Senate Bill sb2290
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Florida Senate - 2003 SB 2290
By Senator Siplin
19-463-03
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 Senate - 2003 SB 2290
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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 Senate - 2003 SB 2290
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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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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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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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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 July 1, 2003.
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24 SENATE 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.
6
CODING: Words stricken are deletions; words underlined are additions.