submitted under section 408.031-408.045, Florida Statutes,
9 before the effective date of this act shall be governed by the
10 law in effect at the time the application was submitted.
11 Section 26. The General Appropriations Act for Fiscal
12 Year 2000-2001 shall be reduced by 4 FTE and $260,719 from the
13 Health Care Trust Fund in the Agency for Health Care
14 Administration for purposes of implementing the provisions of
15 sections 10 through 25 of this act.
16 Section 27. Subsection (12) is added to section
17 216.136, Florida Statutes, to read:
18 216.136 Consensus estimating conferences; duties and
19 principals.--
20 (12) MANDATED HEALTH INSURANCE BENEFITS AND PROVIDERS
21 ESTIMATING CONFERENCE.--
22 (a) Duties.--The Mandated Health Insurance Benefits
23 and Providers Estimating Conference shall:
24 1. Develop and maintain, with the Department of
25 Insurance, a system and program of data collection to assess
26 the impact of mandated benefits and providers, including costs
27 to employers and insurers, impact of treatment, cost savings
28 in the health care system, number of providers, and other
29 appropriate data.
30 2. Prescribe the format, content, and timing of
31 information that is to be submitted to the conference and used
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1 by the conference in its assessment of proposed and existing
2 mandated benefits and providers. Such format, content, and
3 timing requirements are binding upon all parties submitting
4 information for the conference to use in its assessment of
5 proposed and existing mandated benefits and providers.
6 3. Provide assessments of proposed and existing
7 mandated benefits and providers and other studies of mandated
8 benefits and provider issues as requested by the Legislature
9 or the Governor. When a legislative measure containing a
10 mandated health insurance benefit or provider is proposed, the
11 standing committee of the Legislature which has jurisdiction
12 over the proposal shall request that the conference prepare
13 and forward to the Governor and the Legislature a study that
14 provides, for each measure, a cost-benefit analysis that
15 assesses the social and financial impact and the medical
16 efficacy according to prevailing medical standards of the
17 proposed mandate. The conference has 12 months after the
18 committee makes its request in which to complete and submit
19 the conference's report. The standing committee may not
20 consider such a proposed legislative measure until 12 months
21 after it has requested the report and has received the
22 conference's report on the measure.
23 4. The standing committees of the Legislature which
24 have jurisdiction over health insurance matters shall request
25 that the conference assess the social and financial impact and
26 the medical efficacy of existing mandated benefits and
27 providers. The committees shall submit to the conference by
28 January 1, 2001, a schedule of evaluations that sets forth the
29 respective dates by which the conference must have completed
30 its evaluations of particular existing mandates.
31
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1 (b) Principals.--The Executive Office of the Governor,
2 the Insurance Commissioner, the Agency for Health Care
3 Administration, the Director of the Division of Economic and
4 Demographic Research of the Joint Legislative Management
5 Committee, and professional staff of the Senate and the House
6 of Representatives who have health insurance expertise, or
7 their designees, are the principals of the Mandated Health
8 Insurance Benefits and Providers Estimating Conference. The
9 responsibility of presiding over sessions of the conference
10 shall be rotated among the principals.
11 Section 28. Section 624.215, Florida Statutes, is
12 amended to read:
13 624.215 Proposals for legislation which mandates
14 health benefit coverage; review by Legislature.--
15 (1) LEGISLATIVE INTENT.--The Legislature finds that
16 there is an increasing number of proposals which mandate that
17 certain health benefits be provided by insurers and health
18 maintenance organizations as components of individual and
19 group policies. The Legislature further finds that many of
20 these benefits provide beneficial social and health
21 consequences which may be in the public interest. However,
22 the Legislature also recognizes that most mandated benefits
23 contribute to the increasing cost of health insurance
24 premiums. Therefore, it is the intent of the Legislature to
25 conduct a systematic review of current and proposed mandated
26 or mandatorily offered health coverages and to establish
27 guidelines for such a review. This review will assist the
28 Legislature in determining whether mandating a particular
29 coverage is in the public interest.
30 (2) MANDATED HEALTH COVERAGE; REPORT TO THE MANDATED
31 HEALTH INSURANCE BENEFITS AND PROVIDERS ESTIMATING CONFERENCE
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1 AGENCY FOR HEALTH CARE ADMINISTRATION AND LEGISLATIVE
2 COMMITTEES; GUIDELINES FOR ASSESSING IMPACT.--Every person or
3 organization seeking consideration of a legislative proposal
4 which would mandate a health coverage or the offering of a
5 health coverage by an insurance carrier, health care service
6 contractor, or health maintenance organization as a component
7 of individual or group policies, shall submit to the Mandated
8 Health Insurance Benefits and Providers Estimating Conference
9 Agency for Health Care Administration and the legislative
10 committees having jurisdiction a report which assesses the
11 social and financial impacts of the proposed coverage.
12 Guidelines for assessing the impact of a proposed mandated or
13 mandatorily offered health coverage must, to the extent that
14 information is available, shall include:
15 (a) To what extent is the treatment or service
16 generally used by a significant portion of the population.
17 (b) To what extent is the insurance coverage generally
18 available.
19 (c) If the insurance coverage is not generally
20 available, to what extent does the lack of coverage result in
21 persons avoiding necessary health care treatment.
22 (d) If the coverage is not generally available, to
23 what extent does the lack of coverage result in unreasonable
24 financial hardship.
25 (e) The level of public demand for the treatment or
26 service.
27 (f) The level of public demand for insurance coverage
28 of the treatment or service.
29 (g) The level of interest of collective bargaining
30 agents in negotiating for the inclusion of this coverage in
31 group contracts.
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1 (h) A report of the extent to which To what extent
2 will the coverage will increase or decrease the cost of the
3 treatment or service.
4 (i) A report of the extent to which To what extent
5 will the coverage will increase the appropriate uses of the
6 treatment or service.
7 (j) A report of the extent to which To what extent
8 will the mandated treatment or service will be a substitute
9 for a more expensive treatment or service.
10 (k) A report of the extent to which To what extent
11 will the coverage will increase or decrease the administrative
12 expenses of insurance companies and the premium and
13 administrative expenses of policyholders.
14 (l) A report as to the impact of this coverage on the
15 total cost of health care.
16
17 The reports required in paragraphs (h) through (l) shall be
18 reviewed by the Mandated Health Insurance Benefits and
19 Providers Estimating Conference using a certified actuary. The
20 standing committee of the Legislature which has jurisdiction
21 over the legislative proposal must request and receive a
22 report from the Mandated Health Insurance Benefits and
23 Providers Estimating Conference before the committee considers
24 the proposal. The committee may not consider a legislative
25 proposal that would mandate a health coverage or the offering
26 of a health coverage by an insurance carrier, health care
27 service contractor, or health maintenance organization until
28 after the committee's request to the Mandated Health Insurance
29 Benefits and Providers Estimating Conference has been
30 answered. As used in this section, the term "health coverage
31 mandate" includes mandating the use of a type of provider.
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1 Section 29. Effective January 1, 2001, a physician
2 licensed under chapter 458, Florida Statutes, or chapter 459,
3 Florida Statutes, or a hospital licensed under chapter 395,
4 Florida Statutes, shall provide a consumer-assistance notice
5 in the form of a sign that is prominently displayed in the
6 reception area and clearly noticeable by all patients and in
7 the form of a written statement that is given to each person
8 to whom medical services are being provided. Such a sign or
9 statement must state that consumer information regarding a
10 doctor, hospital, or health plan is available through a
11 toll-free number and website maintained by the Agency for
12 Health Care Administration. In addition, the sign and
13 statement must state that any complaint regarding medical
14 services received or the patient's health plan may be
15 submitted through the toll-free number. The agency, in
16 cooperation with other appropriate agencies, shall establish
17 the consumer-assistance program and provide physicians and
18 hospitals with information regarding the toll-free number and
19 website and with signs for posting in facilities at no cost to
20 the provider.
21 Section 30. Subsection (1) of section 408.7056,
22 Florida Statutes, is amended to read:
23 408.7056 Statewide Provider and Subscriber Assistance
24 Program.--
25 (1) As used in this section, the term:
26 (a) "Agency" means the Agency for Health Care
27 Administration.
28 (b) "Department" means the Department of Insurance.
29 (c) "Grievance procedure" means an established set of
30 rules that specify a process for appeal of an organizational
31 decision.
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1 (d) "Health care provider" or "provider" means a
2 state-licensed or state-authorized facility, a facility
3 principally supported by a local government or by funds from a
4 charitable organization that holds a current exemption from
5 federal income tax under s. 501(c)(3) of the Internal Revenue
6 Code, a licensed practitioner, a county health department
7 established under part I of chapter 154, a prescribed
8 pediatric extended care center defined in s. 400.902, a
9 federally supported primary care program such as a migrant
10 health center or a community health center authorized under s.
11 329 or s. 330 of the United States Public Health Services Act
12 that delivers health care services to individuals, or a
13 community facility that receives funds from the state under
14 the Community Alcohol, Drug Abuse, and Mental Health Services
15 Act and provides mental health services to individuals.
16 (e)(a) "Managed care entity" means a health
17 maintenance organization or a prepaid health clinic certified
18 under chapter 641, a prepaid health plan authorized under s.
19 409.912, or an exclusive provider organization certified under
20 s. 627.6472.
21 (f)(b) "Panel" means a statewide provider and
22 subscriber assistance panel selected as provided in subsection
23 (11).
24 Section 31. Section 627.654, Florida Statutes, is
25 amended to read:
26 627.654 Labor union, and association, and small
27 employer health alliance groups.--
28 (1)(a) A group of individuals may be insured under a
29 policy issued to an association, including a labor union,
30 which association has a constitution and bylaws and not less
31 than 25 individual members and which has been organized and
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1 has been maintained in good faith for a period of 1 year for
2 purposes other than that of obtaining insurance, or to the
3 trustees of a fund established by such an association, which
4 association or trustees shall be deemed the policyholder,
5 insuring at least 15 individual members of the association for
6 the benefit of persons other than the officers of the
7 association, the association or trustees.
8 (b) A small employer, as defined in s. 627.6699 and
9 including the employer's eligible employees and the spouses
10 and dependents of such employees, may be insured under a
11 policy issued to a small employer health alliance by a carrier
12 as defined in s. 627.6699. A small employer health alliance
13 must be organized as a not-for-profit corporation under
14 chapter 617. Notwithstanding any other law, if a
15 small-employer member of an alliance loses eligibility to
16 purchase health care through the alliance solely because the
17 business of the small-employer member expands to more than 50
18 and fewer than 75 eligible employees, the small-employer
19 member may, at its next renewal date, purchase coverage
20 through the alliance for not more than 1 additional year. A
21 small employer health alliance shall establish conditions of
22 participation in the alliance by a small employer, including,
23 but not limited to:
24 1. Assurance that the small employer is not formed for
25 the purpose of securing health benefit coverage.
26 2. Assurance that the employees of a small employer
27 have not been added for the purpose of securing health benefit
28 coverage.
29 (2) No such policy of insurance as defined in
30 subsection (1) may be issued to any such association or
31 alliance, unless all individual members of such association,
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1 or all small-employer members of an alliance, or all of any
2 class or classes thereof, are declared eligible and acceptable
3 to the insurer at the time of issuance of the policy.
4 (3) Any such policy issued under paragraph (1)(a) may
5 insure the spouse or dependent children with or without the
6 member being insured.
7 (4) A single master policy issued to an association,
8 labor union, or small-employer health alliance may include
9 more than one health plan from the same insurer or affiliated
10 insurer group as alternatives for an employer, employee, or
11 member to select.
12 Section 32. Paragraph (f) of subsection (2), paragraph
13 (b) of subsection (4), and subsection (6) of section 627.6571,
14 Florida Statutes, are amended to read:
15 627.6571 Guaranteed renewability of coverage.--
16 (2) An insurer may nonrenew or discontinue a group
17 health insurance policy based only on one or more of the
18 following conditions:
19 (f) In the case of health insurance coverage that is
20 made available only through one or more bona fide associations
21 as defined in subsection (5) or through one or more small
22 employer health alliances as described in s. 627.654(1)(b),
23 the membership of an employer in the association or in the
24 small employer health alliance, on the basis of which the
25 coverage is provided, ceases, but only if such coverage is
26 terminated under this paragraph uniformly without regard to
27 any health-status-related factor that relates to any covered
28 individuals.
29 (4) At the time of coverage renewal, an insurer may
30 modify the health insurance coverage for a product offered:
31
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1 (b) In the small-group market if, for coverage that is
2 available in such market other than only through one or more
3 bona fide associations as defined in subsection (5) or through
4 one or more small employer health alliances as described in s.
5 627.654(1)(b), such modification is consistent with s.
6 627.6699 and effective on a uniform basis among group health
7 plans with that product.
8 (6) In applying this section in the case of health
9 insurance coverage that is made available by an insurer in the
10 small-group market or large-group market to employers only
11 through one or more associations or through one or more small
12 employer health alliances as described in s. 627.654(1)(b), a
13 reference to "policyholder" is deemed, with respect to
14 coverage provided to an employer member of the association, to
15 include a reference to such employer.
16 Section 33. Paragraph (h) of subsection (5), and
17 paragraph (a) of subsection (12) of section 627.6699, Florida
18 Statutes, are amended to read:
19 627.6699 Employee Health Care Access Act.--
20 (5) AVAILABILITY OF COVERAGE.--
21 (h) All health benefit plans issued under this section
22 must comply with the following conditions:
23 1. For employers who have fewer than two employees, a
24 late enrollee may be excluded from coverage for no longer than
25 24 months if he or she was not covered by creditable coverage
26 continually to a date not more than 63 days before the
27 effective date of his or her new coverage.
28 2. Any requirement used by a small employer carrier in
29 determining whether to provide coverage to a small employer
30 group, including requirements for minimum participation of
31 eligible employees and minimum employer contributions, must be
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1 applied uniformly among all small employer groups having the
2 same number of eligible employees applying for coverage or
3 receiving coverage from the small employer carrier, except
4 that a small employer carrier that participates in,
5 administers, or issues health benefits pursuant to s. 381.0406
6 which do not include a preexisting condition exclusion may
7 require as a condition of offering such benefits that the
8 employer has had no health insurance coverage for its
9 employees for a period of at least 6 months. A small employer
10 carrier may vary application of minimum participation
11 requirements and minimum employer contribution requirements
12 only by the size of the small employer group.
13 3. In applying minimum participation requirements with
14 respect to a small employer, a small employer carrier shall
15 not consider as an eligible employee employees or dependents
16 who have qualifying existing coverage in an employer-based
17 group insurance plan or an ERISA qualified self-insurance plan
18 in determining whether the applicable percentage of
19 participation is met. However, a small employer carrier may
20 count eligible employees and dependents who have coverage
21 under another health plan that is sponsored by that employer
22 except if such plan is offered pursuant to s. 408.706.
23 4. A small employer carrier shall not increase any
24 requirement for minimum employee participation or any
25 requirement for minimum employer contribution applicable to a
26 small employer at any time after the small employer has been
27 accepted for coverage, unless the employer size has changed,
28 in which case the small employer carrier may apply the
29 requirements that are applicable to the new group size.
30 5. If a small employer carrier offers coverage to a
31 small employer, it must offer coverage to all the small
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1 employer's eligible employees and their dependents. A small
2 employer carrier may not offer coverage limited to certain
3 persons in a group or to part of a group, except with respect
4 to late enrollees.
5 6. A small employer carrier may not modify any health
6 benefit plan issued to a small employer with respect to a
7 small employer or any eligible employee or dependent through
8 riders, endorsements, or otherwise to restrict or exclude
9 coverage for certain diseases or medical conditions otherwise
10 covered by the health benefit plan.
11 7. An initial enrollment period of at least 30 days
12 must be provided. An annual 30-day open enrollment period
13 must be offered to each small employer's eligible employees
14 and their dependents. A small employer carrier must provide
15 special enrollment periods as required by s. 627.65615.
16 (12) STANDARD, BASIC, AND LIMITED HEALTH BENEFIT
17 PLANS.--
18 (a)1. By May 15, 1993, the commissioner shall appoint
19 a health benefit plan committee composed of four
20 representatives of carriers which shall include at least two
21 representatives of HMOs, at least one of which is a staff
22 model HMO, two representatives of agents, four representatives
23 of small employers, and one employee of a small employer. The
24 carrier members shall be selected from a list of individuals
25 recommended by the board. The commissioner may require the
26 board to submit additional recommendations of individuals for
27 appointment. As alliances are established under s. 408.702,
28 each alliance shall also appoint an additional member to the
29 committee.
30 2. The committee shall develop changes to the form and
31 level of coverages for the standard health benefit plan and
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1 the basic health benefit plan, and shall submit the forms, and
2 levels of coverages to the department by September 30, 1993.
3 The department must approve such forms and levels of coverages
4 by November 30, 1993, and may return the submissions to the
5 committee for modification on a schedule that allows the
6 department to grant final approval by November 30, 1993.
7 3. The plans shall comply with all of the requirements
8 of this subsection.
9 4. The plans must be filed with and approved by the
10 department prior to issuance or delivery by any small employer
11 carrier.
12 5. After approval of the revised health benefit plans,
13 if the department determines that modifications to a plan
14 might be appropriate, the commissioner shall appoint a new
15 health benefit plan committee in the manner provided in
16 subparagraph 1. to submit recommended modifications to the
17 department for approval.
18 Section 34. Subsection (1) of section 240.2995,
19 Florida Statutes, is amended to read:
20 240.2995 University health services support
21 organizations.--
22 (1) Each state university is authorized to establish
23 university health services support organizations which shall
24 have the ability to enter into, for the benefit of the
25 university academic health sciences center, and arrangements
26 with other entities as providers for accountable health
27 partnerships, as defined in s. 408.701, and providers in other
28 integrated health care systems or similar entities. To the
29 extent required by law or rule, university health services
30 support organizations shall become licensed as insurance
31 companies, pursuant to chapter 624, or be certified as health
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1 maintenance organizations, pursuant to chapter 641.
2 University health services support organizations shall have
3 sole responsibility for the acts, debts, liabilities, and
4 obligations of the organization. In no case shall the state
5 or university have any responsibility for such acts, debts,
6 liabilities, and obligations incurred or assumed by university
7 health services support organizations.
8 Section 35. Paragraph (a) of subsection (2) of section
9 240.2996, Florida Statutes, is amended to read:
10 240.2996 University health services support
11 organization; confidentiality of information.--
12 (2) The following university health services support
13 organization's records and information are confidential and
14 exempt from the provisions of s. 119.07(1) and s. 24(a), Art.
15 I of the State Constitution:
16 (a) Contracts for managed care arrangements, as
17 managed care is defined in s. 408.701, under which the
18 university health services support organization provides
19 health care services, including preferred provider
20 organization contracts, health maintenance organization
21 contracts, alliance network arrangements, and exclusive
22 provider organization contracts, and any documents directly
23 relating to the negotiation, performance, and implementation
24 of any such contracts for managed care arrangements or
25 alliance network arrangements. As used in this paragraph, the
26 term "managed care" means systems or techniques generally used
27 by third-party payors or their agents to affect access to and
28 control payment for health care services. Managed-care
29 techniques most often include one or more of the following:
30 prior, concurrent, and retrospective review of the medical
31 necessity and appropriateness of services or site of services;
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1 contracts with selected health care providers; financial
2 incentives or disincentives related to the use of specific
3 providers, services, or service sites; controlled access to
4 and coordination of services by a case manager; and payor
5 efforts to identify treatment alternatives and modify benefit
6 restrictions for high-cost patient care.
7
8 The exemptions in this subsection are subject to the Open
9 Government Sunset Review Act of 1995 in accordance with s.
10 119.15 and shall stand repealed on October 2, 2001, unless
11 reviewed and saved from repeal through reenactment by the
12 Legislature.
13 Section 36. Paragraph (b) of subsection (8) of section
14 240.512, Florida Statutes, is amended to read:
15 240.512 H. Lee Moffitt Cancer Center and Research
16 Institute.--There is established the H. Lee Moffitt Cancer
17 Center and Research Institute at the University of South
18 Florida.
19 (8)
20 (b) Proprietary confidential business information is
21 confidential and exempt from the provisions of s. 119.07(1)
22 and s. 24(a), Art. I of the State Constitution. However, the
23 Auditor General and Board of Regents, pursuant to their
24 oversight and auditing functions, must be given access to all
25 proprietary confidential business information upon request and
26 without subpoena and must maintain the confidentiality of
27 information so received. As used in this paragraph, the term
28 "proprietary confidential business information" means
29 information, regardless of its form or characteristics, which
30 is owned or controlled by the not-for-profit corporation or
31 its subsidiaries; is intended to be and is treated by the
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1 not-for-profit corporation or its subsidiaries as private and
2 the disclosure of which would harm the business operations of
3 the not-for-profit corporation or its subsidiaries; has not
4 been intentionally disclosed by the corporation or its
5 subsidiaries unless pursuant to law, an order of a court or
6 administrative body, a legislative proceeding pursuant to s.
7 5, Art. III of the State Constitution, or a private agreement
8 that provides that the information may be released to the
9 public; and which is information concerning:
10 1. Internal auditing controls and reports of internal
11 auditors;
12 2. Matters reasonably encompassed in privileged
13 attorney-client communications;
14 3. Contracts for managed-care arrangements, as managed
15 care is defined in s. 408.701, including preferred provider
16 organization contracts, health maintenance organization
17 contracts, and exclusive provider organization contracts, and
18 any documents directly relating to the negotiation,
19 performance, and implementation of any such contracts for
20 managed-care arrangements;
21 4. Bids or other contractual data, banking records,
22 and credit agreements the disclosure of which would impair the
23 efforts of the not-for-profit corporation or its subsidiaries
24 to contract for goods or services on favorable terms;
25 5. Information relating to private contractual data,
26 the disclosure of which would impair the competitive interest
27 of the provider of the information;
28 6. Corporate officer and employee personnel
29 information;
30 7. Information relating to the proceedings and records
31 of credentialing panels and committees and of the governing
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1 board of the not-for-profit corporation or its subsidiaries
2 relating to credentialing;
3 8. Minutes of meetings of the governing board of the
4 not-for-profit corporation and its subsidiaries, except
5 minutes of meetings open to the public pursuant to subsection
6 (9);
7 9. Information that reveals plans for marketing
8 services that the corporation or its subsidiaries reasonably
9 expect to be provided by competitors;
10 10. Trade secrets as defined in s. 688.002, including
11 reimbursement methodologies or rates; or
12 11. The identity of donors or prospective donors of
13 property who wish to remain anonymous or any information
14 identifying such donors or prospective donors. The anonymity
15 of these donors or prospective donors must be maintained in
16 the auditor's report.
17
18 As used in this paragraph, the term "managed care" means
19 systems or techniques generally used by third-party payors or
20 their agents to affect access to and control payment for
21 health care services. Managed-care techniques most often
22 include one or more of the following: prior, concurrent, and
23 retrospective review of the medical necessity and
24 appropriateness of services or site of services; contracts
25 with selected health care providers; financial incentives or
26 disincentives related to the use of specific providers,
27 services, or service sites; controlled access to and
28 coordination of services by a case manager; and payor efforts
29 to identify treatment alternatives and modify benefit
30 restrictions for high-cost patient care.
31
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1 Section 37. Subsection (14) of section 381.0406,
2 Florida Statutes, is amended to read:
3 381.0406 Rural health networks.--
4 (14) NETWORK FINANCING.--Networks may use all sources
5 of public and private funds to support network activities.
6 Nothing in this section prohibits networks from becoming
7 managed care providers, or accountable health partnerships,
8 provided they meet the requirements for an accountable health
9 partnership as specified in s. 408.706.
10 Section 38. Paragraph (a) of subsection (2) of section
11 395.3035, Florida Statutes, is amended to read:
12 395.3035 Confidentiality of hospital records and
13 meetings.--
14 (2) The following records and information of any
15 hospital that is subject to chapter 119 and s. 24(a), Art. I
16 of the State Constitution are confidential and exempt from the
17 provisions of s. 119.07(1) and s. 24(a), Art. I of the State
18 Constitution:
19 (a) Contracts for managed care arrangements, as
20 managed care is defined in s. 408.701, under which the public
21 hospital provides health care services, including preferred
22 provider organization contracts, health maintenance
23 organization contracts, exclusive provider organization
24 contracts, and alliance network arrangements, and any
25 documents directly relating to the negotiation, performance,
26 and implementation of any such contracts for managed care or
27 alliance network arrangements. As used in this paragraph, the
28 term "managed care" means systems or techniques generally used
29 by third-party payors or their agents to affect access to and
30 control payment for health care services. Managed-care
31 techniques most often include one or more of the following:
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1 prior, concurrent, and retrospective review of the medical
2 necessity and appropriateness of services or site of services;
3 contracts with selected health care providers; financial
4 incentives or disincentives related to the use of specific
5 providers, services, or service sites; controlled access to
6 and coordination of services by a case manager; and payor
7 efforts to identify treatment alternatives and modify benefit
8 restrictions for high-cost patient care.
9 Section 39. Paragraph (b) of subsection (1) of section
10 627.4301, Florida Statutes, is amended to read:
11 627.4301 Genetic information for insurance purposes.--
12 (1) DEFINITIONS.--As used in this section, the term:
13 (b) "Health insurer" means an authorized insurer
14 offering health insurance as defined in s. 624.603, a
15 self-insured plan as defined in s. 624.031, a
16 multiple-employer welfare arrangement as defined in s.
17 624.437, a prepaid limited health service organization as
18 defined in s. 636.003, a health maintenance organization as
19 defined in s. 641.19, a prepaid health clinic as defined in s.
20 641.402, a fraternal benefit society as defined in s. 632.601,
21 an accountable health partnership as defined in s. 408.701, or
22 any health care arrangement whereby risk is assumed.
23 Section 40. Subsection (3) of section 408.70, and
24 sections 408.701, 408.702, 408.703, 408.704, 408.7041,
25 408.7042, 408.7045, 408.7055, and 408.706, Florida Statutes,
26 are repealed.
27 Section 41. Paragraph (n) of subsection (3), paragraph
28 (c) of subsection (5), and paragraphs (b) and (d) of
29 subsection (6) of section 627.6699, Florida Statutes, are
30 amended to read:
31 627.6699 Employee Health Care Access Act.--
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1 (3) DEFINITIONS.--As used in this section, the term:
2 (n) "Modified community rating" means a method used to
3 develop carrier premiums which spreads financial risk across a
4 large population and allows adjustments for age, gender,
5 family composition, tobacco usage, and geographic area as
6 determined under paragraph (5)(j); claims experience, health
7 status, or duration of coverage as permitted under
8 subparagraph (6)(b)5.; and administrative and acquisition
9 expenses as permitted under subparagraph (6)(b)6.
10 (5) AVAILABILITY OF COVERAGE.--
11 (c) Every small employer carrier must, as a condition
12 of transacting business in this state:
13 1. Beginning July 1, 2000, January 1, 1994, offer and
14 issue all small employer health benefit plans on a
15 guaranteed-issue basis to every eligible small employer, with
16 2 3 to 50 eligible employees, that elects to be covered under
17 such plan, agrees to make the required premium payments, and
18 satisfies the other provisions of the plan. A rider for
19 additional or increased benefits may be medically underwritten
20 and may only be added to the standard health benefit plan.
21 The increased rate charged for the additional or increased
22 benefit must be rated in accordance with this section.
23 2. Beginning August 1, 2000 April 15, 1994, offer and
24 issue basic and standard small employer health benefit plans
25 on a guaranteed-issue basis, during a 31-day open enrollment
26 period of August 1 through August 31 of each year, to every
27 eligible small employer, with less than one or two eligible
28 employees, which small employer is not formed primarily for
29 the purpose of buying health insurance and which elects to be
30 covered under such plan, agrees to make the required premium
31 payments, and satisfies the other provisions of the plan.
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1 Coverage provided under this subparagraph shall begin on
2 October 1 of the same year as the date of enrollment, unless
3 the small employer carrier and the small employer agree to a
4 different date. A rider for additional or increased benefits
5 may be medically underwritten and may only be added to the
6 standard health benefit plan. The increased rate charged for
7 the additional or increased benefit must be rated in
8 accordance with this section. For purposes of this
9 subparagraph, a person, his or her spouse, and his or her
10 dependent children constitute a single eligible employee if
11 that person and spouse are employed by the same small employer
12 and either that person or his or her spouse has a normal work
13 week of less than 25 hours.
14 3. Offer to eligible small employers the standard and
15 basic health benefit plans. This paragraph subparagraph does
16 not limit a carrier's ability to offer other health benefit
17 plans to small employers if the standard and basic health
18 benefit plans are offered and rejected.
19 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
20 (b) For all small employer health benefit plans that
21 are subject to this section and are issued by small employer
22 carriers on or after January 1, 1994, premium rates for health
23 benefit plans subject to this section are subject to the
24 following:
25 1. Small employer carriers must use a modified
26 community rating methodology in which the premium for each
27 small employer must be determined solely on the basis of the
28 eligible employee's and eligible dependent's gender, age,
29 family composition, tobacco use, or geographic area as
30 determined under paragraph (5)(j) and in which the premium may
31 be adjusted as permitted by subparagraphs 5. and 6.
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1 2. Rating factors related to age, gender, family
2 composition, tobacco use, or geographic location may be
3 developed by each carrier to reflect the carrier's experience.
4 The factors used by carriers are subject to department review
5 and approval.
6 3. Small employer carriers may not modify the rate for
7 a small employer for 12 months from the initial issue date or
8 renewal date, unless the composition of the group changes or
9 benefits are changed. However, a small employer carrier may
10 modify the rate one time prior to 12 months after the initial
11 issue date for a small employer who enrolls under a previously
12 issued group policy that has a common anniversary date for all
13 employers covered under the policy if:
14 a. The carrier discloses to the employer in a clear
15 and conspicuous manner the date of the first renewal and the
16 fact that the premium may increase on or after that date.
17 b. The insurer demonstrates to the department that
18 efficiencies in administration are achieved and reflected in
19 the rates charged to small employers covered under the policy.
20 4. A carrier may issue a group health insurance policy
21 to a small employer health alliance or other group association
22 with rates that reflect a premium credit for expense savings
23 attributable to administrative activities being performed by
24 the alliance or group association if such expense savings are
25 specifically documented in the insurer's rate filing and are
26 approved by the department. Any such credit may not be based
27 on different morbidity assumptions or on any other factor
28 related to the health status or claims experience of any
29 person covered under the policy. Nothing in this subparagraph
30 exempts an alliance or group association from licensure for
31 any activities that require licensure under the Insurance
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1 Code. A carrier issuing a group health insurance policy to a
2 small-employer health alliance or other group association
3 shall allow any properly licensed and appointed agent of that
4 carrier to market and sell the small-employer health alliance
5 or other group association policy. Such agent shall be paid
6 the usual and customary commission paid to any agent selling
7 the policy. Carriers participating in the alliance program, in
8 accordance with ss. 408.70-408.706, may apply a different
9 community rate to business written in that program.
10 5. Any adjustments in rates for claims experience,
11 health status, or duration of coverage may not be charged to
12 individual employees or dependents. For a small employer's
13 policy, such adjustments may not result in a rate for the
14 small employer which deviates more than 15 percent from the
15 carrier's approved rate. Any such adjustment must be applied
16 uniformly to the rates charged for all employees and
17 dependents of the small employer. A small employer carrier may
18 make an adjustment to a small employer's renewal premium, not
19 to exceed 10 percent annually, due to the claims experience,
20 health status, or duration of coverage of the employees or
21 dependents of the small employer. Semiannually small group
22 carriers shall report information on forms adopted by rule by
23 the department to enable the department to monitor the
24 relationship of aggregate adjusted premiums actually charged
25 policyholders by each carrier to the premiums that would have
26 been charged by application of the carrier's approved modified
27 community rates. If the aggregate resulting from the
28 application of such adjustment exceeds the premium that would
29 have been charged by application of the approved modified
30 community rate by 5 percent for the current reporting period,
31 the carrier shall limit the application of such adjustments
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1 only to minus adjustments beginning not more than 60 days
2 after the report is sent to the department. For any subsequent
3 reporting period, if the total aggregate adjusted premium
4 actually charged does not exceed the premium that would have
5 been charged by application of the approved modified community
6 rate by 5 percent, the carrier may apply both plus and minus
7 adjustments. A small employer carrier may provide a credit to
8 a small employer's premium based on administrative and
9 acquisition expense differences resulting from the size of the
10 group. Group size administrative and acquisition expense
11 factors may be developed by each carrier to reflect the
12 carrier's experience and are subject to department review and
13 approval.
14 6. A small employer carrier rating methodology may
15 include separate rating categories for one dependent child,
16 for two dependent children, and for three or more dependent
17 children for family coverage of employees having a spouse and
18 dependent children or employees having dependent children
19 only. A small employer carrier may have fewer, but not
20 greater, numbers of categories for dependent children than
21 those specified in this subparagraph.
22 7. Small employer carriers may not use a composite
23 rating methodology to rate a small employer with fewer than 10
24 employees. For the purposes of this subparagraph, a "composite
25 rating methodology" means a rating methodology that averages
26 the impact of the rating factors for age and gender in the
27 premiums charged to all of the employees of a small employer.
28 (d) Notwithstanding s. 627.401(2), this section and
29 ss. 627.410 and 627.411 apply to any health benefit plan
30 provided by a small employer carrier that is an insurer, and
31 this section and s. 641.31 apply to any health benefit
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1 provided by a small employer carrier that is a health
2 maintenance organization that provides coverage to one or more
3 employees of a small employer regardless of where the policy,
4 certificate, or contract is issued or delivered, if the health
5 benefit plan covers employees or their covered dependents who
6 are residents of this state.
7 Section 42. Section 641.201, Florida Statutes, is
8 amended to read:
9 641.201 Applicability of other laws.--Except as
10 provided in this part, health maintenance organizations shall
11 be governed by the provisions of this part and part III of
12 this chapter and shall be exempt from all other provisions of
13 the Florida Insurance Code except those provisions of the
14 Florida Insurance Code that are explicitly made applicable to
15 health maintenance organizations.
16 Section 43. Section 641.234, Florida Statutes, is
17 amended to read:
18 641.234 Administrative, provider, and management
19 contracts.--
20 (1) The department may require a health maintenance
21 organization to submit any contract for administrative
22 services, contract with a provider other than an individual
23 physician, contract for management services, and contract with
24 an affiliated entity to the department.
25 (2) After review of a contract the department may
26 order the health maintenance organization to cancel the
27 contract in accordance with the terms of the contract and
28 applicable law if it determines:
29 (a) That the fees to be paid by the health maintenance
30 organization under the contract are so unreasonably high as
31 compared with similar contracts entered into by the health
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1 maintenance organization or as compared with similar contracts
2 entered into by other health maintenance organizations in
3 similar circumstances that the contract is detrimental to the
4 subscribers, stockholders, investors, or creditors of the
5 health maintenance organization; or.
6 (b) That the contract is with an entity that is not
7 licensed under state statutes, if such license is required, or
8 is not in good standing with the applicable regulatory agency.
9 (3) All contracts for administrative services,
10 management services, provider services other than individual
11 physician contracts, and with affiliated entities entered into
12 or renewed by a health maintenance organization on or after
13 October 1, 1988, shall contain a provision that the contract
14 shall be canceled upon issuance of an order by the department
15 pursuant to this section.
16 Section 44. Subsection (2) of section 641.27, Florida
17 Statutes, is amended to read:
18 641.27 Examination by the department.--
19 (2) The department may contract, at reasonable fees
20 for work performed, with qualified, impartial outside sources
21 to perform audits or examinations or portions thereof
22 pertaining to the qualification of an entity for issuance of a
23 certificate of authority or to determine continued compliance
24 with the requirements of this part, in which case the payment
25 must be made, directly to the contracted examiner by the
26 health maintenance organization examined, in accordance with
27 the rates and terms agreed to by the department and the
28 examiner. Any contracted assistance shall be under the direct
29 supervision of the department. The results of any contracted
30 assistance shall be subject to the review of, and approval,
31 disapproval, or modification by, the department.
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1 Section 45. Section 641.226, Florida Statutes, is
2 created to read:
3 641.226 Application of federal solvency requirements
4 to provider-sponsored organizations.--The solvency
5 requirements of sections 1855 and 1856 of the Balanced Budget
6 Act of 1997 and rules adopted by the Secretary of the United
7 States Department of Health and Human Services apply to a
8 health maintenance organization that is a provider-sponsored
9 organization rather than the solvency requirements of this
10 part. However, if the provider-sponsored organization does not
11 meet the solvency requirements of this part, the organization
12 is limited to the issuance of Medicare+Choice plans to
13 eligible individuals. For the purposes of this section, the
14 terms "Medicare+Choice plans," "provider-sponsored
15 organizations," and "solvency requirements" have the same
16 meaning as defined in the federal act and federal rules and
17 regulations.
18 Section 46. Section 641.39, Florida Statutes, is
19 created to read:
20 641.39 Soliciting or accepting new or renewal health
21 maintenance contracts by insolvent or impaired health
22 maintenance organization prohibited; penalty.--
23 (1) Whether or not delinquency proceedings as to a
24 health maintenance organization have been or are to be
25 initiated, a director or officer of a health maintenance
26 organization, except with the written permission of the
27 Department of Insurance, may not authorize or permit the
28 health maintenance organization to solicit or accept new or
29 renewal health maintenance contracts or provider contracts in
30 this state after the director or officer knew, or reasonably
31 should have known, that the health maintenance organization
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1 was insolvent or impaired. As used in this section, the term
2 "impaired" means that the health maintenance organization does
3 not meet the requirements of s. 641.225.
4 (2) Any director or officer who violates this section
5 is guilty of a felony of the third degree, punishable as
6 provided in s. 775.082, s. 775.083, or s. 775.084.
7 Section 47. Section 641.2011, Florida Statutes, is
8 created to read:
9 641.2011 Insurance holding companies.--Part IV of
10 chapter 628 applies to health maintenance organizations
11 licensed under part I of chapter 641.
12 Section 48. Section 641.275, Florida Statutes, is
13 created to read:
14 641.275 Subscriber's rights under health maintenance
15 contracts; required notice.--
16 (1) It is the intent of the Legislature that the
17 rights of subscribers who are covered under health maintenance
18 organization contracts be recognized and summarized in a
19 statement of subscriber rights. An organization may not
20 require a subscriber to waive his or her rights as a condition
21 of coverage or treatment and must operate in conformity with
22 such rights.
23 (2) Each organization must provide subscribers with a
24 copy of their rights as set forth in this section, in such
25 form as approved by the department.
26 (3) An organization shall:
27 (a) Ensure that health care services provided to
28 subscribers are rendered under reasonable standards of quality
29 of care consistent with the prevailing standards of medical
30 practice in the community, as required by s. 641.51;
31
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1 (b) Have a quality assurance program for health care
2 services, as required by s. 641.51;
3 (c) Not modify the professional judgment of a
4 physician unless the course of treatment is inconsistent with
5 the prevailing standards of medical practice in the community,
6 as required by s. 641.51;
7 (d) Not restrict a provider's ability to communicate
8 information to the subscriber/patient regarding medical care
9 options that are in the best interest of the
10 subscriber/patient, as required by s. 641.315(8);
11 (e) Provide for standing referrals to specialists for
12 subscribers with chronic and disabling conditions, as required
13 by s. 641.51;
14 (f) Allow a female subscriber to select an
15 obstetrician/gynecologist as her primary care physician, as
16 required by s. 641.19(13)(e);
17 (g) Provide direct access, without prior
18 authorization, for a female subscriber to visit a
19 obstetrician/gynecologist, as required by s. 641.51(10);
20 (h) Provide direct access, without prior
21 authorization, to a dermatologist, as required by s.
22 641.31(33);
23 (i) Not limit coverage for the length of stay in a
24 hospital for a mastectomy for any time period that is less
25 than that determined to be medically necessary by the treating
26 physician, as required by s. 641.31(33);
27 (j) Not limit coverage for the length of a maternity
28 or newborn stay in a hospital or for follow-up care outside
29 the hospital to any time period less than that determined to
30 be medically necessary by the treating provider, as required
31 by s. 641.31(18);
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1 (k) Not exclude coverage for bone marrow transplant
2 procedures determined by the Agency for Health Care
3 Administration to not be experimental, as required by s.
4 627.4236;
5 (l) Not exclude coverage for drugs on the ground that
6 the drug is not approved by the U.S. Food and Drug
7 Administration, as required by s. 627.4239;
8 (m) Give the subscriber the right to a second medical
9 opinion as required by s. 641.51(4);
10 (n) Allow subscribers to continue treatment from a
11 provider after the provider's contract with the organization
12 has been terminated, as required by s. 641.51(7);
13 (o) Establish a procedure for resolving subscriber
14 grievances, including review of adverse determinations by the
15 organization and expedited review of urgent subscriber
16 grievances, as required by s. 641.511;
17 (p) Notify subscribers of the right to an independent
18 external review of grievances not resolved by the
19 organization, as required by s. 408.7056;
20 (q) Provide, without prior authorization, coverage for
21 emergency services and care, as required by s. 641.513;
22 (r) Not require or solicit genetic information or use
23 genetic test results for any insurance purposes, as required
24 by s. 627.4310;
25 (s) Promptly pay or deny claims as required by s.
26 641.3155;
27 (t) Provide information to subscribers regarding
28 benefits, limitations, resolving grievances, emergency
29 services and care, treatment by non-contract providers, list
30 of contract providers, authorization and referral process, the
31 process used to determine whether services are medically
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1 necessary, quality assurance program, prescription drug
2 benefits and use of a drug formulary, confidentiality and
3 disclosure of medical records, process of determining
4 experimental or investigational medical treatments, and
5 process used to examine qualifications of contract providers,
6 as required by ss. 641.31, 641.495, and 641.54.
7 (4) The statement of rights in subsection (3) is a
8 summary of selected requirements for organizations contained
9 in other sections of the Florida Statutes. This section does
10 not alter the requirements of such other sections.
11 (5)(a) The department may impose a fine against a
12 health maintenance organization for a violation of this
13 section which refers to a section in this part or in chapter
14 627. Such fines shall be in the amounts specified in s.
15 641.25.
16 (b) The agency may impose a fine against a health
17 maintenance organization for a violation of this section which
18 refers to a section in part III of this chapter or in chapter
19 408. Such fines shall be in the amounts specified in s.
20 641.52.
21 Section 49. Section 641.28, Florida Statutes, is
22 amended to read:
23 641.28 Civil remedy.--
24 (1) In any civil action brought to enforce the terms
25 and conditions of a health maintenance organization contract:
26 (a) If the civil action is filed before or within 60
27 days after the subscriber or enrollee filed a notice of intent
28 to sue with the statewide provider and subscriber assistance
29 program established pursuant to s. 408.7056 or a notice
30 pursuant to s. 641.3917, the prevailing party is entitled to
31 recover reasonable attorney's fees and court costs.
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1 (b) If the civil action is filed more than 60 days
2 after the subscriber or enrollee filed a notice of intent to
3 sue with the statewide provider and subscriber assistance
4 program established pursuant to s. 408.7056 or a notice
5 pursuant to s. 641.3917, and the subscriber or enrollee
6 receives a final judgment or decree against the health
7 maintenance organization in favor of the subscriber or
8 enrollee, the court shall enter a judgment or decree against
9 the health maintenance organization in favor of the subscriber
10 or enrollee for reasonable attorney's fees and court costs.
11 (2) This section shall not be construed to authorize a
12 civil action against the department, its employees, or the
13 Insurance Commissioner or against the Agency for Health Care
14 Administration, its employees, or the director of the agency.
15 Section 50. Paragraphs (c), (d), and (e) are added to
16 subsection (10) of section 641.3903, Florida Statutes, and
17 subsection (15) is added to that section, to read:
18 641.3903 Unfair methods of competition and unfair or
19 deceptive acts or practices defined.--The following are
20 defined as unfair methods of competition and unfair or
21 deceptive acts or practices:
22 (10) ILLEGAL DEALINGS IN PREMIUMS; EXCESS OR REDUCED
23 CHARGES FOR HEALTH MAINTENANCE COVERAGE.--
24 (c) Cancelling or otherwise terminating any health
25 maintenance contract or coverage, or requiring execution of a
26 consent to rate endorsement, during the stated contract term
27 for the purpose of offering to issue, or issuing, a similar or
28 identical contract to the same subscriber or enrollee with the
29 same exposure at a higher premium rate or continuing an
30 existing contract with the same exposure at an increased
31 premium.
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1 (d) Issuing a nonrenewal notice on any health
2 maintenance organization contract, or requiring execution of a
3 consent to rate endorsement, for the purpose of offering to
4 issue, or issuing, a similar or identical contract to the same
5 subscriber or enrollee at a higher premium rate or continuing
6 an existing contract at an increased premium without meeting
7 any applicable notice requirements.
8 (e) Cancelling or issuing a nonrenewal notice on any
9 health maintenance organization contract without complying
10 with any applicable cancellation or nonrenewal provision
11 required under the Florida Insurance Code.
12 (15) REFUSAL TO COVER.--In addition to other
13 provisions of this code, the refusal to cover, or continue to
14 cover, any individual solely because of:
15 (a) Race, color, creed, marital status, sex, or
16 national origin;
17 (b) The residence, age, or lawful occupation of the
18 individual, unless there is a reasonable relationship between
19 the residence, age, or lawful occupation of the individual and
20 the coverage issued or to be issued; or
21 (c) The fact that the enrollee or applicant had been
22 previously refused insurance coverage or health maintenance
23 organization coverage by any insurer or health maintenance
24 organization when such refusal to cover or continue to cover
25 for this reason occurs with such frequency as to indicate a
26 general business practice.
27 Section 51. Section 641.3917, Florida Statutes, is
28 amended to read:
29 641.3917 Civil liability.--The provisions of this part
30 are cumulative to rights under the general civil and common
31
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1 law, and no action of the department shall abrogate such
2 rights to damage or other relief in any court.
3 (1) Any person to whom a duty is owed may bring a
4 civil action against a health maintenance organization when
5 such person suffers damages as a result of:
6 (a) A violation of s. 641.3903(5)(a), (b), (c)1.-7.,
7 (10), or (15) by the health maintenance organization; or
8 (b) The health maintenance organization's failure to
9 provide a covered service when in good faith the health
10 maintenance organization should have provided the service if
11 it had acted fairly and honestly toward its subscriber or
12 enrollee and with due regard for his or her interests and, in
13 the independent medical judgment of a contract treating
14 physician or other physician authorized by the health
15 maintenance organization, the service is medically necessary.
16
17 However, a person pursuing a remedy under this section need
18 not prove that such acts were committed or performed with such
19 frequency as to indicate a general business practice.
20 (2)(a) As a condition precedent to bringing an action
21 under this section, the department and the health maintenance
22 organization must have been given 60 days' written notice of
23 the violation. If the department returns a notice for lack of
24 specificity, the 60-day time period does not begin until a
25 proper notice is filed.
26 (b) The notice must be on a form provided by the
27 department and must state with specificity the following
28 information and such other information as the department
29 requires:
30
31
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1 1. The provision of law, including the specific
2 language of the law, which the health maintenance organization
3 has allegedly violated.
4 2. The facts and circumstances giving rise to the
5 violation.
6 3. The name of any individual involved in the
7 violation.
8 4. Any reference to specific contract language that is
9 relevant to the violation.
10 5. A statement that the notice is given in order to
11 perfect the right to pursue the civil remedy authorized by
12 this section.
13 (c) Within 20 days after receipt of the notice, the
14 department may return any notice that does not provide the
15 specific information required by this section, and the
16 department shall indicate the specific deficiencies contained
17 in the notice. A determination by the department to return a
18 notice for lack of specificity is exempt from the requirements
19 of chapter 120.
20 (d) No action shall lie under this section if, within
21 60 days after filing notice, the damages are paid or the
22 circumstances giving rise to the violation are corrected.
23 (e) The health maintenance organization that is the
24 recipient of a notice filed under this section shall report to
25 the department on the disposition of the alleged violation.
26 (f) The applicable statute of limitations for an
27 action under this section shall be tolled for a period of 65
28 days by the mailing of the notice required by this subsection
29 or the mailing of a subsequent notice required by this
30 subsection.
31
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1 (3) Upon adverse adjudication at trial or upon appeal,
2 the health maintenance organization is liable for damages,
3 together with court costs and reasonable attorney's fees,
4 incurred by the plaintiff.
5 (4) Punitive damages shall not be awarded under this
6 section unless the acts giving rise to the violation occur
7 with such frequency as to indicate a general business practice
8 and are either willful, wanton, and malicious or are in
9 reckless disregard for the rights of any subscriber or
10 enrollee. Any person who pursues a claim under this
11 subsection shall post, in advance, the costs of discovery.
12 Such costs shall be awarded to the health maintenance
13 organization if no punitive damages are awarded to the
14 plaintiff.
15 (5) This section shall not be construed to authorize a
16 class action suit against a health maintenance organization or
17 a civil action against the department, its employees, or the
18 Insurance Commissioner, or against the Agency for Health Care
19 Administration, its employees, or the director of the agency
20 or to create a cause of action when a health maintenance
21 organization refuses to pay a claim for reimbursement on the
22 grounds that the charge for a service was unreasonably high or
23 that the service provided was not medically necessary.
24 (6)(a) The civil remedy specified in this section does
25 not preempt any other remedy or cause of action provided for
26 pursuant to any other law or pursuant to the common law of
27 this state. Any person may obtain a judgment under either the
28 common law remedy of bad faith or the remedy provided in this
29 section, but is not entitled to a judgment under both
30 remedies. This section does not create a common law cause of
31 action. The damages recoverable under this section include
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1 damages that are a reasonably foreseeable result of a
2 specified violation of this section by the health maintenance
3 organization and may include an award or judgment in an amount
4 that exceeds contract limits.
5 (b) This section does not create a cause of action for
6 medical malpractice. Such an action is subject to the
7 provisions of chapter 766.
8 (c) This section does not apply to the provision of
9 medical care, treatment, or attendance pursuant to chapter
10 440.
11 Section 52. Subsection (4) of section 440.11, Florida
12 Statutes, is amended to read:
13 440.11 Exclusiveness of liability.--
14 (4) Notwithstanding the provisions of s. 624.155 or s.
15 641.3917, the liability of a carrier or a health maintenance
16 organization to an employee or to anyone entitled to bring
17 suit in the name of the employee shall be as provided in this
18 chapter, which shall be exclusive and in place of all other
19 liability.
20 Section 53. The Legislature finds that the provisions
21 of this act will fulfill an important state interest.
22 Section 54. The sum of $112,000 is appropriated from
23 the Insurance Commissioner's Regulatory Trust Fund to the
24 Department of Insurance and three positions are authorized for
25 the purposes of carrying out the provisions of sections 49
26 through 52 of this act.
27 Section 55. Subsection (39) is added to section
28 641.31, Florida Statutes, to read:
29 641.31 Health maintenance contracts.--
30 (39) A health maintenance organization contract may
31 not prohibit or restrict a subscriber from receiving
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1 in-patient services in a contracted hospital from a contracted
2 primary care or admitting physician if such services are
3 determined by the organization to be medically necessary and
4 covered services under the organization's contract with the
5 contract holder.
6 Section 56. Subsection (11) is added to section
7 641.315, Florida Statutes, to read:
8 641.315 Provider contracts.--
9 (11) A contract between a health maintenance
10 organization and a contracted primary-care or admitting
11 physician may not contain any provision that prohibits such
12 physician from providing in-patient services in a contracted
13 hospital to a subscriber if such services are determined by
14 the organization to be medically necessary and covered
15 services under the organization's contract with the contract
16 holder.
17 Section 57. Subsection (5) is added to section
18 641.3155, Florida Statutes, to read:
19 641.3155 Provider contracts; payment of claims.--
20 (5) A health maintenance organization shall pay a
21 contracted primary-care or admitting physician, pursuant to
22 such physician's contract, for providing in-patient services
23 in a contracted hospital to a subscriber, if such services are
24 determined by the organization to be medically necessary and
25 covered services under the organization's contract with the
26 contract holder.
27 Section 58. Present subsections (4), (5), (6), (7),
28 (8), (9), and (10) of section 641.51, Florida Statutes, are
29 redesignated as subsections (5), (6), (7), (8), (9), (10), and
30 (11), respectively, and a new subsection (4) is added to that
31 section to read:
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1 641.51 Quality assurance program; second medical
2 opinion requirement.--
3 (4) The organization shall ensure that only a
4 physician licensed under chapter 458 or chapter 459; or an
5 M.D. or D.O. physician with an active, unencumbered license in
6 another state with similar licensing requirements may render
7 an adverse determination regarding a service provided by a
8 physician licensed in this state. The organization shall
9 submit to the treating provider and the subscriber written
10 notification regarding the organization's adverse
11 determination within 2 working days after the subscriber or
12 provider is notified of the adverse determination. The written
13 notification must include the utilization review criteria or
14 benefits provisions used in the adverse determination,
15 identify the physician who rendered the adverse determination,
16 and be signed by an authorized representative of the
17 organization or the physician who renders the adverse
18 determination. The organization must include with the
19 notification of an adverse determination information
20 concerning the appeal process for adverse determinations.
21 Section 59. This act shall take effect July 1, 2000,
22 and apply to contracts issued or renewed on or after that
23 date, except as otherwise provided in this act and except that
24 the amendment to section 395.701, Florida Statutes, by this
25 act shall take effect only upon the receipt by the Agency for
26 Health Care Administration of written confirmation from the
27 federal Health Care Financing Administration that the changes
28 contained in such amendment will not adversely affect the use
29 of the remaining assessments as state match for the state's
30 Medicaid program.
31
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS/CS/SB 2154, CS/SB 1900 & SB 282
3
4 Clarifies that provisions of the Insurance Code that
specifically apply to health maintenance organizations, do
5 apply to health maintenance organizations, even though they
are not contained in chapter 641.
6
Provides that the Department of Insurance may terminate a
7 health maintenance organization contract with a third party if
the contract is with an entity that is not licensed under
8 state law, if such license is required, or is not in good
standing with the applicable regulatory agency.
9
Makes it a third-degree felony for an officer or director of a
10 health maintenance organization to accept new or renewal
subscriber contracts if the health maintenance organization is
11 insolvent or impaired (which is current law for officers and
directors of an insurance company).
12
Requires the Mandated Health Insurance Benefits and Providers
13 Estimating Conference to use a certified actuary in reviewing
required reports rather than requiring each report submitted
14 to be prepared by a certified actuary.
15
16
17
18
19
20
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22
23
24
25
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27
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