Senate Bill sb0412
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Florida Senate - 2002 SB 412
By the Committee on Health, Aging and Long-Term Care
317-415B-02
1 A bill to be entitled
2 An act relating to managed care ombudsman
3 committees; creating s. 641.64, F.S.; providing
4 definitions; amending s. 641.65, F.S., relating
5 to district managed care ombudsman committees;
6 requiring the formation of a managed care
7 ombudsman committee in each district of the
8 Agency for Health Care Administration;
9 modifying membership and manner of appointment
10 of committee members; specifying that committee
11 members serve in a voluntary capacity;
12 specifying that committees are to assist in
13 resolving complaints only at the request of an
14 enrollee of a managed care program; eliminating
15 authorization for committees to conduct site
16 visits with the agency; authorizing committees
17 to assist enrollees in appeals of unresolved
18 grievances to the Subscriber Assistance Panel;
19 specifying additional responsibilities for
20 committees; requiring committee members to be
21 screened; requiring training for committee
22 members; prohibiting specified conflicts of
23 interest; amending s. 641.70, F.S.; requiring
24 the Agency for Health Care Administration to
25 adopt rules relating to conflicts of interest
26 for district managed care ombudsman committees;
27 requiring the Agency for Health Care
28 Administration to conduct a public awareness
29 campaign, establish standardized training, and
30 assist in recruiting and retaining managed care
31 ombudsmen; amending s. 641.75, F.S., relating
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Florida Senate - 2002 SB 412
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1 to immunity from liability and limitation on
2 testimony for managed care ombudsman
3 committees; removing references to the
4 statewide committee; conforming
5 cross-references; repealing s. 641.60, F.S.,
6 relating to the Statewide Managed Care
7 Ombudsman Committee; providing an
8 appropriation; providing an effective date.
9
10 Be It Enacted by the Legislature of the State of Florida:
11
12 Section 1. Section 641.64, Florida Statutes, is
13 created to read:
14 641.64 Definitions.--As used in ss. 641.64-641.75, the
15 term:
16 (1) "Agency" means the Agency for Health Care
17 Administration.
18 (2) "Covered medical service" means a service that has
19 been contracted for under the managed care program agreement.
20 (3) "District" means one of the health service
21 planning districts as defined in s. 408.032.
22 (4) "District committee" means a district managed care
23 ombudsman committee.
24 (5) "Enrollee" means an individual who has contracted,
25 or on whose behalf a contract has been entered into, with a
26 managed care program for health care.
27 (6) "Managed care program" means a health care
28 delivery system that emphasizes primary care and integrates
29 the financing and delivery of services to enrolled individuals
30 through arrangements with selected providers, formal quality
31 assurance and utilization review, and financial incentives for
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Florida Senate - 2002 SB 412
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1 enrollees to use the program's providers. Such a health care
2 delivery system may include arrangements in which providers
3 receive prepaid set payments to coordinate and deliver all
4 inpatient and outpatient services to enrollees or arrangements
5 in which providers receive a case management fee to coordinate
6 services and are reimbursed on a fee-for-service basis for the
7 services they provide. A managed care program may include a
8 state-licensed health maintenance organization, a Medicaid
9 prepaid health plan, a Medicaid primary care case management
10 program, or other similar program.
11 (7) "Physician" means a person licensed under chapter
12 458, chapter 459, chapter 460, or chapter 461.
13 Section 2. Section 641.65, Florida Statutes, is
14 amended to read:
15 641.65 District managed care ombudsman committees.--
16 (1) A district managed care ombudsman committee is
17 created in each district of the agency that has staff assigned
18 for the regulation of managed care programs. Each district
19 committee is subject to direction from and the supervision of
20 the statewide committee.
21 (2) Each district committee shall have no fewer than 9
22 members and no more than 20 16 members, including, if possible
23 at least: one physician licensed under chapter 458, one
24 physician licensed under chapter 459, one physician licensed
25 under chapter 460, and one physician licensed under chapter
26 461, one psychologist, one registered nurse, one clinical
27 social worker, one attorney, and at least one recipient of
28 services from a managed care program one consumer. For the
29 members who are recipients of services from a managed care
30 program consumer member, preference shall be given to members
31 of organized consumer or advocacy groups with national or
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Florida Senate - 2002 SB 412
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1 statewide membership. No member may be employed by or
2 affiliated with a managed care program.
3 (3) The agency shall require a Level I background
4 screening of committee members under the provisions of s.
5 453.03. The agency will pay the fees associated with the
6 required screening.
7 (4)(3)(a) The secretary of the agency director shall
8 appoint the first three members of each district committee,
9 and those three members shall select the remaining members,
10 subject to approval of the agency director. The agency shall
11 review all appointments for compliance with this section, and
12 may disqualify an appointee for failure to meet the
13 requirements of this section. If any of the first three
14 members are not appointed within 60 days after the statewide
15 committee is established and after a request is submitted to
16 the agency director, those members shall be appointed by a
17 majority vote of the statewide committee without further
18 action by the agency director.
19 (b) Members shall be appointed to serve for a term of
20 3 years, except that at the time of initial appointment, terms
21 shall be staggered so the first 40 percent of members
22 appointed shall serve for a term of 2 years and the remaining
23 members shall serve for a term of 3 years. Members may serve
24 only two consecutive terms.
25 (c) Upon the expiration of the term of a member or
26 upon the occurrence of a vacancy, the district committee shall
27 appoint a successor, subject to the approval of the agency
28 director. The agency shall review all appointments for
29 compliance with this section, and may disqualify an appointee
30 for failure to meet the requirements of this section.
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1 (d) If the agency director fails to approve or
2 disapprove a replacement member within 30 days after the
3 district committee provides the agency director with a
4 nomination, the nomination is automatically approved.
5 (5)(4) Each district committee shall elect a
6 chairperson for a term of 1 year. A person may not serve as
7 chairperson for more than two consecutive terms.
8 (6)(5) If a district committee member misses, without
9 cause, two-thirds of the regular district committee meetings
10 in a calendar year, the member is automatically removed, and
11 the district committee shall select a replacement.
12 (7)(6) Each district committee or member of the
13 committee:
14 (a) Shall serve in a voluntary capacity to protect the
15 health, safety, and rights of all enrollees participating in
16 managed care programs in this state.
17 (b) Shall receive enrollee complaints regarding
18 quality of care from the agency when the ombudsman's
19 assistance is requested by the enrollee, and may assist the
20 agency and enrollees with the resolution of complaints. At the
21 complainant's request,
22 (c) May conduct site visits with the agency, as the
23 agency determines is appropriate. a complaint must may be
24 referred by the agency to the committee if the complaint
25 relates, as to whether an enrollee's managed care program may
26 have inappropriately denied the enrollee a covered medical
27 service, may be inappropriately delaying the provision of a
28 covered medical service to the enrollee, or is providing
29 substandard covered medical services. The committee shall
30 establish and follow uniform criteria in reviewing information
31 and receiving complaints. If a district managed care ombudsman
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1 committee or committee member receives such a complaint
2 directly from an enrollee, the committee shall assist the
3 enrollee with resolution of the complaint and report the
4 complaint to the agency.
5 (c) At the request of an enrollee, a district managed
6 care ombudsman committee shall assist the enrollee in any
7 appeal of an unresolved grievance to the Subscriber Assistance
8 Panel under s. 408.7056.
9 (d) Shall educate enrollees about their rights and
10 responsibilities in managed care programs.
11 (e) Shall train consumers to understand and use the
12 annual consumer guide on plan performance and the marketing
13 information prepared by managed care programs and may assist
14 consumers in selecting health care plans appropriate for their
15 needs.
16 (f) Shall assist enrollees with filing formal appeals
17 of managed care program determinations, including preservice
18 denials and the termination of services.
19 (g)(d) Shall submit an annual report to the agency
20 statewide committee concerning activities, recommendations,
21 and complaints reviewed or developed by the district committee
22 during the year.
23 (h)(e) Shall conduct meetings as required at the call
24 of its chairperson, the call of the agency director, the call
25 of the statewide committee, or by written request of a
26 majority of the district committee members.
27 (8) A member or employee of a district committee may
28 not:
29 (a) Have a direct involvement in the licensing,
30 certification, or accreditation of, or an ownership or
31 investment interest in, a managed care program.
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Florida Senate - 2002 SB 412
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1 (b) Be employed by or participate in the management of
2 a managed care program.
3 (c) Receive, or have a right to receive, directly or
4 indirectly, remuneration, in cash or in kind, under a
5 compensation agreement with a managed care program.
6 (d) Gain, or stand to gain, financially through an
7 action or potential action brought on behalf of individuals
8 the ombudsman serves.
9 Section 3. Section 641.70, Florida Statutes, is
10 amended to read:
11 641.70 Agency duties relating to the Statewide Managed
12 Care Ombudsman Committee and the district managed care
13 ombudsman committees.--
14 (1) The agency shall adopt rules that specify:
15 (a) Procedures by which the statewide committee and
16 district committees receive reports of enrollee complaints
17 from the agency.
18 (b) Procedures by which enrollee information shall be
19 made available to members of the statewide committee and to
20 the district committees by managed care programs.
21 (c) Procedures by which recommendations made by the
22 committees may shall be considered for incorporation into
23 policies and procedures of the agency.
24 (d) In consultation with the district committees,
25 procedures to identify and eliminate conflicts of interest as
26 described in s. 641.65.
27 (e)(d) Procedures by which statewide committee members
28 shall be reimbursed for authorized expenditures.
29 (f)(e) Any other procedures that are necessary to
30 administer ss. 641.64-641.75 this section and ss. 641.60 and
31 641.65.
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Florida Senate - 2002 SB 412
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1 (2) The agency for Health Care Administration shall
2 provide a meeting place for district committees in agency
3 offices and shall provide the necessary administrative support
4 to assist the statewide committee and district committees,
5 within available resources.
6 (3) The agency shall, in cooperation with the district
7 committees, conduct a public awareness campaign to increase
8 the public's knowledge of the services provided by the
9 district committees.
10 (4) The agency, in cooperation with the district
11 committees, shall establish standardized training of committee
12 members.
13 (5) All volunteers serving on district committees must
14 be given a minimum of 8 hours of training upon appointment and
15 8 hours of continuing education annually thereafter. The
16 agency must provide standardized training for all committee
17 members.
18 (6) The agency may assist the district committees in
19 recruiting and retaining managed care ombudsmen.
20 (7)(3) The secretary of the agency shall ensure the
21 full cooperation and assistance of agency employees with
22 members of the statewide committee and district committees.
23 Section 4. Section 641.75, Florida Statutes, is
24 amended to read:
25 641.75 Immunity from liability; limitation on
26 testimony.--
27 (1) Any member of the statewide committee or a
28 district committee who receives or investigates a complaint of
29 an enrollee of a managed care program in accordance with the
30 procedures and guidelines of the agency shall be immune from
31 liability for good faith action on behalf of such an enrollee.
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1 (2) Except as otherwise provided by law, all other
2 matters before the statewide committee or district committees
3 shall be open to the public and subject to chapter 119 and s.
4 286.011.
5 (3) Members of any state or district ombudsman
6 committee shall not be required to testify in any court with
7 respect to matters held to be confidential except as may be
8 necessary to enforce ss. 641.64-641.75 ss. 641.60-641.75.
9 Section 5. Section 641.60, Florida Statutes, is
10 repealed.
11 Section 6. The sum of $300,000 is appropriated from
12 the General Revenue Fund to the Agency for Health Care
13 Administration and one position is authorized for the purposes
14 of implementing this act during the 2002-2003 fiscal year.
15 Section 7. This act shall take effect July 1, 2002.
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18 SENATE SUMMARY
19 Requires the creation of a managed care ombudsman
committee in each district of the Agency for Health Care
20 Administration. Modifies the membership and manner of
appointment of committee members. Eliminates
21 authorization for committees to conduct site visits with
the agency. Authorizes committees to assist enrollees in
22 appeals of unresolved grievances. Prohibits specified
conflicts of interest of members or employees of a
23 district committee. Provides for rulemaking authority.
Requires the agency to conduct a public information
24 campaign, establish standardized training, and assist in
recruiting and retaining managed care ombudsmen.
25 Abolishes the Statewide Managed Care Ombudsman Committee.
Provides an appropriation.
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