Senate Bill sb0256e1
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 A bill to be entitled
2 An act relating to the Subscriber Assistance
3 Program; amending s. 408.7056, F.S.;
4 redesignating the Statewide Provider and
5 Subscriber Assistance Program as the Subscriber
6 Assistance Program; requiring the Subscriber
7 Assistance Panel to hold the record of a
8 grievance hearing open for a specified period
9 after the hearing; revising the Agency for
10 Health Care Administration's authority to
11 obtain records associated with subscriber
12 grievances; requiring the Agency for Health
13 Care Administration to impose a fine for each
14 violation relating to the production of records
15 from a health care provider or managed care
16 entity; specifying procedures for handling a
17 tie vote by the Subscriber Assistance Panel;
18 specifying circumstances under which the agency
19 or the Department of Insurance may delay
20 issuance of a proposed final order or emergency
21 order recommended by the panel; requiring that
22 the Agency for Health Care Administration
23 develop a training program for panel members;
24 amending ss. 641.3154, 641.511, 641.58, F.S.;
25 redesignating the Statewide Provider and
26 Subscriber Assistance Panel as the Subscriber
27 Assistance Panel; requiring that a subscriber
28 or the provider acting on behalf of a
29 subscriber be notified of the right to submit a
30 written grievance if a case is unresolved;
31 providing an effective date.
1
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 Be It Enacted by the Legislature of the State of Florida:
2
3 Section 1. Section 408.7056, Florida Statutes, is
4 amended to read:
5 408.7056 Statewide Provider and Subscriber Assistance
6 Program.--
7 (1) As used in this section, the term:
8 (a) "Agency" means the Agency for Health Care
9 Administration.
10 (b) "Department" means the Department of Insurance.
11 (c) "Grievance procedure" means an established set of
12 rules that specify a process for appeal of an organizational
13 decision.
14 (d) "Health care provider" or "provider" means a
15 state-licensed or state-authorized facility, a facility
16 principally supported by a local government or by funds from a
17 charitable organization that holds a current exemption from
18 federal income tax under s. 501(c)(3) of the Internal Revenue
19 Code, a licensed practitioner, a county health department
20 established under part I of chapter 154, a prescribed
21 pediatric extended care center defined in s. 400.902, a
22 federally supported primary care program such as a migrant
23 health center or a community health center authorized under s.
24 329 or s. 330 of the United States Public Health Services Act
25 that delivers health care services to individuals, or a
26 community facility that receives funds from the state under
27 the Community Alcohol, Drug Abuse, and Mental Health Services
28 Act and provides mental health services to individuals.
29 (e) "Managed care entity" means a health maintenance
30 organization or a prepaid health clinic certified under
31 chapter 641, a prepaid health plan authorized under s.
2
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 409.912, or an exclusive provider organization certified under
2 s. 627.6472.
3 (f) "Panel" means a statewide provider and subscriber
4 assistance panel selected as provided in subsection (11).
5 (2) The agency shall adopt and implement a program to
6 provide assistance to subscribers and providers, including
7 those whose grievances are not resolved by the managed care
8 entity to the satisfaction of the subscriber or provider. The
9 program shall consist of one or more panels that meet as often
10 as necessary to timely review, consider, and hear grievances
11 and recommend to the agency or the department any actions that
12 should be taken concerning individual cases heard by the
13 panel. The panel shall hear every grievance filed by
14 subscribers and providers on behalf of subscribers, unless the
15 grievance:
16 (a) Relates to a managed care entity's refusal to
17 accept a provider into its network of providers;
18 (b) Is part of an internal grievance in a Medicare
19 managed care entity or a reconsideration appeal through the
20 Medicare appeals process which does not involve a quality of
21 care issue;
22 (c) Is related to a health plan not regulated by the
23 state such as an administrative services organization,
24 third-party administrator, or federal employee health benefit
25 program;
26 (d) Is related to appeals by in-plan suppliers and
27 providers, unless related to quality of care provided by the
28 plan;
29 (e) Is part of a Medicaid fair hearing pursued under
30 42 C.F.R. ss. 431.220 et seq.;
31
3
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 (f) Is the basis for an action pending in state or
2 federal court;
3 (g) Is related to an appeal by nonparticipating
4 providers, unless related to the quality of care provided to a
5 subscriber by the managed care entity and the provider is
6 involved in the care provided to the subscriber;
7 (h) Was filed before the subscriber or provider
8 completed the entire internal grievance procedure of the
9 managed care entity, the managed care entity has complied with
10 its timeframes for completing the internal grievance
11 procedure, and the circumstances described in subsection (6)
12 do not apply;
13 (i) Has been resolved to the satisfaction of the
14 subscriber or provider who filed the grievance, unless the
15 managed care entity's initial action is egregious or may be
16 indicative of a pattern of inappropriate behavior;
17 (j) Is limited to seeking damages for pain and
18 suffering, lost wages, or other incidental expenses, including
19 accrued interest on unpaid balances, court costs, and
20 transportation costs associated with a grievance procedure;
21 (k) Is limited to issues involving conduct of a health
22 care provider or facility, staff member, or employee of a
23 managed care entity which constitute grounds for disciplinary
24 action by the appropriate professional licensing board and is
25 not indicative of a pattern of inappropriate behavior, and the
26 agency or department has reported these grievances to the
27 appropriate professional licensing board or to the health
28 facility regulation section of the agency for possible
29 investigation; or
30
31
4
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 (l) Is withdrawn by the subscriber or provider.
2 Failure of the subscriber or the provider to attend the
3 hearing shall be considered a withdrawal of the grievance.
4 (3) The agency shall review all grievances within 60
5 days after receipt and make a determination whether the
6 grievance shall be heard. Once the agency notifies the panel,
7 the subscriber or provider, and the managed care entity that a
8 grievance will be heard by the panel, the panel shall hear the
9 grievance either in the network area or by teleconference no
10 later than 120 days after the date the grievance was filed.
11 The agency shall notify the parties, in writing, by facsimile
12 transmission, or by phone, of the time and place of the
13 hearing. The panel may take testimony under oath, request
14 certified copies of documents, and take similar actions to
15 collect information and documentation that will assist the
16 panel in making findings of fact and a recommendation. A
17 managed care entity, subscriber, or provider may within 5
18 working days after the hearing of the grievance submit
19 additional information to supplement the record before the
20 panel. Five working days after the hearing of the grievance,
21 the record shall be closed. The panel shall issue a written
22 recommendation, supported by findings of fact, to the provider
23 or subscriber, to the managed care entity, and to the agency
24 or the department no later than 10 15 working days after the
25 record is closed hearing the grievance. If at the hearing the
26 panel requests additional documentation or additional records,
27 the time for issuing a recommendation is tolled until the
28 information or documentation requested has been provided to
29 the panel. Except as provided in this section, the
30 proceedings of the panel are not subject to chapter 120. In
31 the event of a tie vote by the panel, the tie shall be decided
5
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 by a second vote and additional votes if necessary. In the
2 event of a deadlock, defined as three consecutive votes
3 resulting in a tie vote, such deadlock shall result in a
4 recommendation by the panel that no further action should be
5 taken by the agency or department.
6 (4) If, upon receiving a proper patient authorization
7 along with a properly filed grievance, the agency requests
8 medical records from a health care provider or managed care
9 entity, the health care provider or managed care entity that
10 has custody of the records has 10 days to provide the records
11 to the agency. Records include all medical records, all
12 telephone communication logs associated with the grievance
13 both to and from the subscriber, and any other contents of the
14 internal grievance file associated with the complaint filed
15 with the Subscriber Assistance Program. The agency must
16 impose a fine of up to $500 for each day that the requested
17 records are not produced. Failure to provide requested medical
18 records may result in the imposition of a fine of up to $500.
19 Each day that records are not produced is considered a
20 separate violation.
21 (5) Grievances that the agency determines pose an
22 immediate and serious threat to a subscriber's health must be
23 given priority over other grievances. The panel may meet at
24 the call of the chair to hear the grievances as quickly as
25 possible but no later than 45 days after the date the
26 grievance is filed, unless the panel receives a waiver of the
27 time requirement from the subscriber. The panel shall issue a
28 written recommendation, supported by findings of fact, to the
29 department or the agency within 10 days after hearing the
30 expedited grievance.
31
6
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 (6) When the agency determines that the life of a
2 subscriber is in imminent and emergent jeopardy, the chair of
3 the panel may convene an emergency hearing, within 24 hours
4 after notification to the managed care entity and to the
5 subscriber, to hear the grievance. The grievance must be
6 heard notwithstanding that the subscriber has not completed
7 the internal grievance procedure of the managed care entity.
8 The panel shall, upon hearing the grievance, issue a written
9 emergency recommendation, supported by findings of fact, to
10 the managed care entity, to the subscriber, and to the agency
11 or the department for the purpose of deferring the imminent
12 and emergent jeopardy to the subscriber's life. Within 24
13 hours after receipt of the panel's emergency recommendation,
14 the agency or department may issue an emergency order to the
15 managed care entity. An emergency order remains in force
16 until:
17 (a) The grievance has been resolved by the managed
18 care entity;
19 (b) Medical intervention is no longer necessary; or
20 (c) The panel has conducted a full hearing under
21 subsection (3) and issued a recommendation to the agency or
22 the department, and the agency or department has issued a
23 final order.
24 (7) After hearing a grievance, the panel shall make a
25 recommendation to the agency or the department which may
26 include specific actions the managed care entity must take to
27 comply with state laws or rules regulating managed care
28 entities.
29 (8) A managed care entity, subscriber, or provider
30 that is affected by a panel recommendation may within 10 days
31 after receipt of the panel's recommendation, or 72 hours after
7
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 receipt of a recommendation in an expedited grievance, furnish
2 to the agency or department written exceptions evidence in
3 opposition to the recommendation or findings of fact of the
4 panel.
5 (9) No later than 30 days after the issuance of the
6 panel's recommendation and, for an expedited grievance, no
7 later than 10 days after the issuance of the panel's
8 recommendation, the agency or the department shall issue may
9 adopt the panel's recommendation or findings of fact in a
10 proposed final order or an emergency order, as provided in
11 chapter 120, which it shall issue to the managed care entity.
12 However, the agency or department may delay issuance of a
13 proposed final order or emergency order if the agency or
14 department finds that additional investigative information is
15 needed to resolve the subscriber's grievance or if the agency
16 or department finds that the panel's recommendation or
17 findings of fact have been improvidently issued by the panel.
18 The agency or department may issue a proposed final order or
19 an emergency order, as provided in chapter 120, imposing fines
20 or sanctions, including those contained in ss. 641.25 and
21 641.52. The agency or the department may reject all or part
22 of the panel's recommendation or amend the panel's findings of
23 fact based upon:
24 (a) Written exceptions provided in opposition to the
25 panel's recommendation or findings of fact;
26 (b) Facts that the agency or department has discovered
27 at such times when additional investigative information is
28 required; or
29 (c) The agency's or department's finding that the
30 panel's recommendation or findings of fact have been
31 improvidently issued.
8
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1
2 All fines collected under this subsection must be deposited
3 into the Health Care Trust Fund.
4 (10) In determining any fine or sanction to be
5 imposed, the agency and the department may consider the
6 following factors:
7 (a) The severity of the noncompliance, including the
8 probability that death or serious harm to the health or safety
9 of the subscriber will result or has resulted, the severity of
10 the actual or potential harm, and the extent to which
11 provisions of chapter 641 were violated.
12 (b) Actions taken by the managed care entity to
13 resolve or remedy any quality-of-care grievance.
14 (c) Any previous incidents of noncompliance by the
15 managed care entity.
16 (d) Any other relevant factors the agency or
17 department considers appropriate in a particular grievance.
18 (11) The panel shall consist of members employed by
19 the agency and members employed by the department, chosen by
20 their respective agencies; a consumer appointed by the
21 Governor; a physician appointed by the Governor, as a standing
22 member; and physicians who have expertise relevant to the case
23 to be heard, on a rotating basis. The agency may contract with
24 a medical director and a primary care physician who shall
25 provide additional technical expertise to the panel. The
26 medical director shall be selected from a health maintenance
27 organization with a current certificate of authority to
28 operate in Florida. The agency shall develop a training
29 program for persons appointed to membership on the panel. The
30 program shall familiarize such persons with the substantive
31 and procedural laws and rules regarding their responsibilities
9
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 on the panel, including training with respect to the panel's
2 past recommendations and any subsequent agency action by the
3 agency or department in such cases.
4 (12) Every managed care entity shall submit a
5 quarterly report to the agency and the department listing the
6 number and the nature of all subscribers' and providers'
7 grievances that which have not been resolved to the
8 satisfaction of the subscriber or provider after the
9 subscriber or provider follows the entire internal grievance
10 procedure of the managed care entity. The agency shall notify
11 all subscribers and providers included in the quarterly
12 reports of their right to file an unresolved grievance with
13 the panel.
14 (13) Any information that which would identify a
15 subscriber or the spouse, relative, or guardian of a
16 subscriber and that which is contained in a report obtained by
17 the Department of Insurance pursuant to this section is
18 confidential and exempt from the provisions of s. 119.07(1)
19 and s. 24(a), Art. I of the State Constitution.
20 (14) A proposed final order issued by the agency or
21 department which only requires the managed care entity to take
22 a specific action under subsection (7) is subject to a summary
23 hearing in accordance with s. 120.574, unless all of the
24 parties agree otherwise. If the managed care entity does not
25 prevail at the hearing, the managed care entity must pay
26 reasonable costs and attorney's fees of the agency or the
27 department incurred in that proceeding.
28 (15)(a) Any information that which would identify a
29 subscriber or the spouse, relative, or guardian of a
30 subscriber and that which is contained in a document, report,
31 or record prepared or reviewed by the panel or obtained by the
10
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 agency pursuant to this section is confidential and exempt
2 from the provisions of s. 119.07(1) and s. 24(a), Art. I of
3 the State Constitution.
4 (b) Meetings of the panel shall be open to the public
5 unless the provider or subscriber whose grievance will be
6 heard requests a closed meeting or the agency or the
7 Department of Insurance determines that information of a
8 sensitive personal nature which discloses the subscriber's
9 medical treatment or history; or information that which
10 constitutes a trade secret as defined by s. 812.081; or
11 information relating to internal risk-management risk
12 management programs as defined in s. 641.55(5)(c), (6), and
13 (8) may be revealed at the panel meeting, in which case that
14 portion of the meeting during which such sensitive personal
15 information, trade secret information, or internal
16 risk-management-program risk management program information is
17 discussed shall be exempt from the provisions of s. 286.011
18 and s. 24(b), Art. I of the State Constitution. All closed
19 meetings shall be recorded by a certified court reporter.
20
21 This subsection is subject to the Open Government Sunset
22 Review Act of 1995 in accordance with s. 119.15, and shall
23 stand repealed on October 2, 2003, unless reviewed and saved
24 from repeal through reenactment by the Legislature.
25 Section 2. Subsection (4) of section 641.3154, Florida
26 Statutes, is amended to read:
27 641.3154 Organization liability; provider billing
28 prohibited.--
29 (4) A provider or any representative of a provider,
30 regardless of whether the provider is under contract with the
31 health maintenance organization, may not collect or attempt to
11
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 collect money from, maintain any action at law against, or
2 report to a credit agency a subscriber of an organization for
3 payment of services for which the organization is liable, if
4 the provider in good faith knows or should know that the
5 organization is liable. This prohibition applies during the
6 pendency of any claim for payment made by the provider to the
7 organization for payment of the services and any legal
8 proceedings or dispute resolution process to determine whether
9 the organization is liable for the services if the provider is
10 informed that such proceedings are taking place. It is
11 presumed that a provider does not know and should not know
12 that an organization is liable unless:
13 (a) The provider is informed by the organization that
14 it accepts liability;
15 (b) A court of competent jurisdiction determines that
16 the organization is liable; or
17 (c) The department or agency makes a final
18 determination that the organization is required to pay for
19 such services subsequent to a recommendation made by the
20 Statewide Provider and Subscriber Assistance Panel pursuant to
21 s. 408.7056.
22 Section 3. Subsection (1), paragraphs (b) and (e) of
23 subsection (3), paragraph (d) of subsection (4), paragraph (g)
24 of subsection (6), and subsections (9), (10), and (11) of
25 section 641.511, Florida Statutes, are amended to read:
26 641.511 Subscriber grievance reporting and resolution
27 requirements.--
28 (1) Each Every organization must have a grievance
29 procedure available to its subscribers for the purpose of
30 addressing complaints and grievances. Each Every organization
31 must notify its subscribers that a subscriber must submit a
12
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 grievance within 1 year after the date of occurrence of the
2 action that initiated the grievance, and may submit the
3 grievance for review to the Statewide Provider and Subscriber
4 Assistance Program panel as provided in s. 408.7056 after
5 receiving a final disposition of the grievance through the
6 organization's grievance process. An organization shall
7 maintain records of all grievances and shall report annually
8 to the agency the total number of grievances handled, a
9 categorization of the cases underlying the grievances, and the
10 final disposition of the grievances.
11 (3) Each organization's grievance procedure, as
12 required under subsection (1), must include, at a minimum:
13 (b) The names of the appropriate employees or a list
14 of grievance departments that are responsible for implementing
15 the organization's grievance procedure. The list must include
16 the address and the toll-free telephone number of each
17 grievance department, the address of the agency and its
18 toll-free telephone hotline number, and the address of the
19 Statewide Provider and Subscriber Assistance Program and its
20 toll-free telephone number.
21 (e) A notice that a subscriber may voluntarily pursue
22 binding arbitration in accordance with the terms of the
23 contract if offered by the organization, after completing the
24 organization's grievance procedure and as an alternative to
25 the Statewide Provider and Subscriber Assistance Program. Such
26 notice shall include an explanation that the subscriber may
27 incur some costs if the subscriber pursues binding
28 arbitration, depending upon the terms of the subscriber's
29 contract.
30 (4)
31
13
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 (d) In any case in which when the review process does
2 not resolve a difference of opinion between the organization
3 and the subscriber or the provider acting on behalf of the
4 subscriber, the subscriber or the provider acting on behalf of
5 the subscriber may submit a written grievance to the Statewide
6 Provider and Subscriber Assistance Program.
7 (6)
8 (g) In any case in which when the expedited review
9 process does not resolve a difference of opinion between the
10 organization and the subscriber or the provider acting on
11 behalf of the subscriber, the subscriber or the provider
12 acting on behalf of the subscriber may submit a written
13 grievance to the Statewide Provider and Subscriber Assistance
14 Program. In the letter of final decision for any case in which
15 the expedited review does not resolve a difference of opinion
16 between the organization and the subscriber or the provider
17 acting on behalf of the subscriber, the organization must
18 notify the subscriber or the provider acting on behalf of the
19 subscriber of the right to submit the written grievance to the
20 Subscriber Assistance Program.
21 (9)(a) The agency shall advise subscribers with
22 grievances to follow their organization's formal grievance
23 process for resolution prior to review by the Statewide
24 Provider and Subscriber Assistance Program. The subscriber
25 may, however, submit a copy of the grievance to the agency at
26 any time during the process.
27 (b) Requiring completion of the organization's
28 grievance process before the Statewide Provider and Subscriber
29 Assistance Program panel's review does not preclude the agency
30 from investigating any complaint or grievance before the
31 organization makes its final determination.
14
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 (10) Each organization must notify the subscriber in a
2 final decision letter that the subscriber may request review
3 of the organization's decision concerning the grievance by the
4 Statewide Provider and Subscriber Assistance Program, as
5 provided in s. 408.7056, if the grievance is not resolved to
6 the satisfaction of the subscriber. The final decision letter
7 must inform the subscriber that the request for review must be
8 made within 365 days after receipt of the final decision
9 letter, must explain how to initiate such a review, and must
10 include the addresses and toll-free telephone numbers of the
11 agency and the Statewide Provider and Subscriber Assistance
12 Program.
13 (11) Each organization, as part of its contract with
14 any provider, must require the provider to post a consumer
15 assistance notice prominently displayed in the reception area
16 of the provider and clearly noticeable by all patients. The
17 consumer assistance notice must state the addresses and
18 toll-free telephone numbers of the Agency for Health Care
19 Administration, the Statewide Provider and Subscriber
20 Assistance Program, and the Department of Insurance. The
21 consumer assistance notice must also clearly state that the
22 address and toll-free telephone number of the organization's
23 grievance department shall be provided upon request. The
24 agency may adopt is authorized to promulgate rules necessary
25 to administer implement this section.
26 Section 4. Subsection (4) of section 641.58, Florida
27 Statutes, is amended to read:
28 641.58 Regulatory assessment; levy and amount; use of
29 funds; tax returns; penalty for failure to pay.--
30 (4) The moneys received and deposited into the Health
31 Care Trust Fund shall be used to defray the expenses of the
15
CODING: Words stricken are deletions; words underlined are additions.
CS for SB 256 First Engrossed
1 agency in the discharge of its administrative and regulatory
2 powers and duties under this part, including conducting an
3 annual survey of the satisfaction of members of health
4 maintenance organizations; contracting with physician
5 consultants for the Statewide Provider and Subscriber
6 Assistance Panel; maintaining offices and necessary supplies,
7 essential equipment, and other materials, salaries and
8 expenses of required personnel; and discharging the
9 administrative and regulatory powers and duties imposed under
10 this part.
11 Section 5. This act shall take effect July 1, 2002.
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
16
CODING: Words stricken are deletions; words underlined are additions.