Senate Bill 0336

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    Florida Senate - 2000                                   SB 336

    By Senator Saunders





    25-338-00

  1                      A bill to be entitled

  2         An act relating to managed care; requiring the

  3         Agency for Health Care Administration to

  4         establish the Statewide Managed-Care Ombudsman

  5         Office to direct a managed-care ombudsman

  6         program; specifying the purpose of the

  7         managed-care ombudsman program; requiring that

  8         the managed-care ombudsman office contract with

  9         district managed-care ombudsman organizations

10         to assist consumers in resolving complaints

11         against managed-care plans; requiring that the

12         ombudsman office issue an annual report;

13         requiring that the managed-care ombudsman

14         program provide certain public-outreach

15         services; providing requirements for contracts

16         with district managed-care ombudsman

17         organizations; providing for the appointment of

18         a program director for the ombudsman office;

19         providing duties of the ombudsman office;

20         providing for the appointment of members to the

21         Statewide Managed-Care Advisory Council;

22         specifying the duties of the advisory council;

23         providing for a pilot project to test the

24         managed-care ombudsman program; providing for

25         funding the managed-care ombudsman program

26         through an assessment on health plan premiums;

27         requiring the Agency for Health Care

28         Administration to adopt rules; repealing ss.

29         641.60, 641.61, 641.62, 641.65, 641.67, 641.68,

30         641.70, 641.75, F.S., relating to the Statewide

31         Managed Care Ombudsman Committee and district

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    Florida Senate - 2000                                   SB 336
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  1         managed care ombudsman committees; providing an

  2         effective date.

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

  5

  6         Section 1.  Managed-care ombudsman program.--

  7         (1)  PURPOSE AND INTENT.--The Agency for Health Care

  8  Administration shall establish a Statewide Managed-Care

  9  Ombudsman Office to direct a managed-care ombudsman program.

10  The ombudsman office shall be advised by a Statewide

11  Managed-Care Advisory Council. The purpose of the managed-care

12  ombudsman program shall be to:

13         (a)  Educate consumers concerning managed care, health

14  plans, and health plan options.

15         (b)  Educate consumers concerning their rights and

16  responsibilities as members of a health plan.

17         (c)  Facilitate the resolution of the concerns and

18  problems of health plan members.

19         (2)  ASSISTANCE FUNCTIONS OF THE MANAGED-CARE OMBUDSMAN

20  PROGRAM.--The ombudsman office shall contract with district

21  managed-care ombudsman organizations to perform, at a minimum,

22  the following functions:

23         (a)  Assist consumers in understanding managed care,

24  health plans, and their options as health plan members, and

25  educate consumers in understanding and using objective,

26  comparative plan information in selecting a health plan.

27         (b)  Educate consumers regarding their rights and

28  responsibilities as health plan members, including the right

29  to various complaint, grievance, and appeals processes.

30         (c)  Receive, evaluate, and catalogue all concerns of

31  plan members and complaints concerning health plans.

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  1         (d)  Facilitate the resolution of problems through

  2  active communication with health plans, particularly member

  3  service departments. A health plan may release medical

  4  information directly only to the plan member, or his or her

  5  designated representative, upon the member's written

  6  authorization. The plan member shall release the health plan

  7  from any liability for providing such information.

  8         (e)  Assist health plan members in filing formal

  9  grievances and appeals when complaints cannot be resolved by

10  working with the health plan, and assist members throughout

11  the grievance and appeals processes.

12         (f)  Refer health plan members, when appropriate, to

13  other organizations for assistance, particularly for legal

14  representation during the grievance and appeals processes.

15         (g)  Conduct periodic meetings and share information

16  with health plan representatives and officials of the

17  ombudsman office. The purpose of these meetings is to discuss

18  issues of concern which arise from the activities of the

19  managed-care ombudsman program and to provide feedback

20  concerning systematic failures to help identify opportunities

21  for improving health plans and state rules governing health

22  plans.

23         (h)  Collect and analyze data gathered through the

24  activities of the managed-care ombudsman program, or otherwise

25  available to the program, and provide an annual report to the

26  ombudsman office on program initiatives, results, and issues

27  of concern to consumers. The annual report must include

28  recommendations for improving the managed-care delivery system

29  and the state regulatory system for managed care.

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  1         (i)  Provide a resource to all employers, particularly

  2  small employers, by establishing an independent assistance

  3  program for employers and their families.

  4         (j)  Provide a resource for health plans by educating

  5  plan members, assisting in resolving member problems, and

  6  identifying opportunities for improving health plans.

  7         (3)  PUBLIC OUTREACH STRATEGIES OF THE MANAGED-CARE

  8  OMBUDSMAN PROGRAM.--The managed-care ombudsman program shall

  9  implement innovative strategies and maximize its outreach to

10  consumers. Each health plan must include in its marketing and

11  membership materials information regarding the availability of

12  the managed-care ombudsman program. The public outreach

13  strategies must, at a minimum, include:

14         (a)  A toll-free telephone number.

15         (b)  A web site on the Internet.

16         (c)  Person-to-person counseling.

17         (d)  Publication and distribution of printed materials

18  and reports.

19         (e)  Active liaison services, partnership services, and

20  information-sharing with community, consumer, health,

21  disability, religious, and ethnic-based organizations and

22  other organizations that represent consumers.

23         (4)  SELECTION CRITERIA FOR DISTRICT MANAGED-CARE

24  OMBUDSMAN ORGANIZATIONS.--The ombudsman office shall contract,

25  through a competitive bidding process, with independent

26  district managed-care ombudsman organizations to perform

27  program functions. The ombudsman office shall establish

28  criteria for selecting organizations. The criteria must, at a

29  minimum, include:

30         (a)  Status as a private entity.

31         (b)  Not-for-profit status.

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  1         (c)  Public interest mission.

  2         (d)  A governing board that consists of a majority of

  3  consumers.

  4         (e)  Qualified staff expertise in managed care, public

  5  education and outreach, program resolution, and

  6  quality-of-care evaluation.

  7         (5)  FUNCTIONS OF THE STATEWIDE MANAGED-CARE OMBUDSMAN

  8  OFFICE.--The director of the Agency for Health Care

  9  Administration shall appoint a program director of the

10  ombudsman office. The ombudsman office shall design,

11  implement, and evaluate the managed-care ombudsman program. At

12  a minimum, the ombudsman office shall:

13         (a)  Administer competitive contracts with district

14  managed-care ombudsman organizations for performing the

15  functions of the managed-care ombudsman program.

16         (b)  Establish the scope of work for the organizations

17  under contract with the ombudsman office.

18         (c)  Adopt rules to administer the managed-care

19  ombudsman program. The rules must authorize and describe the

20  process by which an organization under contract with the

21  ombudsman office may access health plan information necessary

22  to facilitate resolving problems of health plan members.

23         (d)  Evaluate the performance of all organizations

24  under contract with the ombudsman office.

25         (e)  Provide technical assistance and training to all

26  organizations under contract with the ombudsman office.

27         (f)  Collect and analyze data gathered through the

28  activities of the managed-care ombudsman program, or otherwise

29  available to the ombudsman office, and publish an annual

30  report on the initiatives, results, and issues of concern to

31  consumers. The annual report must include recommendations for

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  1  improving the managed-care delivery system and the state

  2  regulatory system for managed care.

  3         1.  The ombudsman office shall have access to

  4  managed-care information that is available through state

  5  licensing agencies, external quality reviews, independent

  6  appeals, and report-card programs of managed-care programs.

  7         2.  The ombudsman office shall coordinate the sharing

  8  of data and managed-care information among organizations under

  9  contract with the ombudsman office. The annual report shall be

10  widely disseminated to state agencies and to the public.

11         (6)  COMPOSITION AND FUNCTIONS OF THE STATEWIDE

12  MANAGED-CARE ADVISORY COUNCIL.--The members of the Statewide

13  Managed-Care Advisory Council shall be appointed, in equal

14  number, by the Governor, the Insurance Commissioner, the

15  President of the Senate, and the Speaker of the House of

16  Representatives. The members of the advisory council must be

17  broadly representative of the health care community and shall,

18  at a minimum, include consumers, employers, providers, and

19  representatives of the district ombudsman organizations, the

20  managed-care industry, and state agencies that regulate and

21  oversee managed care. The Statewide Managed-Care Advisory

22  Council shall, at a minimum, perform the following functions:

23         (a)  Advise the ombudsman office on program design and

24  operational issues, including the scope of work to be included

25  in contracts with district ombudsman organizations and the

26  rules of the managed-care ombudsman program.

27         (b)  Recommend to the ombudsman office the eligibility

28  criteria to be used in selecting district ombudsman

29  organizations.

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    Florida Senate - 2000                                   SB 336
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  1         (c)  Recommend to the ombudsman office the criteria to

  2  be used in evaluating the performance of district ombudsman

  3  organizations.

  4         (d)  Recommend to the ombudsman office possible changes

  5  to the managed-care ombudsman program and standards and

  6  consumer protections for managed care.

  7         (7)  TWO-YEAR PILOT PROJECT.--The managed-care

  8  ombudsman program shall be initially tested through a 2-year

  9  pilot project. The director of the Agency for Health Care

10  Administration shall select two locations, one urban and one

11  rural, for implementing the pilot project. The ombudsman

12  office shall select a different district managed-care

13  ombudsman organization to conduct the managed-care ombudsman

14  program in each location. The state contract with each

15  district managed-care ombudsman organization shall be for 2

16  years and must be consistent with all requirements of the

17  managed-care ombudsman program.

18         (8)  FUNDING FOR THE MANAGED-CARE OMBUDSMAN

19  PROGRAM.--The managed-care ombudsman program shall be funded

20  by an assessment on health plan premiums. The ombudsman office

21  shall determine the exact assessment on health plans, which

22  must be based on the scope of work of the managed-care

23  ombudsman program and include the cost of contracts with

24  district managed-care ombudsman organizations.

25         (a)  As a condition of the contract, any district

26  managed-care ombudsman organization under contract with the

27  managed-care ombudsman program to perform program functions

28  shall be required to raise funds from the private sector.

29         (b)  The 2-year pilot project shall be funded in the

30  General Appropriations Act.

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  1         (9)  RULEMAKING AUTHORITY.--The Agency for Health Care

  2  Administration shall adopt rules to administer this section.

  3         Section 2.  Sections 641.60, 641.61, 641.62, 641.65,

  4  641.67, 641.68, 641.70, and 641.75, Florida Statutes, are

  5  repealed.

  6         Section 3.  This act shall take effect July 1, 2000.

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  9                          SENATE SUMMARY

10    Creates the Statewide Managed-Care Ombudsman Office
      within the Agency for Health Care Administration.
11    Provides for the ombudsman office to contract with
      district managed-care ombudsman organizations to assist
12    consumers in resolving complaints against managed-care
      plans and to perform additional duties. Creates the
13    Statewide Managed-Care Advisory Council and provides for
      the appointment of members. Requires that the advisory
14    council make recommendations to the ombudsman office.
      Provides for a 2-year pilot project to test the
15    managed-care ombudsman program. Requires that the
      managed-care ombudsman program be funded by an assessment
16    on health plan premiums. Repeals provisions that
      establish the Statewide Managed Care Ombudsman Committee
17    and district managed care ombudsman committees. (See bill
      for details.)
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