House Bill hb1213

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    Florida House of Representatives - 2001                HB 1213

        By Representatives Siplin, Joyner, Weissman, Smith,
    Wilson, Cusack, Bendross-Mindingall, Peterman, Negron and
    Bennett




  1                      A bill to be entitled

  2         An act relating to a managed care patient's

  3         bill of rights; providing a short title;

  4         providing requirements and limitations for

  5         group health plans and health insurance issuers

  6         that provide health insurance coverage relating

  7         to utilization review, internal and external

  8         appeals, grievances, consumer choice options,

  9         choice of health care professionals, emergency

10         care, specialty care, obstetrical and

11         gynecological care, pediatric care, continuity

12         of care, prescription drugs, access to

13         information, interference with medical

14         communications, discrimination against

15         providers, payment of claims, and protection of

16         patient advocacy; providing an effective date.

17

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

19

20         Section 1.  (1)  This act may be cited as the "Managed

21  Care Patient's Bill of Rights Act."

22         (2)  Each group health plan, and each health insurance

23  issuer that provides health insurance coverage:

24         (a)  Shall conduct utilization review activities in

25  connection with the provision of benefits under such plan or

26  coverage.

27         (b)  Shall provide adequate notice in writing to the

28  appropriate affected person of any denial of a claim for

29  benefits and the reasons for such denial, written in a manner

30  calculated to be understood by such person, and shall afford

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    Florida House of Representatives - 2001                HB 1213

    796-102-01






  1  such person the opportunity to request a full and fair review

  2  of such denial.

  3         (c)  Shall provide for an external appeals process for

  4  any denial of a claim for benefits.

  5         (d)  Shall establish and maintain a system to provide

  6  for the presentation and resolution of oral and written

  7  grievances regarding any aspect of the plan's or issuer's

  8  services.

  9         (e)  Which offers health insurance coverage for

10  services which are only furnished through health care

11  professionals and providers who are members of a network of

12  health care professionals and providers who have entered into

13  a contract with the plan or issuer to provide such services,

14  shall also offer or arrange to be offered the option of health

15  insurance coverage or health benefits for such services which

16  are not furnished through health care professionals and

17  providers who are members of such a network.

18         (f)  That requires or provides for designation of a

19  participating primary care provider, shall permit a covered

20  person to designate any participating primary care provider

21  who is available to accept such individual and shall permit a

22  covered person to receive medically necessary or appropriate

23  specialty care from any qualified participating health care

24  professional who is available to accept such individual for

25  such care.

26         (g)  Which provides benefits with respect to services

27  in an emergency department of a hospital, shall cover

28  emergency services without the need for any prior

29  authorization, whether or not the health care provider

30  furnishing such services is a participating provider with

31  respect to such services, and in a manner such that, if such

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    Florida House of Representatives - 2001                HB 1213

    796-102-01






  1  services are provided to a covered person by a

  2  nonparticipating health care provider with or without prior

  3  authorization or by a participating health care provider

  4  without prior authorization, the covered person is not liable

  5  for amounts that exceed the amounts of liability that would be

  6  incurred if the services were provided by a participating

  7  health care provider with prior authorization and without

  8  regard to any other term or condition of such coverage.

  9         (h)  Shall make or provide for referral to a specialist

10  who is available and accessible to provide for the treatment

11  of a covered person who has a condition or disease of

12  sufficient seriousness and complexity to require treatment by

13  a specialist and benefits for such treatment are provided

14  under the plan or coverage.

15         (i)  Which requires or provides for a covered person to

16  designate a participating primary care health care

17  professional, may not require authorization or a referral by

18  the individual's primary care health care professional or

19  otherwise for coverage of gynecological care, including

20  preventive women's health examinations, and pregnancy-related

21  services provided by a participating health care professional,

22  including a physician, who specializes in obstetrics and

23  gynecology to the extent such care is otherwise covered and

24  shall treat the ordering of other obstetrical or gynecological

25  care by such a participating professional as the authorization

26  of the primary care health care professional with respect to

27  such care under the plan or coverage.

28         (j)  Which requires or provides for a covered person to

29  designate a participating primary care provider for such

30  person's child, shall permit the person to designate a

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    Florida House of Representatives - 2001                HB 1213

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  1  physician who specializes in pediatrics as the child's primary

  2  care provider.

  3         (k)  Upon termination of a contract between the group

  4  health plan, or the health insurance issuer, and a health care

  5  provider or termination of benefits or coverage provided by a

  6  health care provider because of a change in the terms of

  7  provider participation in a group health plan, and a covered

  8  person is undergoing treatment from the provider for an

  9  ongoing special condition at the time of such termination,

10  shall notify the covered person on a timely basis of such

11  termination and of the right to elect continuation of coverage

12  of treatment by the provider under this section and permit the

13  individual to elect to continue to be covered with respect to

14  treatment by the provider of such condition during a

15  transitional period. If a contract for the provision of health

16  insurance coverage between a group health plan and a health

17  insurance issuer is terminated and, as a result of such

18  termination, coverage of services of a health care provider is

19  terminated with respect to an individual, this paragraph shall

20  apply under the plan in the same manner as if there had been a

21  contract between the plan and the provider that had been

22  terminated, but only with respect to benefits that are covered

23  under the plan after the contract termination.

24         (l)  Which provides coverage for benefits with respect

25  to prescription drugs, and limits such coverage to drugs

26  included in a formulary, shall ensure the participation of

27  physicians and pharmacists in developing and reviewing such

28  formulary, provide for disclosure of the formulary to

29  providers, and in accordance with the applicable quality

30  assurance and utilization review standards of the plan or

31  issuer, provide for exceptions from the formulary limitation

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    Florida House of Representatives - 2001                HB 1213

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  1  when a non-formulary alternative is medically necessary and

  2  appropriate and, in the case of such an exception, apply the

  3  same cost-sharing requirements that would have applied in the

  4  case of a drug covered under the formulary.

  5         (m)  Shall provide to covered persons, upon initial

  6  enrollment or coverage and at least annually thereafter,

  7  prospective covered persons, and applicable authorities, in

  8  printed form, information relating to service area, benefits,

  9  access, out-of-area coverage, emergency coverage, percentage

10  of premiums used for benefits, prior authorization rules,

11  grievance and appeals procedures, quality assurance, issuer

12  information, notice of requirements, and information available

13  on request.

14         (n)  Shall not prohibit or otherwise restrict a health

15  care professional, under the provisions of any contract or

16  agreement, or the operation of any contract or agreement,

17  between a group health plan or health insurance issuer in

18  relation to health insurance coverage, including any

19  partnership, association, or other organization that enters

20  into or administers such a contract or agreement, and a health

21  care provider or group of health care providers, from advising

22  a covered person who is a patient of the professional about

23  the health status of such person or medical care or treatment

24  for such person's condition or disease, regardless of whether

25  benefits for such care or treatment are provided under the

26  plan or coverage, if the professional is acting within the

27  lawful scope of practice.

28         (o)  Shall not discriminate with respect to

29  participation or indemnification as to any provider who is

30  acting within the scope of the provider's license or

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    Florida House of Representatives - 2001                HB 1213

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  1  certification under the law of this state, solely on the basis

  2  of such license or certification.

  3         (p)  Shall provide for prompt payment of claims

  4  submitted for health care services or supplies furnished to a

  5  covered person with respect to benefits covered by the plan or

  6  issuer.

  7         (q)1.  May not retaliate against a covered person or

  8  health care provider based on the covered person's or

  9  provider's use of, or participation in, a utilization review

10  process or a grievance process of the plan or issuer.

11         2.  May not retaliate or discriminate against a

12  protected health care professional because the professional in

13  good faith discloses information relating to the care,

14  services, or conditions affecting one or more covered persons

15  of the plan or issuer to an appropriate public regulatory

16  agency, an appropriate private accreditation body, or

17  appropriate management personnel of the plan or issuer or

18  initiates, cooperates, or otherwise participates in an

19  investigation or proceeding by such an agency with respect to

20  such care, services, or conditions.

21         Section 2.  This act shall take effect October 1, 2001.

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23            *****************************************

24                          HOUSE SUMMARY

25
      Creates the "Managed Care Patient's Bill of Rights Act"
26    to provide requirements and limitations for group health
      plans and health insurance issuers that provide health
27    insurance coverage relating to utilization review,
      internal and external appeals, grievances, consumer
28    choice options, choice of health care professionals,
      emergency care, specialty care, obstetrical and
29    gynecological care, pediatric care, continuity of care,
      prescription drugs, access to information, interference
30    with medical communications, discrimination against
      providers, payment of claims, and protection of patient
31    advocacy.

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