Senate Bill sb2910c2
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Florida Senate - 2004 CS for CS for SB 2910
By the Committees on Banking and Insurance; Health, Aging, and
Long-Term Care; and Senator Peaden
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1 A bill to be entitled
2 An act relating to affordable health care;
3 providing a popular name; providing purpose;
4 amending s. 381.026, F.S.; requiring certain
5 licensed facilities to provide public Internet
6 access to certain financial information;
7 providing a penalty; amending s. 381.734, F.S.;
8 including participation by health care
9 providers, small businesses, and health
10 insurers in the Healthy Communities, Healthy
11 People Program; requiring the Department of
12 Health to provide public Internet access to
13 certain public health programs; requiring the
14 department to monitor and assess the
15 effectiveness of such programs; requiring a
16 report; requiring the Office of Program Policy
17 and Government Accountability to evaluate the
18 effectiveness of such programs; requiring a
19 report; amending s. 395.1041, F.S.; authorizing
20 hospitals to develop certain emergency room
21 diversion programs; amending s. 395.301, F.S.;
22 requiring certain licensed facilities to
23 provide public Internet access to certain
24 financial information; requiring certain
25 licensed facilities to provide prospective
26 patients certain estimates of charges for
27 services; amending s. 408.061, F.S.; requiring
28 the Agency for Health Care Administration to
29 require health care facilities, health care
30 providers, and health insurers to submit
31 certain information; requiring the agency to
1
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1 adopt certain rules; amending s. 408.062, F.S.;
2 requiring the agency to conduct certain health
3 care costs and access research, analyses, and
4 studies; expanding the scope of such studies to
5 include collection of pharmacy retail price
6 data, use of emergency departments, and
7 Internet patient charge information
8 availability; requiring a report; requiring the
9 agency to conduct additional data-based studies
10 and make recommendations to the Legislature;
11 requiring the agency to implement a strategy
12 for the use of electronic health records and
13 make recommendations to the Legislature to
14 protect the confidentiality of such records;
15 amending s. 408.05, F.S.; requiring the agency
16 to develop a plan to make performance outcome
17 and financial data available to consumers for
18 health care services comparison purposes;
19 requiring submittal of the plan to the Governor
20 and Legislature; requiring the agency to update
21 the plan; requiring the agency to make the plan
22 available electronically; providing plan
23 requirements; amending s. 409.9066, F.S.;
24 requiring the agency to provide certain
25 information relating to the Medicare
26 prescription discount program; amending s.
27 408.7056, F.S.; renaming the Statewide Provider
28 and Subscriber Assistance Program as the
29 Subscriber Assistance Program; revising
30 provisions to conform; expanding certain
31 records availability provisions; revising
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1 membership provisions relating to a subscriber
2 grievance hearing panel; providing hearing
3 procedures; amending s. 641.3154, F.S., to
4 conform to the renaming of the Subscriber
5 Assistance Program; amending s. 641.511, F.S.,
6 to conform to the renaming of the Subscriber
7 Assistance Program; adopting and incorporating
8 by reference the Employee Retirement Income
9 Security Act of 1974, as implemented by federal
10 regulations; amending s. 641.58, F.S., to
11 conform to the renaming of the Subscriber
12 Assistance Program; amending s. 408.909, F.S.;
13 expanding a definition of "health flex plan
14 entity" to include public-private partnerships;
15 making a pilot health flex plan program apply
16 permanently statewide; providing additional
17 program requirements; creating s. 381.0271,
18 F.S.; providing definitions; creating the
19 Florida Patient Safety Corporation, which shall
20 be registered, incorporated, organized, and
21 operated in compliance with ch. 617, F.S.;
22 authorizing the corporation to create
23 not-for-profit subsidiaries; specifying that
24 the corporation is not an agency within the
25 meaning of s. 20.03(11), F.S.; requiring the
26 corporation to be subject to public meetings
27 and records requirements; specifying that the
28 corporation is not subject to the provisions of
29 ch. 297, F.S., relating to procurement of
30 personal property and services; providing a
31 purpose for the corporation; establishing the
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1 membership of the board of directors of the
2 corporation; requiring the formation of certain
3 advisory committees for the corporation;
4 requiring the Agency for Health Care
5 Administration to provide assistance in
6 establishing the corporation; specifying the
7 powers and duties of the corporation; requiring
8 annual reports; requiring the Office of Program
9 Policy Analysis and Government Accountability,
10 in consultation with the Agency for Health Care
11 Administration and the Department of Health, to
12 develop performance measures for the
13 corporation; requiring a performance audit;
14 requiring a report to the Governor and the
15 Legislature; requiring the Patient Safety
16 Center at the Florida State University College
17 of Medicine to study the return on investment
18 by hospitals from implementing computerized
19 physician order entry and other information
20 technologies related to patient safety;
21 providing requirements for the study; requiring
22 a report to the Governor and the Legislature;
23 amending s. 395.1012, F.S.; providing
24 additional duties of the patient safety
25 committee at hospitals and other licensed
26 facilities; requiring such facilities to adopt
27 a plan to reduce medication errors and adverse
28 drug events, including the use of computerized
29 physician order entry and other information
30 technologies; repealing s. 766.1016(3), F.S.,
31 which requires a patient safety organization to
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1 promptly remove patient-identifying information
2 from patient safety data reported to the
3 organization and requires such organization to
4 maintain the confidentiality of
5 patient-identifying information; amending s.
6 409.91255, F.S.; expanding assistance to
7 certain health centers to include community
8 emergency room diversion programs and urgent
9 care services; amending s. 627.410, F.S.;
10 requiring insurers to file certain rates with
11 the Office of Insurance Regulation; exempting
12 group health insurance policies insuring groups
13 of a certain size from a requirement to file
14 rates with the Office of Insurance Regulation;
15 creating s. 624.6405, F.S.; making legislative
16 findings related to inappropriate utilization
17 of emergency room care; requiring health
18 insurers to take certain actions and
19 authorizing higher copayments for certain uses
20 of emergency departments; amending s. 627.6487,
21 F.S.; revising a definition; creating s.
22 627.64872, F.S.; providing legislative intent;
23 creating the Florida Health Insurance Plan for
24 certain purposes; providing definitions;
25 providing requirements for operation of the
26 plan; providing for a board of directors;
27 providing for appointment of members; providing
28 for terms; specifying service without
29 compensation; providing for travel and per diem
30 expenses; requiring a plan of operation;
31 providing requirements; providing for powers of
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1 the plan; requiring reports to the Governor and
2 Legislature; providing certain immunity from
3 liability for plan obligations; authorizing the
4 board to provide for indemnification of certain
5 costs; requiring an annually audited financial
6 statement; providing for eligibility for
7 coverage under the plan; providing criteria;
8 requirements, and limitations; specifying
9 certain activity as an unfair trade practice;
10 providing for a plan administrator; providing
11 criteria; providing requirements; providing
12 term limits for the plan administrator;
13 providing duties; providing for paying the
14 administrator; providing for funding mechanisms
15 of the plan; providing for premium rates for
16 plan coverage; providing rate limitations;
17 providing for assessing certain insurers
18 providing coverage for persons under the Health
19 Insurance Portability and Accountability Act;
20 specifying benefits under the plan; providing
21 criteria, requirements, and limitations;
22 providing for nonduplication of benefits;
23 providing for annual and maximum lifetime
24 benefits; providing for tax exempt status;
25 providing for abolition of the Florida
26 Comprehensive Health Association upon
27 implementation of the plan; providing for
28 enrollment in the plan of persons enrolled in
29 the association; requiring insurers to pay
30 certain assessments to the board for certain
31 purposes; providing criteria, requirements, and
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1 limitations for such assessments; providing for
2 repeal of ss. 627.6488, 627.6489, 627.649,
3 627.6492, 627.6494, 627.6496, and 627.6498,
4 F.S., relating to the Florida Comprehensive
5 Health Association, upon implementation of the
6 plan; amending s. 627.662, F.S.; providing for
7 application of certain claim payment
8 methodologies and actions related to
9 inappropriate use of emergency care to certain
10 types of insurance; amending s. 627.6699, F.S.;
11 revising provisions requiring small employer
12 carriers to offer certain health benefit plans;
13 preserving a right to open enrollment for
14 certain small groups; revising size limits on
15 small employer groups to which premium rate
16 guidelines are applicable for purposes of the
17 Employee Health Care Access Act; requiring
18 small employer carriers to file and provide
19 coverage under certain high deductible plans;
20 including high deductible plans under certain
21 required plan provisions; creating the Small
22 Employers Access Program; providing legislative
23 intent; providing definitions; providing
24 participation eligibility requirements and
25 criteria; requiring the Office of Insurance
26 Regulation to administer the program by
27 selecting an insurer through competitive
28 bidding; providing requirements; specifying
29 insurer qualifications; providing duties of the
30 insurer; providing a contract term; providing
31 insurer reporting requirements; providing
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1 application requirements; providing for
2 benefits under the program; requiring the
3 office to annually report to the Governor and
4 Legislature; providing for decreases in
5 inappropriate use of emergency care; providing
6 legislative intent; requiring health insurers
7 to provide certain information electronically
8 and develop community emergency department
9 diversion programs; amending s. 627.9175, F.S.;
10 requiring certain health insurers to annually
11 report certain coverage information to the
12 office; providing requirements; deleting
13 certain reporting requirements; creating part I
14 of ch. 636, F.S., relating to prepaid limited
15 health services organization; providing a short
16 title; revising the definition of the term
17 "prepaid limited health services organization";
18 creating part II of ch. 636, F.S., relating to
19 discount medical plan organization; providing a
20 short title; providing definitions; requiring
21 that a person be licensed before conducting
22 business in this state as a discount medical
23 plan organizations; providing for an
24 application to receive a license; providing for
25 the contents of the application; requiring each
26 discount medical plan organization to create an
27 Internet website; authorizing the Office of
28 Insurance Regulation to investigate or examine
29 a discount medical plan organization under
30 certain conditions; specifying the permitted
31 and prohibited activities of a discount medical
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1 plan organization; directing each discount
2 medical plan organization to disclose certain
3 specified information to members and
4 prospective members; providing for contracts
5 and agreements with providers and networks of
6 providers; detailing the required contents of
7 the contract or agreement; requiring each
8 discount medical plan organization to file its
9 proposed rates with the office; directing each
10 discount medical plan organization to file an
11 annual report with the office; specifying the
12 contents of the report; providing for fines
13 when a discount medical plan organization is
14 delinquent in filing the annual report;
15 requiring minimum capitalization; providing the
16 circumstances and procedures when the office
17 proposes to suspend or revoke the license of a
18 discount medical plan organization; directing
19 each discount medical plan organization to
20 maintain an up-to-date list of the names and
21 addresses of the providers with whom it has a
22 contract to deliver medical services; directing
23 that the list be posted on the organization's
24 website; providing for marketing plans;
25 authorizing the office to adopt rules;
26 providing for service of process; providing for
27 a security deposit by each discount medical
28 plan organization; providing criminal penalties
29 for violations of the act; authorizing the
30 office to seek temporary and permanent
31 injunctive relief against a discount medical
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1 plan organization under certain conditions;
2 providing civil remedies for any person injured
3 by another acting in violation of the act;
4 providing venue for a civil action; creating
5 ss. 627.65626 and 627.6402, F.S.; providing for
6 insurance rebates for healthy lifestyles;
7 providing for rebate of certain premiums for
8 participation in health wellness, maintenance,
9 or improvement programs under certain
10 circumstances; providing requirements; amending
11 s. 641.31, F.S.; authorizing health maintenance
12 organizations offering certain point-of-service
13 riders to offer such riders to certain
14 employers for certain employees; providing
15 requirements and limitations; providing for
16 application of certain claim payment
17 methodologies to certain types of insurance;
18 providing for rebate of certain premiums for
19 participation in health wellness, maintenance,
20 or improvement programs under certain
21 circumstances; providing requirements;
22 preserving certain rights to enrollment in
23 certain health benefit coverage for certain
24 groups under certain circumstances; creating s.
25 465.0244, F.S.; requiring each pharmacy to make
26 available on its Internet website a link to
27 certain performance outcome and financial data
28 of the Agency for Health Care Administration
29 and a notice of the availability of such
30 information; amending s. 627.6499, F.S.;
31 requiring each health insurer to make available
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1 on its Internet website a link to certain
2 performance outcome and financial data of the
3 Agency for Health Care Administration and a
4 notice in policies of the availability of such
5 information; amending s. 641.54, F.S.;
6 requiring health maintenance organizations to
7 make certain insurance financial information
8 available to subscribers; requiring health
9 maintenance organizations to make available on
10 its Internet website a link to certain
11 performance outcome and financial data of the
12 Agency for Health Care Administration and a
13 notice in policies of the availability of such
14 information; repealing s. 408.02, F.S.,
15 relating to the development, endorsement,
16 implementation, and evaluation of patient
17 management practice parameters by the Agency
18 for Health Care Administration; repealing s.
19 766.1016(3), F.S., which requires a patient
20 safety organization to promptly remove
21 patient-identifying information from patient
22 safety data reported to the organization and
23 requires such organization to maintain the
24 confidentiality of patient-identifying
25 information; providing appropriations;
26 providing an effective date.
27
28 WHEREAS, according to the Kaiser Family Foundation,
29 eight out of ten uninsured Americans are workers or dependents
30 of workers and nearly eight out of ten uninsured Americans
31 have family incomes above the poverty level, and
11
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1 WHEREAS, fifty-five percent of those who do not have
2 insurance state the reason they don't have insurance is lack
3 of affordability, and
4 WHEREAS, average health insurance premium increases for
5 the last two years have been in the range of ten to twenty
6 percent for Florida's employers, and
7 WHEREAS, an increasing number of employers are opting
8 to cease providing insurance coverage to their employees due
9 to the high cost, and
10 WHEREAS, an increasing number of employers who continue
11 providing coverage are forced to shift more premium cost to
12 their employees, thus diminishing the value of employee wage
13 increases, and
14 WHEREAS, according to studies, the rate of avoidable
15 hospitalization is fifty to seventy percent lower for the
16 insured versus the uninsured, and
17 WHEREAS, according to Florida Cancer Registry data, the
18 uninsured have a seventy percent greater chance of a late
19 diagnosis, thus decreasing the chances of a positive health
20 outcome, and
21 WHEREAS, according to the Agency for Health Care
22 Administration's 2002 financial data, uncompensated care in
23 Florida's hospitals is growing at the rate of twelve to
24 thirteen percent per year, and, at $4.3 billion in 2001, this
25 cost, when shifted to Floridians who remain insured, is not
26 sustainable, and
27 WHEREAS, the Florida Legislature, through the creation
28 of Health Flex, has already identified the need for lower cost
29 alternatives, and
30 WHEREAS, it is of vital importance and in the best
31 interests of the people of the State of Florida that the issue
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1 of available, affordable health care insurance be addressed in
2 a cohesive and meaningful manner, and
3 WHEREAS, there is general recognition that the issues
4 surrounding the problem of access to affordable health
5 insurance are complicated and multifaceted, NOW, THEREFORE,
6
7 Be It Enacted by the Legislature of the State of Florida:
8
9 Section 1. This act may be referred to by the popular
10 name "The 2004 Affordable Health Care for Floridians Act."
11 Section 2. The purpose of this act is to address the
12 underlying cause of the double-digit increases in health
13 insurance premiums by mitigating the overall growth in health
14 care costs.
15 Section 3. Paragraph (c) of subsection (4) of section
16 381.026, Florida Statutes, is amended to read:
17 381.026 Florida Patient's Bill of Rights and
18 Responsibilities.--
19 (4) RIGHTS OF PATIENTS.--Each health care facility or
20 provider shall observe the following standards:
21 (c) Financial information and disclosure.--
22 1. A patient has the right to be given, upon request,
23 by the responsible provider, his or her designee, or a
24 representative of the health care facility full information
25 and necessary counseling on the availability of known
26 financial resources for the patient's health care.
27 2. A health care provider or a health care facility
28 shall, upon request, disclose to each patient who is eligible
29 for Medicare, in advance of treatment, whether the health care
30 provider or the health care facility in which the patient is
31 receiving medical services accepts assignment under Medicare
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1 reimbursement as payment in full for medical services and
2 treatment rendered in the health care provider's office or
3 health care facility.
4 3. A health care provider or a health care facility
5 shall, upon request, furnish a patient, prior to provision of
6 medical services, a reasonable estimate of charges for such
7 services. Such reasonable estimate shall not preclude the
8 health care provider or health care facility from exceeding
9 the estimate or making additional charges based on changes in
10 the patient's condition or treatment needs.
11 4. Each licensed facility not operated by the state
12 shall make available to the public on its Internet website or
13 by other electronic means information regarding package price
14 of service. The term "package pricing" means all
15 facility-related charges for all services typically associated
16 with a procedure or diagnosis-related group. The facility
17 shall maintain on its website a description of and a link to
18 the agency's website which provides an average cost of the top
19 50 inpatient and top 50 outpatient services provided. The
20 facility shall place a notice in the reception areas that such
21 information is available electronically and the website
22 address. The licensed facility may indicate that the pricing
23 information is based on a compilation of charges for the
24 average patient and that each patient's bill may vary from the
25 average depending upon the severity of illness and individual
26 resources consumed. The licensed facility may also indicate
27 that the price of service is negotiable for eligible patients
28 based upon the patient's ability to pay.
29 5.4. A patient has the right to receive a copy of an
30 itemized bill upon request. A patient has a right to be given
31 an explanation of charges upon request.
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1 6. Failure to provide data upon request as required by
2 this paragraph shall result in a fine of $500 for each
3 instance of the facility's failure to provide the requested
4 information.
5 Section 4. Subsection (1) and paragraph (g) of
6 subsection (3) of section 381.734, Florida Statutes, are
7 amended, and subsections (4), (5), and (6) are added to that
8 section, to read:
9 381.734 Healthy Communities, Healthy People Program.--
10 (1) The department shall develop and implement the
11 Healthy Communities, Healthy People Program, a comprehensive
12 and community-based health promotion and wellness program. The
13 program shall be designed to reduce major behavioral risk
14 factors associated with chronic diseases, including those
15 chronic diseases identified in chapter 385, by enhancing the
16 knowledge, skills, motivation, and opportunities for
17 individuals, organizations, health care providers, small
18 businesses, health insurers, and communities to develop and
19 maintain healthy lifestyles.
20 (3) The program shall include:
21 (g) The establishment of a comprehensive program to
22 inform the public, health care professionals, health insurers,
23 and communities about the prevalence of chronic diseases in
24 the state; known and potential risks, including social and
25 behavioral risks; and behavior changes that would reduce
26 risks.
27 (4) The department shall make available on its
28 Internet website, no later than October 1, 2004, and in a
29 hard-copy format upon request, a listing of age-specific,
30 disease-specific, and community-specific health promotion,
31 preventive care, and wellness programs offered and established
15
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1 under the Healthy Communities, Healthy People Program. The
2 website shall also provide residents with information to
3 identify behavior risk factors that lead to diseases that are
4 preventable by maintaining a healthy lifestyle. The website
5 shall allow consumers to select by county or region
6 disease-specific statistical information.
7 (5) The department shall monitor and assess the
8 effectiveness of such programs. The department shall submit a
9 status report based on this monitoring and assessment to the
10 Governor, the President of the Senate, the Speaker of the
11 House of Representatives, and the substantive committees of
12 each house of the Legislature, with the first annual report
13 due January 31, 2005.
14 (6) The Office of Program Policy and Government
15 Accountability shall evaluate and report to the Governor, the
16 President of the Senate, and the Speaker of the House of
17 Representatives, by March 1, 2005, on the effectiveness of the
18 department's monitoring and assessment of the program's
19 effectiveness.
20 Section 5. Subsection (7) is added to section
21 395.1041, Florida Statutes, to read:
22 395.1041 Access to emergency services and care.--
23 (7) EMERGENCY ROOM DIVERSION PROGRAMS.--Hospitals may
24 develop emergency room diversion programs, including, but not
25 limited to, an "Emergency Hotline" which allows patients to
26 help determine if emergency department services are
27 appropriate or if other health care settings may be more
28 appropriate for care, and a "Fast Track" program allowing
29 nonemergency patients to be treated at an alternative site.
30 Alternative sites may include health care programs funded with
31 local tax revenue and federally funded community health
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1 centers, county health departments, or other nonhospital
2 providers of health care services. The program may include
3 provisions for followup care and case management.
4 Section 6. Subsections (7) and (8) are added to
5 section 395.301, Florida Statutes, to read:
6 395.301 Itemized patient bill; form and content
7 prescribed by the agency.--
8 (7) Each licensed facility not operated by the state
9 shall provide, prior to provision of any medical services, an
10 estimate of charges for the proposed service upon request of a
11 prospective patient who does not have insurance coverage or
12 whose insurer or health maintenance organization does not have
13 a contract with the hospital and an emergency medical
14 condition does not exist or the service is not a covered
15 service. The estimate may be the average charges for that
16 diagnosis-related group or the average charges for that
17 procedure. Such estimate shall not preclude the actual charges
18 from exceeding the estimate. The facility shall place a notice
19 in reception areas that such information is available
20 electronically and the website address.
21 (8) Each licensed facility shall make available on its
22 Internet website a link to the performance outcome and
23 financial data that is published by the Agency for Health Care
24 Administration pursuant to s. 408.05(3)(l).
25 Section 7. Subsection (1) of section 408.061, Florida
26 Statutes, is amended to read:
27 408.061 Data collection; uniform systems of financial
28 reporting; information relating to physician charges;
29 confidential information; immunity.--
30 (1) The agency shall may require the submission by
31 health care facilities, health care providers, and health
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1 insurers of data necessary to carry out the agency's duties.
2 Specifications for data to be collected under this section
3 shall be developed by the agency with the assistance of
4 technical advisory panels including representatives of
5 affected entities, consumers, purchasers, and such other
6 interested parties as may be determined by the agency.
7 (a) Data to be submitted by health care facilities,
8 including the facilities as defined in chapter 395, shall may
9 include, but are not limited to: case-mix data, patient
10 admission and or discharge data, outpatient data which shall
11 include the number of patients treated in the emergency
12 department of a licensed hospital reported by patient acuity
13 level, data on hospital-acquired infections as specified by
14 rule, data on complications including date of diagnosis as
15 specified by rule, data on readmissions as specified by rule,
16 with patient and provider-specific identifiers included,
17 actual charge data by diagnostic groups, financial data,
18 accounting data, operating expenses, expenses incurred for
19 rendering services to patients who cannot or do not pay,
20 interest charges, depreciation expenses based on the expected
21 useful life of the property and equipment involved, and
22 demographic data. The agency shall adopt the 3M All Patient
23 Refined DRG software risk and severity adjustment methodology
24 for all data submitted as required by this section. Data may
25 be obtained from documents such as, but not limited to:
26 leases, contracts, debt instruments, itemized patient bills,
27 medical record abstracts, and related diagnostic information.
28 Reported data elements shall be reported electronically in
29 accordance with Rule 59E-7.012, Florida Administrative Code.
30 Data submitted shall be certified by the Chief Executive
31 Officer or an appropriate and duly authorized representative
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1 or employee of the licensed facility that the information
2 submitted is true and accurate.
3 (b) Data to be submitted by health care providers may
4 include, but are not limited to: Medicare and Medicaid
5 participation, types of services offered to patients, amount
6 of revenue and expenses of the health care provider, and such
7 other data which are reasonably necessary to study utilization
8 patterns.
9 (c) Data to be submitted by health insurers may
10 include percentage of claims denied, percentage of claims
11 meeting prompt pay requirements, and medical and
12 administrative loss ratios, but are not limited to: claims,
13 premium, administration, and financial information. Data
14 submitted shall be certified by the appropriate and duly
15 authorized representative or employee of the insurer that the
16 information submitted is true and accurate.
17 (d) Data required to be submitted by health care
18 facilities, health care providers, or health insurers shall
19 not include specific provider contract reimbursement
20 information. However, such specific provider reimbursement
21 data shall be reasonably available for onsite inspection by
22 the agency as is necessary to carry out the agency's
23 regulatory duties. Any such data obtained by the agency as a
24 result of onsite inspections may not be used by the state for
25 purposes of direct provider contracting and are confidential
26 and exempt from the provisions of s. 119.07(1) and s. 24(a),
27 Art. I of the State Constitution.
28 (e) A requirement to submit data shall be adopted by
29 rule if the submission of data is being required of all
30 members of any type of health care facility, health care
31 provider, or health insurer. Rules are not required, however,
19
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1 for the submission of data for a special study mandated by the
2 Legislature or when information is being requested for a
3 single health care facility, health care provider, or health
4 insurer.
5 Section 8. Subsections (1) and (4) of section 408.062,
6 Florida Statutes, are amended to read:
7 408.062 Research, analyses, studies, and reports.--
8 (1) The agency shall have the authority to conduct
9 research, analyses, and studies relating to health care costs
10 and access to and quality of health care services as access
11 and quality are affected by changes in health care costs. Such
12 research, analyses, and studies shall include, but not be
13 limited to, research and analysis relating to:
14 (a) The financial status of any health care facility
15 or facilities subject to the provisions of this chapter.
16 (b) The impact of uncompensated charity care on health
17 care facilities and health care providers.
18 (c) The state's role in assisting to fund indigent
19 care.
20 (d) In conjunction with the Office of Insurance
21 Regulation, the availability and affordability of health
22 insurance for small businesses.
23 (e) Total health care expenditures in the state
24 according to the sources of payment and the type of
25 expenditure.
26 (f) The quality of health services, using techniques
27 such as small area analysis, severity adjustments, and
28 risk-adjusted mortality rates.
29 (g) The development of physician information payment
30 systems which are capable of providing data for health care
31 consumers taking into account the amount of resources consumed
20
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1 at licensed facilities as defined in chapter 395 and the
2 outcomes produced in the delivery of care.
3 (h) The collection of a statistically valid sample of
4 data on the retail prices charged by pharmacies for the 50
5 most frequently prescribed medicines from any pharmacy
6 licensed by this state as a special study authorized by the
7 Legislature to be performed by the agency quarterly. If the
8 drug is available generically, price data shall be reported
9 for the generic drug and price data of a brand-named drug for
10 which the generic drug is the equivalent shall be reported.
11 The agency shall make drug prices for a 30-day supply at a
12 standard dose available on its Internet website for each
13 pharmacy no later than October 1, 2005. The data collected
14 shall be reported for each drug by pharmacy and by
15 metropolitan statistical area or region and updated quarterly
16 The impact of subacute admissions on hospital revenues and
17 expenses for purposes of calculating adjusted admissions as
18 defined in s. 408.07.
19 (i) The use of emergency department services by
20 patient acuity level and the implication of increasing
21 hospital cost by providing nonurgent care in emergency
22 departments. The agency shall submit an annual report based on
23 this monitoring and assessment to the Governor, the Speaker of
24 the House of Representatives, the President of the Senate, and
25 the substantive legislative committees with the first report
26 due January 1, 2006.
27 (j) The making available on its Internet website no
28 later than October 1, 2004, and in a hard-copy format upon
29 request, of patient charge, volumes, length of stay, and
30 performance outcome indicators collected from health care
31 facilities pursuant to s. 408.061(1)(a) for specific medical
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1 conditions, surgeries, and procedures provided in inpatient
2 and outpatient facilities as determined by the agency. In
3 making the determination of specific medical conditions,
4 surgeries, and procedures to include, the agency shall
5 consider such factors as volume, severity of the illness,
6 urgency of admission, individual and societal costs, and
7 whether the condition is acute or chronic. Performance outcome
8 indicators shall be risk adjusted or severity adjusted as
9 applicable using 3M All Patient Refined DRG's. The website
10 shall also provide an interactive search that allows consumers
11 to view and compare the information for specific facilities, a
12 map that allows consumers to select a county or region,
13 definitions of all of the data, descriptions of each
14 procedure, and an explanation about why the data may differ
15 from facility to facility. Such public data shall be updated
16 quarterly. The agency shall submit an annual status report on
17 the collection of data and publication of performance outcome
18 indicators to the Governor, the Speaker of the House of
19 Representatives, the President of the Senate, and the
20 substantive legislative committees with the first status
21 report due January 1, 2005.
22 (4)(a) The agency shall may conduct data-based studies
23 and evaluations and make recommendations to the Legislature
24 and the Governor concerning exemptions, the effectiveness of
25 limitations of referrals, restrictions on investment interests
26 and compensation arrangements, and the effectiveness of public
27 disclosure. Such analysis shall may include, but need not be
28 limited to, utilization of services, cost of care, quality of
29 care, and access to care. The agency may require the
30 submission of data necessary to carry out this duty, which may
31 include, but need not be limited to, data concerning
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1 ownership, Medicare and Medicaid, charity care, types of
2 services offered to patients, revenues and expenses,
3 patient-encounter data, and other data reasonably necessary to
4 study utilization patterns and the impact of health care
5 provider ownership interests in health-care-related entities
6 on the cost, quality, and accessibility of health care.
7 (b) The agency may collect such data from any health
8 facility or licensed health care provider as a special study.
9 (5) The agency shall develop and implement a strategy
10 for the adoption and use of electronic health records. The
11 agency may develop rules to facilitate the functionality and
12 protect the confidentiality of electronic health records. The
13 agency shall report to the Governor, the Speaker of the House,
14 and the President of the Senate on legislative recommendations
15 to protect the confidentiality of electronic health records.
16 Section 9. Paragraph (l) is added to subsection (3) of
17 section 408.05, Florida Statutes, to read:
18 408.05 State Center for Health Statistics.--
19 (3) COMPREHENSIVE HEALTH INFORMATION SYSTEM.--In order
20 to produce comparable and uniform health information and
21 statistics, the agency shall perform the following functions:
22 (l) Develop, in conjunction with the State
23 Comprehensive Health Information System Advisory Council, and
24 implement a long-range plan for making available performance
25 outcome and financial data that will allow consumers to
26 compare health care services. The performance outcomes and
27 financial data the agency must make available shall include,
28 but is not limited to, pharmaceuticals, physicians, health
29 care facilities, and health plans and managed care entities.
30 The agency shall submit the initial plan to the Governor, the
31 President of the Senate, and the Speaker of the House of
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1 Representatives by March 1, 2005, and shall update the plan
2 and report on the status of its implementation annually
3 thereafter. The agency shall also make the plan and status
4 report available to the public on its Internet website. As
5 part of the plan, the agency shall identify the process and
6 timeframes for implementation, any barriers to implementation,
7 and recommendations of changes in the law that may be enacted
8 by the Legislature to eliminate the barriers. As preliminary
9 elements of the plan, the agency shall:
10 1. Make available performance outcome and patient
11 charge data collected from health care facilities pursuant to
12 s. 408.061(1)(a) and (2). The agency shall determine which
13 conditions and procedures, performance outcomes, and patient
14 charge data to disclose based upon input from the council.
15 When determining which conditions and procedures are to be
16 disclosed, the council and the agency shall consider variation
17 in costs, variation in outcomes, and magnitude of variations
18 and other relevant information. When determining which
19 performance outcomes to disclose, the agency:
20 a. Shall consider such factors as volume of cases;
21 average patient charges; average length of stay; complication
22 rates; mortality rates; and infection rates, among others,
23 which shall be adjusted for case mix and severity, if
24 applicable.
25 b. May consider such additional measures that are
26 adopted by the Centers for Medicare and Medicaid Studies,
27 National Quality Forum, the Joint Commission on Accreditation
28 of Healthcare Organizations, the Agency for Healthcare
29 Research and Quality, or a similar national entity that
30 establishes standards to measure the performance of health
31 care providers, or by other states.
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1
2 When determining which patient charge data to disclose, the
3 agency shall consider such measures as average charge, average
4 net revenue per adjusted patient day, average cost per
5 adjusted patient day, and average cost per admission, among
6 others.
7 2. Make available performance measures, benefit
8 design, and premium cost data from health plans licensed
9 pursuant to chapter 627 or chapter 641. The agency shall
10 determine which performance outcome and member and subscriber
11 cost data to disclose, based upon input from the council. When
12 determining which data to disclose, the agency shall consider
13 information that may be required by either individual or group
14 purchasers to assess the value of the product, which may
15 include membership satisfaction, quality of care, current
16 enrollment or membership, coverage areas, accreditation
17 status, premium costs, plan costs, premium increases, range of
18 benefits, copayments and deductibles, accuracy and speed of
19 claims payment, credentials of physicians, number of
20 providers, names of network providers, and hospitals in the
21 network.
22 3. Determine the method and format for public
23 disclosure of data reported pursuant to this paragraph. The
24 agency shall make its determination based upon input from the
25 Comprehensive Health Information System Advisory Council. At a
26 minimum, the data shall be made available on the agency's
27 Internet website in a manner that allows consumers to conduct
28 an interactive search that allows them to view and compare the
29 information for specific providers. The website must include
30 such additional information as is determined necessary to
31 ensure that the website enhances informed decision making
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1 among consumers and health care purchasers, which shall
2 include, at a minimum, appropriate guidance on how to use the
3 data and an explanation of why the data may vary from provider
4 to provider. The data specified in subparagraph 1. shall be
5 released no later than March 1, 2005. The data specified in
6 subparagraph 2. shall be released no later than March 1, 2006.
7 Section 10. Subsection (3) of section 409.9066,
8 Florida Statutes, is amended to read:
9 409.9066 Medicare prescription discount program.--
10 (3) The Agency for Health Care Administration shall
11 publish, on a free website available to the public, the most
12 recent average wholesale prices for the 200 drugs most
13 frequently dispensed to the elderly and, to the extent
14 possible, shall provide a mechanism that consumers may use to
15 calculate the retail price and the price that should be paid
16 after the discount required in subsection (1) is applied. The
17 agency shall provide retail information by geographic area and
18 retail information by provider within geographical areas.
19 Section 11. Section 408.7056, Florida Statutes, is
20 amended to read:
21 408.7056 Statewide Provider and Subscriber Assistance
22 Program.--
23 (1) As used in this section, the term:
24 (a) "Agency" means the Agency for Health Care
25 Administration.
26 (b) "Department" means the Department of Financial
27 Services.
28 (c) "Grievance procedure" means an established set of
29 rules that specify a process for appeal of an organizational
30 decision.
31
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1 (d) "Health care provider" or "provider" means a
2 state-licensed or state-authorized facility, a facility
3 principally supported by a local government or by funds from a
4 charitable organization that holds a current exemption from
5 federal income tax under s. 501(c)(3) of the Internal Revenue
6 Code, a licensed practitioner, a county health department
7 established under part I of chapter 154, a prescribed
8 pediatric extended care center defined in s. 400.902, a
9 federally supported primary care program such as a migrant
10 health center or a community health center authorized under s.
11 329 or s. 330 of the United States Public Health Services Act
12 that delivers health care services to individuals, or a
13 community facility that receives funds from the state under
14 the Community Alcohol, Drug Abuse, and Mental Health Services
15 Act and provides mental health services to individuals.
16 (e) "Managed care entity" means a health maintenance
17 organization or a prepaid health clinic certified under
18 chapter 641, a prepaid health plan authorized under s.
19 409.912, or an exclusive provider organization certified under
20 s. 627.6472.
21 (f) "Office" means the Office of Insurance Regulation
22 of the Financial Services Commission.
23 (g) "Panel" means a statewide provider and subscriber
24 assistance panel selected as provided in subsection (11).
25 (2) The agency shall adopt and implement a program to
26 provide assistance to subscribers and providers, including
27 those whose grievances are not resolved by the managed care
28 entity to the satisfaction of the subscriber or provider. The
29 program shall consist of one or more panels that meet as often
30 as necessary to timely review, consider, and hear grievances
31 and recommend to the agency or the office any actions that
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1 should be taken concerning individual cases heard by the
2 panel. The panel shall hear every grievance filed by
3 subscribers and providers on behalf of subscribers, unless the
4 grievance:
5 (a) Relates to a managed care entity's refusal to
6 accept a provider into its network of providers;
7 (b) Is part of an internal grievance in a Medicare
8 managed care entity or a reconsideration appeal through the
9 Medicare appeals process which does not involve a quality of
10 care issue;
11 (c) Is related to a health plan not regulated by the
12 state such as an administrative services organization,
13 third-party administrator, or federal employee health benefit
14 program;
15 (d) Is related to appeals by in-plan suppliers and
16 providers, unless related to quality of care provided by the
17 plan;
18 (e) Is part of a Medicaid fair hearing pursued under
19 42 C.F.R. ss. 431.220 et seq.;
20 (f) Is the basis for an action pending in state or
21 federal court;
22 (g) Is related to an appeal by nonparticipating
23 providers, unless related to the quality of care provided to a
24 subscriber by the managed care entity and the provider is
25 involved in the care provided to the subscriber;
26 (h) Was filed before the subscriber or provider
27 completed the entire internal grievance procedure of the
28 managed care entity, the managed care entity has complied with
29 its timeframes for completing the internal grievance
30 procedure, and the circumstances described in subsection (6)
31 do not apply;
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1 (i) Has been resolved to the satisfaction of the
2 subscriber or provider who filed the grievance, unless the
3 managed care entity's initial action is egregious or may be
4 indicative of a pattern of inappropriate behavior;
5 (j) Is limited to seeking damages for pain and
6 suffering, lost wages, or other incidental expenses, including
7 accrued interest on unpaid balances, court costs, and
8 transportation costs associated with a grievance procedure;
9 (k) Is limited to issues involving conduct of a health
10 care provider or facility, staff member, or employee of a
11 managed care entity which constitute grounds for disciplinary
12 action by the appropriate professional licensing board and is
13 not indicative of a pattern of inappropriate behavior, and the
14 agency, office, or department has reported these grievances to
15 the appropriate professional licensing board or to the health
16 facility regulation section of the agency for possible
17 investigation; or
18 (l) Is withdrawn by the subscriber or provider.
19 Failure of the subscriber or the provider to attend the
20 hearing shall be considered a withdrawal of the grievance.
21 (3) The agency shall review all grievances within 60
22 days after receipt and make a determination whether the
23 grievance shall be heard. Once the agency notifies the panel,
24 the subscriber or provider, and the managed care entity that a
25 grievance will be heard by the panel, the panel shall hear the
26 grievance either in the network area or by teleconference no
27 later than 120 days after the date the grievance was filed.
28 The agency shall notify the parties, in writing, by facsimile
29 transmission, or by phone, of the time and place of the
30 hearing. The panel may take testimony under oath, request
31 certified copies of documents, and take similar actions to
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1 collect information and documentation that will assist the
2 panel in making findings of fact and a recommendation. The
3 panel shall issue a written recommendation, supported by
4 findings of fact, to the provider or subscriber, to the
5 managed care entity, and to the agency or the office no later
6 than 15 working days after hearing the grievance. If at the
7 hearing the panel requests additional documentation or
8 additional records, the time for issuing a recommendation is
9 tolled until the information or documentation requested has
10 been provided to the panel. The proceedings of the panel are
11 not subject to chapter 120.
12 (4) If, upon receiving a proper patient authorization
13 along with a properly filed grievance, the agency requests
14 medical records from a health care provider or managed care
15 entity, the health care provider or managed care entity that
16 has custody of the records has 10 days to provide the records
17 to the agency. Records include medical records, communication
18 logs associated with the grievance both to and from the
19 subscriber, contracts, and any other contents of the internal
20 grievance file associated with the complaint filed with the
21 Subscriber Assistance Program. Failure to provide requested
22 medical records may result in the imposition of a fine of up
23 to $500. Each day that records are not produced is considered
24 a separate violation.
25 (5) Grievances that the agency determines pose an
26 immediate and serious threat to a subscriber's health must be
27 given priority over other grievances. The panel may meet at
28 the call of the chair to hear the grievances as quickly as
29 possible but no later than 45 days after the date the
30 grievance is filed, unless the panel receives a waiver of the
31 time requirement from the subscriber. The panel shall issue a
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1 written recommendation, supported by findings of fact, to the
2 office or the agency within 10 days after hearing the
3 expedited grievance.
4 (6) When the agency determines that the life of a
5 subscriber is in imminent and emergent jeopardy, the chair of
6 the panel may convene an emergency hearing, within 24 hours
7 after notification to the managed care entity and to the
8 subscriber, to hear the grievance. The grievance must be heard
9 notwithstanding that the subscriber has not completed the
10 internal grievance procedure of the managed care entity. The
11 panel shall, upon hearing the grievance, issue a written
12 emergency recommendation, supported by findings of fact, to
13 the managed care entity, to the subscriber, and to the agency
14 or the office for the purpose of deferring the imminent and
15 emergent jeopardy to the subscriber's life. Within 24 hours
16 after receipt of the panel's emergency recommendation, the
17 agency or office may issue an emergency order to the managed
18 care entity. An emergency order remains in force until:
19 (a) The grievance has been resolved by the managed
20 care entity;
21 (b) Medical intervention is no longer necessary; or
22 (c) The panel has conducted a full hearing under
23 subsection (3) and issued a recommendation to the agency or
24 the office, and the agency or office has issued a final order.
25 (7) After hearing a grievance, the panel shall make a
26 recommendation to the agency or the office which may include
27 specific actions the managed care entity must take to comply
28 with state laws or rules regulating managed care 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
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1 receipt of a recommendation in an expedited grievance, furnish
2 to the agency or office written evidence in opposition to the
3 recommendation or findings of fact of the panel.
4 (9) No later than 30 days after the issuance of the
5 panel's recommendation and, for an expedited grievance, no
6 later than 10 days after the issuance of the panel's
7 recommendation, the agency or the office may adopt the panel's
8 recommendation or findings of fact in a proposed order or an
9 emergency order, as provided in chapter 120, which it shall
10 issue to the managed care entity. The agency or office may
11 issue a proposed order or an emergency order, as provided in
12 chapter 120, imposing fines or sanctions, including those
13 contained in ss. 641.25 and 641.52. The agency or the office
14 may reject all or part of the panel's recommendation. All
15 fines collected under this subsection must be deposited into
16 the Health Care Trust Fund.
17 (10) In determining any fine or sanction to be
18 imposed, the agency and the office may consider the following
19 factors:
20 (a) The severity of the noncompliance, including the
21 probability that death or serious harm to the health or safety
22 of the subscriber will result or has resulted, the severity of
23 the actual or potential harm, and the extent to which
24 provisions of chapter 641 were violated.
25 (b) Actions taken by the managed care entity to
26 resolve or remedy any quality-of-care grievance.
27 (c) Any previous incidents of noncompliance by the
28 managed care entity.
29 (d) Any other relevant factors the agency or office
30 considers appropriate in a particular grievance.
31
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1 (11)(a) The panel shall consist of the Insurance
2 Consumer Advocate, or designee thereof, established by s.
3 627.0613; at least two members employed by the agency and at
4 least two members employed by the department, chosen by their
5 respective agencies; a consumer appointed by the Governor; a
6 physician appointed by the Governor, as a standing member;
7 and, if necessary, physicians who have expertise relevant to
8 the case to be heard, on a rotating basis. The agency may
9 contract with a medical director, and a primary care
10 physician, or both, who shall provide additional technical
11 expertise to the panel but shall not be voting members of the
12 panel. The medical director shall be selected from a health
13 maintenance organization with a current certificate of
14 authority to operate in Florida.
15 (b) A majority of those panel members required under
16 paragraph (a) shall constitute a quorum for any meeting or
17 hearing of the panel. A grievance may not be heard or voted
18 upon at any panel meeting or hearing unless a quorum is
19 present, except that a minority of the panel may adjourn a
20 meeting or hearing until a quorum is present. A panel convened
21 for the purpose of hearing a subscriber's grievance in
22 accordance with subsections (2) and (3) shall not consist of
23 more than 11 members.
24 (12) Every managed care entity shall submit a
25 quarterly report to the agency, the office, and the department
26 listing the number and the nature of all subscribers' and
27 providers' grievances which have not been resolved to the
28 satisfaction of the subscriber or provider after the
29 subscriber or provider follows the entire internal grievance
30 procedure of the managed care entity. The agency shall notify
31 all subscribers and providers included in the quarterly
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1 reports of their right to file an unresolved grievance with
2 the panel.
3 (13) A proposed order issued by the agency or office
4 which only requires the managed care entity to take a specific
5 action under subsection (7) is subject to a summary hearing in
6 accordance with s. 120.574, unless all of the parties agree
7 otherwise. If the managed care entity does not prevail at the
8 hearing, the managed care entity must pay reasonable costs and
9 attorney's fees of the agency or the office incurred in that
10 proceeding.
11 (14)(a) Any information that identifies a subscriber
12 which is held by the panel, agency, or department pursuant to
13 this section is confidential and exempt from the provisions of
14 s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
15 However, at the request of a subscriber or managed care entity
16 involved in a grievance procedure, the panel, agency, or
17 department shall release information identifying the
18 subscriber involved in the grievance procedure to the
19 requesting subscriber or managed care entity.
20 (b) Meetings of the panel shall be open to the public
21 unless the provider or subscriber whose grievance will be
22 heard requests a closed meeting or the agency or the
23 department determines that information which discloses the
24 subscriber's medical treatment or history or information
25 relating to internal risk management programs as defined in s.
26 641.55(5)(c), (6), and (8) may be revealed at the panel
27 meeting, in which case that portion of the meeting during
28 which a subscriber's medical treatment or history or internal
29 risk management program information is discussed shall be
30 exempt from the provisions of s. 286.011 and s. 24(b), Art. I
31
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1 of the State Constitution. All closed meetings shall be
2 recorded by a certified court reporter.
3 Section 12. Paragraph (c) of subsection (4) of section
4 641.3154, Florida Statutes, is amended to read:
5 641.3154 Organization liability; provider billing
6 prohibited.--
7 (4) A provider or any representative of a provider,
8 regardless of whether the provider is under contract with the
9 health maintenance organization, may not collect or attempt to
10 collect money from, maintain any action at law against, or
11 report to a credit agency a subscriber of an organization for
12 payment of services for which the organization is liable, if
13 the provider in good faith knows or should know that the
14 organization is liable. This prohibition applies during the
15 pendency of any claim for payment made by the provider to the
16 organization for payment of the services and any legal
17 proceedings or dispute resolution process to determine whether
18 the organization is liable for the services if the provider is
19 informed that such proceedings are taking place. It is
20 presumed that a provider does not know and should not know
21 that an organization is liable unless:
22 (c) The office or agency makes a final determination
23 that the organization is required to pay for such services
24 subsequent to a recommendation made by the Statewide Provider
25 and Subscriber Assistance Panel pursuant to s. 408.7056; or
26 Section 13. Subsection (1), paragraphs (b) and (e) of
27 subsection (3), paragraph (d) of subsection (4), subsection
28 (5), paragraph (g) of subsection (6), and subsections (9),
29 (10), and (11) of section 641.511, Florida Statutes, are
30 amended to read:
31
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1 641.511 Subscriber grievance reporting and resolution
2 requirements.--
3 (1) Every organization must have a grievance procedure
4 available to its subscribers for the purpose of addressing
5 complaints and grievances. Every organization must notify its
6 subscribers that a subscriber must submit a grievance within 1
7 year after the date of occurrence of the action that initiated
8 the grievance, and may submit the grievance for review to the
9 Statewide Provider and Subscriber Assistance Program panel as
10 provided in s. 408.7056 after receiving a final disposition of
11 the grievance through the organization's grievance process. An
12 organization shall maintain records of all grievances and
13 shall report annually to the agency the total number of
14 grievances handled, a categorization of the cases underlying
15 the grievances, and the final disposition of the grievances.
16 (3) Each organization's grievance procedure, as
17 required under subsection (1), must include, at a minimum:
18 (b) The names of the appropriate employees or a list
19 of grievance departments that are responsible for implementing
20 the organization's grievance procedure. The list must include
21 the address and the toll-free telephone number of each
22 grievance department, the address of the agency and its
23 toll-free telephone hotline number, and the address of the
24 Statewide Provider and Subscriber Assistance Program and its
25 toll-free telephone number.
26 (e) A notice that a subscriber may voluntarily pursue
27 binding arbitration in accordance with the terms of the
28 contract if offered by the organization, after completing the
29 organization's grievance procedure and as an alternative to
30 the Statewide Provider and Subscriber Assistance Program. Such
31 notice shall include an explanation that the subscriber may
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1 incur some costs if the subscriber pursues binding
2 arbitration, depending upon the terms of the subscriber's
3 contract.
4 (4)
5 (d) In any case when the review process does not
6 resolve a difference of opinion between the organization and
7 the subscriber or the provider acting on behalf of the
8 subscriber, the subscriber or the provider acting on behalf of
9 the subscriber may submit a written grievance to the Statewide
10 Provider and Subscriber Assistance Program.
11 (5) Except as provided in subsection (6), the
12 organization shall resolve a grievance within 60 days after
13 receipt of the grievance, or within a maximum of 90 days if
14 the grievance involves the collection of information outside
15 the service area. These time limitations are tolled if the
16 organization has notified the subscriber, in writing, that
17 additional information is required for proper review of the
18 grievance and that such time limitations are tolled until such
19 information is provided. After the organization receives the
20 requested information, the time allowed for completion of the
21 grievance process resumes. The Employee Retirement Income
22 Security Act of 1974, as implemented by 29 C.F.R. 2560.503-1,
23 is adopted and incorporated by reference as applicable to all
24 organizations that administer small and large group health
25 plans that are subject to 29 C.F.R. 2560.503-1. The claims
26 procedures of the regulations of the Employee Retirement
27 Income Security Act of 1974 as implemented by 29 C.F.R.
28 2560.503-1 shall be the minimum standards for grievance
29 processes for claims for benefits for small and large group
30 health plans that are subject to 29 C.F.R. 2560.503-1.
31 (6)
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1 (g) In any case when the expedited 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 (9)(a) The agency shall advise subscribers with
8 grievances to follow their organization's formal grievance
9 process for resolution prior to review by the Statewide
10 Provider and Subscriber Assistance Program. The subscriber
11 may, however, submit a copy of the grievance to the agency at
12 any time during the process.
13 (b) Requiring completion of the organization's
14 grievance process before the Statewide Provider and Subscriber
15 Assistance Program panel's review does not preclude the agency
16 from investigating any complaint or grievance before the
17 organization makes its final determination.
18 (10) Each organization must notify the subscriber in a
19 final decision letter that the subscriber may request review
20 of the organization's decision concerning the grievance by the
21 Statewide Provider and Subscriber Assistance Program, as
22 provided in s. 408.7056, if the grievance is not resolved to
23 the satisfaction of the subscriber. The final decision letter
24 must inform the subscriber that the request for review must be
25 made within 365 days after receipt of the final decision
26 letter, must explain how to initiate such a review, and must
27 include the addresses and toll-free telephone numbers of the
28 agency and the Statewide Provider and Subscriber Assistance
29 Program.
30 (11) Each organization, as part of its contract with
31 any provider, must require the provider to post a consumer
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1 assistance notice prominently displayed in the reception area
2 of the provider and clearly noticeable by all patients. The
3 consumer assistance notice must state the addresses and
4 toll-free telephone numbers of the Agency for Health Care
5 Administration, the Statewide Provider and Subscriber
6 Assistance Program, and the Department of Financial Services.
7 The consumer assistance notice must also clearly state that
8 the address and toll-free telephone number of the
9 organization's grievance department shall be provided upon
10 request. The agency may adopt rules to implement this section.
11 Section 14. Subsection (4) of section 641.58, Florida
12 Statutes, is amended to read:
13 641.58 Regulatory assessment; levy and amount; use of
14 funds; tax returns; penalty for failure to pay.--
15 (4) The moneys received and deposited into the Health
16 Care Trust Fund shall be used to defray the expenses of the
17 agency in the discharge of its administrative and regulatory
18 powers and duties under this part, including conducting an
19 annual survey of the satisfaction of members of health
20 maintenance organizations; contracting with physician
21 consultants for the Statewide Provider and Subscriber
22 Assistance Panel; maintaining offices and necessary supplies,
23 essential equipment, and other materials, salaries and
24 expenses of required personnel; and discharging the
25 administrative and regulatory powers and duties imposed under
26 this part.
27 Section 15. Paragraph (f) of subsection (2) and
28 subsections (3) and (9) of section 408.909, Florida Statutes,
29 are amended to read:
30 408.909 Health flex plans.--
31 (2) DEFINITIONS.--As used in this section, the term:
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1 (f) "Health flex plan entity" means a health insurer,
2 health maintenance organization,
3 health-care-provider-sponsored organization, local government,
4 health care district, or other public or private
5 community-based organization, or public-private partnership
6 that develops and implements an approved health flex plan and
7 is responsible for administering the health flex plan and
8 paying all claims for health flex plan coverage by enrollees
9 of the health flex plan.
10 (3) PILOT PROGRAM.--The agency and the office shall
11 each approve or disapprove health flex plans that provide
12 health care coverage for eligible participants who reside in
13 the three areas of the state that have the highest number of
14 uninsured persons, as identified in the Florida Health
15 Insurance Study conducted by the agency and in Indian River
16 County . A health flex plan may limit or exclude benefits
17 otherwise required by law for insurers offering coverage in
18 this state, may cap the total amount of claims paid per year
19 per enrollee, may limit the number of enrollees, or may take
20 any combination of those actions. A health flex plan offering
21 may include the option of a catastrophic plan supplementing
22 the health flex plan.
23 (a) The agency shall develop guidelines for the review
24 of applications for health flex plans and shall disapprove or
25 withdraw approval of plans that do not meet or no longer meet
26 minimum standards for quality of care and access to care. The
27 agency shall ensure that the health flex plans follow
28 standardized grievance procedures similar to those required of
29 health maintenance organizations.
30 (b) The office shall develop guidelines for the review
31 of health flex plan applications and provide regulatory
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1 oversight of health flex plan advertisement and marketing
2 procedures. The office shall disapprove or shall withdraw
3 approval of plans that:
4 1. Contain any ambiguous, inconsistent, or misleading
5 provisions or any exceptions or conditions that deceptively
6 affect or limit the benefits purported to be assumed in the
7 general coverage provided by the health flex plan;
8 2. Provide benefits that are unreasonable in relation
9 to the premium charged or contain provisions that are unfair
10 or inequitable or contrary to the public policy of this state,
11 that encourage misrepresentation, or that result in unfair
12 discrimination in sales practices; or
13 3. Cannot demonstrate that the health flex plan is
14 financially sound and that the applicant is able to underwrite
15 or finance the health care coverage provided.
16 (c) The agency and the Financial Services Commission
17 may adopt rules as needed to administer this section.
18 (9) PROGRAM EVALUATION.--The agency and the office
19 shall evaluate the pilot program and its effect on the
20 entities that seek approval as health flex plans, on the
21 number of enrollees, and on the scope of the health care
22 coverage offered under a health flex plan; shall provide an
23 assessment of the health flex plans and their potential
24 applicability in other settings; shall use health flex plans
25 to gather more information to evaluate low-income consumer
26 driven benefit packages; and shall, by January 1, 2005 2004,
27 jointly submit a report to the Governor, the President of the
28 Senate, and the Speaker of the House of Representatives.
29 Section 16. Section 381.0271, Florida Statutes, is
30 created to read:
31 381.0271 Florida Patient Safety Corporation.--
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1 (1) DEFINITIONS.--As used in this section, the term:
2 (a) "Adverse incident" has the same meanings as
3 provided in ss. 395.0197, 458.351, and 459.026.
4 (b) "Corporation" means the Florida Patient Safety
5 Corporation created in this section.
6 (c) "Patient safety data" has the same meaning as
7 provided in s. 766.1016.
8 (2) CREATION.--
9 (a) There is created a not-for-profit corporation to
10 be known as the Florida Patient Safety Corporation, which
11 shall be registered, incorporated, organized, and operated in
12 compliance with chapter 617. Upon the prior approval of the
13 board of directors, the corporation may create not-for-profit
14 corporate subsidiaries, organized under the provisions of
15 chapter 617, as necessary to fulfill the mission of the
16 corporation.
17 (b) The corporation or any authorized and approved
18 subsidiary is not an agency within the meaning of s.
19 20.03(11).
20 (c) The corporation and its authorized and approved
21 subsidiaries are subject to the public meetings and records
22 requirements of s. 24, Art I of the State Constitution,
23 chapter 119, and s. 286.011.
24 (d) The corporation and its authorized and approved
25 subsidiaries are not subject to the provisions of chapter 287.
26 (e) The corporation is a patient safety organization
27 for purposes of s. 766.1016.
28 (3) PURPOSE.--
29 (a) The purpose of the Florida Patient Safety
30 Corporation is to serve as a learning organization dedicated
31 to assisting health care providers in the state to improve the
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1 quality and safety of health care rendered and to reduce harm
2 to patients. The corporation shall promote the development of
3 a culture of patient safety in the health care system in the
4 state. The corporation may not regulate health care providers
5 in this state.
6 (b) In the fulfillment of its purpose, the corporation
7 shall work with a consortium of patient safety centers and
8 other patient safety programs within the universities in this
9 state.
10 (4) BOARD OF DIRECTORS; MEMBERSHIP.--The corporation
11 shall be governed by a board of directors. The board of
12 directors shall consist of:
13 (a) The chairperson of the Council of Medical School
14 Deans.
15 (b) The person responsible for patient safety issues
16 for the authorized health insurer with the largest market
17 share as measured by premiums written in the state for the
18 most recent calendar year, appointed by such insurer.
19 (c) A representative of the authorized medical
20 malpractice insurer with the largest market share as measured
21 by premiums written in the state for the most recent calendar
22 year, appointed by such insurer.
23 (d) The president of the Florida Health Care
24 Coalition.
25 (e) A representative of a hospital in the state that
26 is implementing innovative patient safety initiatives,
27 appointed by the Florida Hospital Association.
28 (f) A physician with expertise in patient safety,
29 appointed by the Florida Medical Association.
30 (g) A physician with expertise in patient safety,
31 appointed by the Florida Osteopathic Medical Association.
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1 (h) A nurse with expertise in patient safety,
2 appointed by the Florida Nurses Association.
3 (i) An institutional pharmacist, appointed by the
4 Florida Society of Health System Pharmacists, Inc.
5 (j) A representative of Florida AARP, appointed by the
6 state director of the Florida AARP.
7 (k) An independent consultant on health care
8 information systems, appointed jointly by the Central Florida
9 Chapter and the South Florida Chapter of the Healthcare
10 Information and Management Systems Society.
11 (5) ADVISORY COMMITTEES.--In addition to any
12 committees that the corporation may establish, the corporation
13 shall establish the following advisory committees:
14 (a) A scientific research advisory committee that
15 includes, at a minimum, a representative from each patient
16 safety center or other patient safety program in the
17 universities of this state, who are licensed physicians under
18 ch. 458 or 459, F.S., with experience in patient safety and
19 evidence based medicine.
20 (b) A technology advisory committee that includes, at
21 a minimum, a representative of a hospital that has implemented
22 a computerized physician order entry system and a health care
23 provider that has implemented an electronic medical records
24 system.
25 (c) A health care provider advisory committee that
26 includes, at a minimum, representatives of hospitals,
27 ambulatory surgical centers, physicians, nurses, and
28 pharmacists licensed in this state and a representative of the
29 Veterans Integrated Service Network 8 VA Patient Safety
30 Center.
31
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1 (d) A health care consumer advisory committee that
2 includes, at a minimum, representatives of businesses that
3 provide health insurance coverage to their employees, consumer
4 advocacy groups, and representatives of patient organizations.
5 (e) A state agency advisory committee that includes,
6 at a minimum, a representative from each state agency that has
7 regulatory responsibilities related to patient safety.
8 (f) A litigation alternatives advisory committee that
9 includes, at a minimum, representatives of attorneys who
10 represent plaintiffs and defendants in medical malpractice
11 cases and a representative of each law school in the state.
12 (g) An education advisory committee that includes, at
13 a minimum, the associate dean for education, or the equivalent
14 position, as a representative from each school of medicine,
15 nursing, public health, or allied health to provide advice on
16 the development, implementation, and measurement of core
17 competencies for patient safety to be considered for
18 incorporation in the educational programs of the universities
19 of this state.
20 (6) ORGANIZATION; MEETINGS.--
21 (a) The Agency for Health Care Administration shall
22 assist the corporation in its organizational activities
23 required under chapter 617, including, but not limited to:
24 1. Eliciting appointments for the initial board of
25 directors.
26 2. Convening the first meeting of the board of
27 directors and assisting with other meetings of the board of
28 directors, upon the request of the board of directors, during
29 the first year of operation of the corporation.
30 3. Drafting articles of incorporation for the board of
31 directors and, upon the request of the board of directors,
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1 delivering articles of incorporation to the Department of
2 State for filing.
3 4. Drafting proposed bylaws for the corporation.
4 5. Paying fees related to incorporation.
5 6. Providing office space and administrative support,
6 at the request of the board of directors, but not beyond July
7 1, 2005.
8 (b) The board of directors must conduct its first
9 meeting no later than August 1, 2004, and shall meet
10 thereafter as frequently as necessary to carry out the duties
11 of the corporation.
12 (7) POWERS AND DUTIES.--In addition to the powers and
13 duties prescribed in chapter 617 and the articles and bylaws
14 adopted under that chapter, the corporation shall directly or
15 through contract:
16 (a) Secure staff necessary to properly administer the
17 corporation.
18 (b) Collect, analyze, and evaluate patient safety
19 data, quality and patient safety indicators, medical
20 malpractice closed claims, and adverse incidents reported to
21 the Agency for Health Care Administration and the Department
22 of Health for the purpose of recommending changes in practices
23 and procedures which may be implemented by health care
24 practitioners and health care facilities to improve the
25 quality of health care and to prevent future adverse
26 incidents. Notwithstanding any other law, the Agency for
27 Health Care Administration and the Department of Health shall
28 make available to the corporation any adverse incident report
29 submitted under s. 395.0197, s. 458.351, or s. 459.026. To the
30 extent that adverse incident reports submitted under s.
31 395.0197 are confidential and exempt from disclosure, the
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1 confidential and exempt status of such reports must be
2 maintained by the corporation.
3 (c) Maintain an active library of best practices
4 relating to patient safety and patient safety literature,
5 along with the emerging evidence supporting the retention or
6 modification of such practices, and make this information
7 available to health care practitioners, health care
8 facilities, and the public.
9 (d) Assess the patient safety culture at volunteering
10 hospitals and recommend methods to improve the working
11 environment related to patient safety at these hospitals.
12 (e) Inventory the information technology capabilities
13 related to patient safety of health care facilities and health
14 care practitioners and recommend a plan for expediting
15 implementation of safety technologies statewide.
16 (f) Facilitate the development of core competencies
17 relevant to patient safety which can be made available to be
18 considered for incorporation into the undergraduate and
19 graduate curriculums in schools of medicine, nursing, and
20 allied health in this state.
21 (g) Facilitate continuing professional education
22 regarding patient safety for practicing health care
23 practitioners.
24 (h) Study and facilitate the testing of alternative
25 systems of encouraging the implementation of effective risk
26 management strategies and clinical best practices, and of
27 compensating injured patients as a means of reducing and
28 preventing medical errors and promoting patient safety.
29 (i) Develop programs to educate the public about the
30 role of health care consumers in promoting patient safety.
31
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1 (j) Provide interagency coordination of patient safety
2 efforts in this state.
3 (k) Conduct other activities identified by the board
4 of directors to promote patient safety in this state.
5 (8) ANNUAL REPORT.--By December 1, 2004, the
6 corporation shall prepare a report on the start-up activities
7 of the corporation and any proposals for legislative action
8 needed to enable the corporation to fulfill its purposes under
9 this section. By December 1 of each year thereafter, the
10 corporation shall prepare a report for the preceding fiscal
11 year. The report, at a minimum, must include:
12 (a) A description of the activities of the corporation
13 under this section.
14 (b) Progress made in improving patient safety and
15 reducing medical errors.
16 (c) A compliance and financial audit of the accounts
17 and records of the corporation at the end of the preceding
18 fiscal year conducted by an independent certified public
19 accountant.
20 (d) An assessment of the ability of the corporation to
21 fulfill the duties specified in subsection (7) and the
22 appropriateness of those duties for the corporation.
23 (e) Recommendations for legislative action needed to
24 improve patient safety in this state.
25
26 The corporation shall submit the report to the Governor, the
27 President of the Senate, and the Speaker of the House of
28 Representatives.
29 (9) PERFORMANCE EXPECTATIONS.--The Office of Program
30 Policy Analysis and Government Accountability, in consultation
31 with the Agency for Health Care Administration, the Department
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1 of Health, and the corporation, shall develop performance
2 standards by which to measure the success of the corporation
3 in organizing to fulfill and beginning to implement the
4 purposes and duties established in this section. The Office of
5 Program Policy Analysis and Government Accountability shall
6 conduct a performance audit of the corporation during 2006,
7 using the performance standards, and shall submit a report to
8 the Governor, the President of the Senate, and the Speaker of
9 the House of Representatives by January 1, 2007.
10 Section 17. The Patient Safety Center at the Florida
11 State University College of Medicine, in collaboration with
12 researchers at other state universities, shall conduct a study
13 to analyze the return on investment that hospitals in this
14 state could realize from implementing computerized physician
15 order entry and other information technologies related to
16 patient safety. For the purposes of this analysis, the return
17 on investment shall include both financial results and
18 benefits relating to quality of care and patient safety. The
19 study must include a representative sample of large and small
20 hospitals, located in urban and rural areas, in the north,
21 central, and southern regions of the state. By February 1,
22 2005, the Patient Safety Center at the Florida State
23 University College of Medicine must submit a report to the
24 Governor, the President of the Senate, and the Speaker of the
25 House of Representatives concerning the results of the study.
26 Section 18. Section 395.1012, Florida Statutes, is
27 amended to read:
28 395.1012 Patient safety.--
29 (1) Each licensed facility must adopt a patient safety
30 plan. A plan adopted to implement the requirements of 42
31
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1 C.F.R. part 482.21 shall be deemed to comply with this
2 requirement.
3 (2) Each licensed facility shall appoint a patient
4 safety officer and a patient safety committee, which shall
5 include at least one person who is neither employed by nor
6 practicing in the facility, for the purpose of promoting the
7 health and safety of patients, reviewing and evaluating the
8 quality of patient safety measures used by the facility,
9 recommending improvements in the patient safety measures used
10 by the facility, and assisting in the implementation of the
11 facility patient safety plan.
12 (3) Each licensed facility shall adopt a plan to
13 reduce medication errors and adverse drug events, which must
14 consider the use of computerized physician order entry and
15 other information technologies related to patient safety.
16 Section 19. Subsection (3) of section 409.91255,
17 Florida Statutes, is amended to read:
18 409.91255 Federally qualified health center access
19 program.--
20 (3) ASSISTANCE TO FEDERALLY QUALIFIED HEALTH
21 CENTERS.--The Department of Health shall develop a program for
22 the expansion of federally qualified health centers for the
23 purpose of providing comprehensive primary and preventive
24 health care and urgent care services, including services that
25 may reduce the morbidity, mortality, and cost of care among
26 the uninsured population of the state. The program shall
27 provide for distribution of financial assistance to federally
28 qualified health centers that apply and demonstrate a need for
29 such assistance in order to sustain or expand the delivery of
30 primary and preventive health care services. In selecting
31 centers to receive this financial assistance, the program:
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1 (a) Shall give preference to communities that have few
2 or no community-based primary care services or in which the
3 current services are unable to meet the community's needs.
4 (b) Shall require that primary care services be
5 provided to the medically indigent using a sliding fee
6 schedule based on income.
7 (c) Shall allow innovative and creative uses of
8 federal, state, and local health care resources.
9 (d) Shall require that the funds provided be used to
10 pay for operating costs of a projected expansion in patient
11 caseloads or services or for capital improvement projects.
12 Capital improvement projects may include renovations to
13 existing facilities or construction of new facilities,
14 provided that an expansion in patient caseloads or services to
15 a new patient population will occur as a result of the capital
16 expenditures. The department shall include in its standard
17 contract document a requirement that any state funds provided
18 for the purchase of or improvements to real property are
19 contingent upon the contractor granting to the state a
20 security interest in the property at least to the amount of
21 the state funds provided for at least 5 years from the date of
22 purchase or the completion of the improvements or as further
23 required by law. The contract must include a provision that,
24 as a condition of receipt of state funding for this purpose,
25 the contractor agrees that, if it disposes of the property
26 before the department's interest is vacated, the contractor
27 will refund the proportionate share of the state's initial
28 investment, as adjusted by depreciation.
29 (e) May require in-kind support from other sources.
30
31
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1 (f) May encourage coordination among federally
2 qualified health centers, other private-sector providers, and
3 publicly supported programs.
4 (g) Shall allow the development of community emergency
5 room diversion programs in conjunction with local resources,
6 providing extended hours of operation to urgent care patients.
7 Diversion programs shall include case management for emergency
8 room followup care.
9 Section 20. Paragraph (a) of subsection (6) of section
10 627.410, Florida Statutes, is amended to read:
11 627.410 Filing, approval of forms.--
12 (6)(a) An insurer shall not deliver or issue for
13 delivery or renew in this state any health insurance policy
14 form until it has filed with the office a copy of every
15 applicable rating manual, rating schedule, change in rating
16 manual, and change in rating schedule; if rating manuals and
17 rating schedules are not applicable, the insurer must file
18 with the office order applicable premium rates and any change
19 in applicable premium rates. This paragraph does not apply to
20 group health insurance policies, effectuated and delivered in
21 this state, insuring groups of 26 51 or more persons, except
22 for Medicare supplement insurance, long-term care insurance,
23 and any coverage under which the increase in claim costs over
24 the lifetime of the contract due to advancing age or duration
25 is prefunded in the premium.
26 Section 21. Section 624.6405, Florida Statutes, is
27 created to read:
28 624.6405 Decrease in inappropriate utilization of
29 emergency care.--
30 (1) The Legislature finds and declares it to be of
31 vital importance that emergency services and care be provided
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1 by hospitals and physicians to every person in need of such
2 care, but with the double-digit increases in health insurance
3 premiums, health care providers and insurers should encourage
4 patients and the insured to assume responsibility for their
5 treatment, including emergency care. The Legislature finds
6 that inappropriate utilization of emergency department
7 services increases the overall cost of providing health care
8 and these costs are ultimately borne by the hospital, the
9 insured patients, and, many times, by the taxpayers of this
10 state. Finally, the Legislature declares that the providers
11 and insurers must share the responsibility of providing
12 alternative treatment options to urgent care patients outside
13 of the emergency department. Therefore, it is the intent of
14 the Legislature to place the obligation for educating
15 consumers and creating mechanisms for delivery of care that
16 will decrease the overutilization of emergency service on
17 health insurers and providers.
18 (2) Health insurers shall provide on their websites
19 information regarding appropriate utilization of emergency
20 care services which shall include, but not be limited to, a
21 list of alternative urgent care contracted providers, the
22 types of services offered by these providers, and what to do
23 in the event of a true emergency.
24 (3) Health insurers shall develop community emergency
25 department diversion programs. Such programs may include, but
26 not be limited to, enlisting providers to be on call to
27 insurers after hours, coordinating care through local
28 community resources, and incentives to providers for case
29 management.
30 (4) As a disincentive for insureds to inappropriately
31 use emergency department services, health insurers may require
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1 higher copayments for nonemergency use of emergency
2 departments and higher copayments for use of out-of-network
3 emergency departments. For the purposes of this section, the
4 term "emergency care" has the same meaning as provided in s.
5 395.002, and shall include services provided to rule out an
6 emergency medical condition.
7 Section 22. Paragraph (b) of subsection (3) of section
8 627.6487, Florida Statutes, is amended to read:
9 627.6487 Guaranteed availability of individual health
10 insurance coverage to eligible individuals.--
11 (3) For the purposes of this section, the term
12 "eligible individual" means an individual:
13 (b) Who is not eligible for coverage under:
14 1. A group health plan, as defined in s. 2791 of the
15 Public Health Service Act;
16 2. A conversion policy or contract issued by an
17 authorized insurer or health maintenance organization under s.
18 627.6675 or s. 641.3921, respectively, offered to an
19 individual who is no longer eligible for coverage under either
20 an insured or self-insured employer plan;
21 3. Part A or part B of Title XVIII of the Social
22 Security Act; or
23 4. A state plan under Title XIX of such act, or any
24 successor program, and does not have other health insurance
25 coverage; or
26 5. The Florida Health Insurance Plan as specified in
27 s. 627.64872 and such plan is accepting new enrollment;
28 Section 23. Effective upon this act becoming a law,
29 section 627.64872, Florida Statutes, is created to read:
30 627.64872 Florida Health Insurance Plan.--
31
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1 (1) LEGISLATIVE INTENT; FLORIDA HEALTH INSURANCE
2 PLAN.--
3 (a) The Legislature recognizes that to secure a more
4 stable and orderly health insurance market, the establishment
5 of a plan to assume risks deemed uninsurable by the private
6 marketplace is required.
7 (b) The Florida Health Insurance Plan is created to
8 make coverage available to individuals who have no other
9 option for similar coverage, at a premium that is commensurate
10 with the risk and benefits provided, and with benefit designs
11 that are reasonable in relation to the general market. While
12 plan operations may include supplementary funding, the plan
13 shall fundamentally operate on sound actuarial principles,
14 using basic insurance management techniques to ensure that the
15 plan is run in an economical, cost-efficient, and sound
16 manner, conserving plan resources to serve the maximum number
17 of people possible in a sustainable fashion.
18 (2) DEFINITIONS.--As used in this section:
19 (a) "Board" means the board of directors of the plan.
20 (b) "Commission" means the Financial Services
21 Commission.
22 (c) "Dependent" means a resident spouse or resident
23 unmarried child under the age of 19 years, a child who is a
24 student under the age of 25 years and who is financially
25 dependent upon the parent, or a child of any age who is
26 disabled and dependent upon the parent.
27 (d) "Director" means the director of the Office of
28 Insurance Regulation.
29 (e) "Health insurance" means any hospital or medical
30 expense incurred policy pursuant to this chapter or health
31 maintenance organization subscriber contract pursuant to
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1 chapter 641. The term does not include short term, accident,
2 dental-only, vision-only, fixed indemnity, limited benefit,
3 credit, or disability income insurance; coverage for onsite
4 medical clinics; insurance coverage specified in federal
5 regulations issued pursuant to Pub. L. No. 104-191, under
6 which benefits for medical care are secondary or incidental to
7 other insurance benefits; benefits for long-term care, nursing
8 home care, home health care, community-based care, or any
9 combination thereof, or other similar, limited benefits
10 specified in federal regulations issued pursuant to Pub. L.
11 No. 104-191; benefits provided under a separate policy,
12 certificate, or contract of insurance where there is no
13 coordination between the provision of the benefits and any
14 exclusion of benefits under any group health plan maintained
15 by the same plan sponsor, and the benefits are paid with
16 respect to an event without regard to whether benefits are
17 provided with respect to such an event under any group health
18 plan maintained by the same plan sponsor, such as for coverage
19 only for a specified disease or illness; hospital indemnity or
20 other fixed indemnity insurance; coverage offered as a
21 separate policy, certificate, or contract of insurance, such
22 as Medicare supplemental health insurance as defined under s.
23 1882(g)(1) of the Social Security Act; coverage supplemental
24 to the coverage provided under Chapter 55 of Title 10, United
25 States Code (Civilian Health and Medical Program of the
26 Uniformed Services (CHAMPUS)); similar supplemental coverage
27 provided to coverage under a group health plan; coverage
28 issued as a supplement to liability insurance; insurance
29 arising out of a workers' compensation or similar law;
30 automobile medical-payment insurance; or insurance under which
31 benefits are payable with or without regard to fault and which
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1 is statutorily required to be contained in any liability
2 insurance policy or equivalent self-insurance.
3 (f) "Implementation" means the effective date on which
4 the board is established.
5 (g) "Insurer" means any entity that provides health
6 insurance in this state. For purposes of this section, insurer
7 includes an insurance company with a valid certificate in
8 accordance with chapter 624, a health maintenance organization
9 with a valid certificate of authority in accordance with part
10 I or part III of chapter 641, a prepaid health clinic
11 authorized to transact business in this state pursuant to part
12 II of chapter 641, multiple employer welfare arrangements
13 authorized to transact business in this state pursuant to ss.
14 624.436-624.45, or a fraternal benefit society providing
15 health benefits to its members as authorized pursuant to
16 chapter 632.
17 (h) "Medicare" means coverage under both Parts A and B
18 of Title XVIII of the Social Security Act, 42 USC 1395 et
19 seq., as amended.
20 (i) "Medicaid" means coverage under Title XIX of the
21 Social Security Act.
22 (j) "Office" means the Office of Insurance Regulation
23 of the Financial Services Commission.
24 (k) "Participating insurer" means any insurer
25 providing health insurance to citizens of this state.
26 (l) "Provider" means any physician, hospital, or other
27 institution, organization, or person that furnishes health
28 care services and is licensed or otherwise authorized to
29 practice in the state.
30 (m) "Plan" means the Florida Health Insurance Plan
31 created in subsection (1).
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1 (n) "Plan of operation" means the articles, bylaws,
2 and operating rules and procedures adopted by the board
3 pursuant to this section.
4 (o) "Resident" means an individual who has been
5 legally domiciled in this state for a period of at least 6
6 months with exception of residents deemed eligible under the
7 federal Health Insurance Portability and Accountability Act of
8 1996.
9 (3) BOARD OF DIRECTORS.--
10 (a) The plan shall operate subject to the supervision
11 and control of the board. The board shall consist of the
12 director or his or her designated representative, who shall
13 serve as a member of the board and shall be its chair, and an
14 additional eight members, five of whom shall be appointed by
15 the Governor, at least three of whom shall be individuals not
16 representative of insurers or health care providers, one of
17 whom shall be appointed by the Chief Financial Officer, one of
18 whom shall be appointed by the President of the Senate, and
19 one of whom shall be appointed by the Speaker of the House of
20 Representatives.
21 (b) The initial board members shall be appointed as
22 follows: one-third of the members to serve a term of 2 years;
23 one-third of the members to serve a term of 4 years; and
24 one-third of the members to serve a term of 6 years.
25 Subsequent board members shall serve for a term of 3 years. A
26 board member's term shall continue until his or her successor
27 is appointed.
28 (c) Vacancies in the board shall be filled by the
29 appointing authority, such authority being the Governor, the
30 Chief Financial Officer, the President of the Senate, or the
31
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1 Speaker of the House of Representatives. Board members may be
2 removed by the appointing authority for cause.
3 (d) The board shall conduct its first meeting by
4 September 1, 2004.
5 (e) Members shall not be compensated in their capacity
6 as board members but shall be reimbursed for reasonable
7 expenses incurred in the necessary performance of their duties
8 in accordance with s. 112.061.
9 (f) The board shall submit to the commission a plan of
10 operation for the plan and any amendments thereto necessary or
11 suitable to ensure the fair, reasonable, and equitable
12 administration of the plan. The plan of operation shall ensure
13 that the plan qualifies to apply for any available funding
14 from the Federal Government that adds to the financial
15 viability of the plan. The plan of operation shall become
16 effective upon approval in writing by the commission
17 consistent with the date on which the coverage under this
18 section must be made available. If the board fails to submit a
19 suitable plan of operation within 1 year after the appointment
20 of the board of directors, or at any time thereafter fails to
21 submit suitable amendments to the plan of operation, the
22 commission shall adopt such rules as are necessary or
23 advisable to effectuate the provisions of this section. Such
24 rules shall continue in force until modified by the office or
25 superseded by a plan of operation submitted by the board and
26 approved by the commission.
27 (g) The board shall take no action to implement the
28 plan, other than the completion of the actuarial study
29 authorized in subsection (6), until funds are appropriated for
30 start-up costs and any projected deficits.
31 (4) PLAN OF OPERATION.--The plan of operation shall:
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1 (a) Establish procedures for operation of the plan.
2 (b) Establish procedures for selecting an
3 administrator in accordance with subsection (11).
4 (c) Establish procedures to create a fund, under
5 management of the board, for administrative expenses.
6 (d) Establish procedures for the handling, accounting,
7 and auditing of assets, moneys, and claims of the plan and the
8 plan administrator.
9 (e) Develop and implement a program to publicize the
10 existence of the plan, plan eligibility requirements, and
11 procedures for enrollment and maintain public awareness of the
12 plan.
13 (f) Establish procedures under which applicants and
14 participants may have grievances reviewed by a grievance
15 committee appointed by the board. The grievances shall be
16 reported to the board after completion of the review, with the
17 committee's recommendation for grievance resolution. The board
18 shall retain all written grievances regarding the plan for at
19 least 3 years.
20 (g) Provide for other matters as may be necessary and
21 proper for the execution of the board's powers, duties, and
22 obligations under this section.
23 (5) POWERS OF THE PLAN.--The plan shall have the
24 general powers and authority granted under the laws of this
25 state to health insurers and, in addition thereto, the
26 specific authority to:
27 (a) Enter into such contracts as are necessary or
28 proper to carry out the provisions and purposes of this
29 section, including the authority, with the approval of the
30 commission, to enter into contracts with similar plans of
31 other states for the joint performance of common
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1 administrative functions, or with persons or other
2 organizations for the performance of administrative functions.
3 (b) Take any legal actions necessary or proper to
4 recover or collect assessments due the plan.
5 (c) Take such legal action as is necessary to:
6 1. Avoid payment of improper claims against the plan
7 or the coverage provided by or through the plan;
8 2. Recover any amounts erroneously or improperly paid
9 by the plan;
10 3. Recover any amounts paid by the plan as a result of
11 mistake of fact or law; or
12 4. Recover other amounts due the plan.
13 (d) Establish, and modify as appropriate, rates, rate
14 schedules, rate adjustments, expense allowances, agents'
15 commissions, claims reserve formulas, and any other actuarial
16 functions appropriate to the operation of the plan. Rates and
17 rate schedules may be adjusted for appropriate factors such as
18 age, sex, and geographic variation in claim cost and shall
19 take into consideration appropriate factors in accordance with
20 established actuarial and underwriting practices. For purposes
21 of this paragraph, usual and customary agent's commissions
22 shall be paid for the initial placement of coverage with the
23 plan and for one renewal only.
24 (e) Issue policies of insurance in accordance with the
25 requirements of this section.
26 (f) Appoint appropriate legal, actuarial, investment,
27 and other committees as necessary to provide technical
28 assistance in the operation of the plan and develop and
29 educate its policyholders regarding health savings accounts,
30 policy and contract design, and any other function within the
31 authority of the plan.
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1 (g) Borrow money to effectuate the purposes of the
2 plan. Any notes or other evidence of indebtedness of the plan
3 not in default shall be legal investments for insurers and may
4 be carried as admitted assets.
5 (h) Employ and fix the compensation of employees.
6 (i) Prepare and distribute certificate of eligibility
7 forms and enrollment instruction forms to insurance producers
8 and to the general public.
9 (j) Provide for reinsurance of risks incurred by the
10 plan.
11 (k) Provide for and employ cost-containment measures
12 and requirements, including, but not limited to, preadmission
13 screening, second surgical opinion, concurrent utilization
14 review, and individual case management for the purpose of
15 making the plan more cost-effective.
16 (l) Design, use, contract, or otherwise arrange for
17 the delivery of cost-effective health care services,
18 including, but not limited to, establishing or contracting
19 with preferred provider organizations, health maintenance
20 organizations, and other limited network provider
21 arrangements.
22 (m) Adopt such bylaws, policies, and procedures as may
23 be necessary or convenient for the implementation of this
24 section and the operation of the plan.
25 (6)(a) Interim report.--No later than December 1,
26 2004, the board shall submit to the Governor, the President of
27 the Senate, and the Speaker of the House of Representatives an
28 actuarial study to determine, including, but not limited to:
29 1. The impact the creation of this plan will have on
30 the small group insurance market, specifically on the premiums
31 paid by insureds. This shall include an estimate of the total
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1 anticipated aggregate savings for all small employers in the
2 state.
3 2. The number of individuals the pool could reasonably
4 cover at various funding levels.
5 3. A recommendation as to the best source of funding
6 for the anticipated deficits of the pool.
7 (b) Annual report.--No later than December 1, 2005,
8 and annually thereafter, the board shall submit to the
9 Governor, the President of the Senate, the Speaker of the
10 House of Representatives, and the substantive legislative
11 committees of the Legislature a report which includes an
12 independent actuarial study to determine, including, but not
13 be limited to:
14 1. The impact the creation of the plan has on the
15 small group and individual insurance market, specifically on
16 the premiums paid by insureds. This shall include an estimate
17 of the total anticipated aggregate savings for all small
18 employers in the state.
19 2. The actual number of individuals covered at the
20 current funding and benefit level, the projected number of
21 individuals that may seek coverage in the forthcoming fiscal
22 year, and the projected funding needed to cover anticipated
23 increase or decrease in plan participation.
24 3. A recommendation as to the best source of funding
25 for the anticipated deficits of the pool.
26 4. A summarization of the activities of the plan in
27 the preceding calendar year, including the net written and
28 earned premiums, plan enrollment, the expense of
29 administration, and the paid and incurred losses.
30 5. A review of the operation of the plan as to whether
31 the plan has met the intent of this section.
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1 (7) LIABILITY OF THE PLAN.--Neither the board nor its
2 employees shall be liable for any obligations of the plan. No
3 member or employee of the board shall be liable, and no cause
4 of action of any nature may arise against a member or employee
5 of the board, for any act or omission related to the
6 performance of any powers and duties under this section,
7 unless such act or omission constitutes willful or wanton
8 misconduct. The board may provide in its bylaws or rules for
9 indemnification of, and legal representation for, its members
10 and employees.
11 (8) AUDITED FINANCIAL STATEMENT.--No later than June 1
12 following the close of each calendar year, the plan shall
13 submit to the Governor an audited financial statement prepared
14 in accordance with statutory accounting principles as adopted
15 by the National Association of Insurance Commissioners.
16 (9) ELIGIBILITY.--
17 (a) Any individual person who is and continues to be a
18 resident of this state shall be eligible for coverage under
19 the plan if:
20 1. Evidence is provided that the person received at
21 least two notices of rejection or refusal to issue
22 substantially similar insurance for health reasons by one
23 insurer. A rejection or refusal by an insurer offering only
24 stoploss, excess of loss, or reinsurance coverage with respect
25 to the applicant shall not be sufficient evidence under this
26 paragraph; or
27 2. The person is enrolled in the Florida Comprehensive
28 Health Association as of the date the plan is implemented.
29 (b) Each resident dependent of a person who is
30 eligible for coverage under the plan shall also be eligible
31 for such coverage.
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1 (c) A person shall not be eligible for coverage under
2 the plan if:
3 1. The person has or obtains health insurance coverage
4 substantially similar to or more comprehensive than a plan
5 policy, or would be eligible to obtain such coverage, unless a
6 person may maintain other coverage for the period of time the
7 person is satisfying any preexisting condition waiting period
8 under a plan policy or may main tain plan coverage for the
9 period of time the person is satisfying a preexisting
10 condition waiting period under another health insurance policy
11 intended to replace the plan policy;
12 2. The person is determined to be eligible for health
13 care benefits under Medicaid, Medicare, the state's children's
14 health insurance program, or any other federal, state, or
15 local government program that provides health benefits;
16 3. The person voluntarily terminated plan coverage
17 unless 12 months have elapsed since such termination;
18 4. The person is an inmate or resident of a public
19 institution; or
20 5. The person's premiums are paid for or reimbursed
21 under any government-sponsored program or by any government
22 agency or health care provider.
23 (d) Coverage shall cease:
24 1. On the date a person is no longer a resident of
25 this state;
26 2. On the date a person requests coverage to end;
27 3. Upon the death of the covered person;
28 4. On the date state law requires cancellation or
29 nonrenewal of the policy;
30
31
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1 5. At the option of the plan, 30 days after the plan
2 makes any inquiry concerning the person's eligibility or place
3 of residence to which the person does not reply; or
4 6. Upon failure of the insured to pay for continued
5 coverage.
6 (e) Except under the circumstances described in this
7 subsection, coverage of a person who ceased to meet the
8 eligibility requirements of this subsection shall be
9 terminated at the end of the policy period for which the
10 necessary premiums have been paid.
11 (10) UNFAIR REFERRAL TO PLAN.--It is an unfair trade
12 practice for the purposes of part IX of chapter 626 or s.
13 641.3901 for an insurer, health maintenance organization
14 insurance agent, insurance broker, or third-party
15 administrator to refer an individual employee to the plan, or
16 arrange for an individual employee to apply to the plan, for
17 the purpose of separating that employee from group health
18 insurance coverage provided in connection with the employee's
19 employment.
20 (11) PLAN ADMINISTRATOR.--The board shall select
21 through a competitive bidding process a plan administrator to
22 administer the plan. The board shall evaluate bids submitted
23 based on criteria established by the board, which shall
24 include:
25 (a) The plan administrator's proven ability to handle
26 health insurance coverage to individuals.
27 (b) The efficiency and timeliness of the plan
28 administrator's claim processing procedures.
29 (c) An estimate of total charges for administering the
30 plan.
31
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1 (d) The plan administrator's ability to apply
2 effective cost-containment programs and procedures and to
3 administer the plan in a cost-efficient manner.
4 (e) The financial condition and stability of the plan
5 administrator.
6
7 The administrator shall be an insurer, a health maintenance
8 organization, or a third-party administrator, or another
9 organization duly authorized to provide insurance pursuant to
10 the Florida Insurance Code.
11 (12) ADMINISTRATOR TERM LIMITS.--The plan
12 administrator shall serve for a period specified in the
13 contract between the plan and the plan administrator subject
14 to removal for cause and subject to any terms, conditions, and
15 limitations of the contract between the plan and the plan
16 administrator. At least 1 year prior to the expiration of each
17 period of service by a plan administrator, the board shall
18 invite eligible entities, including the current plan
19 administrator, to submit bids to serve as the plan
20 administrator. Selection of the plan administrator for each
21 succeeding period shall be made at least 6 months prior to the
22 end of the current period.
23 (13) DUTIES OF THE PLAN ADMINISTRATOR.--
24 (a) The plan administrator shall perform such
25 functions relating to the plan as may be assigned to it,
26 including, but not limited to:
27 1. Determination of eligibility.
28 2. Payment of claims.
29 3. Establishment of a premium billing procedure for
30 collection of premiums from persons covered under the plan.
31
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1 4. Other necessary functions to ensure timely payment
2 of benefits to covered persons under the plan.
3 (b) The plan administrator shall submit regular
4 reports to the board regarding the operation of the plan. The
5 frequency, content, and form of the reports shall be specified
6 in the contract between the board and the plan administrator.
7 (c) On March 1 following the close of each calendar
8 year, the plan administrator shall determine net written and
9 earned premiums, the expense of administration, and the paid
10 and incurred losses for the year and report this information
11 to the board and the Governor on a form prescribed by the
12 Governor.
13 (14) PAYMENT OF THE PLAN ADMINISTRATOR.--The plan
14 administrator shall be paid as provided in the contract
15 between the plan and the plan administrator.
16 (15) FUNDING OF THE PLAN.--
17 (a) Premiums.--
18 1. The plan shall establish premium rates for plan
19 coverage as provided in this section. Separate schedules of
20 premium rates based on age, sex, and geographical location may
21 apply for individual risks. Premium rates and schedules shall
22 be submitted to the office for approval prior to use.
23 2. Initial rates for plan coverage shall be limited to
24 200 percent of rates established as applicable for individual
25 standard risks as specified in s. 627.6675(3)(c). Subject to
26 the limits provided in this paragraph, subsequent rates shall
27 be established to provide fully for the expected costs of
28 claims, including recovery of prior losses, expenses of
29 operation, investment income of claim reserves, and any other
30 cost factors subject to the limitations described herein, but
31 in no event shall premiums exceed the 200-percent rate
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1 limitation provided in this section. Notwithstanding the
2 200-percent rate limitation, sliding scale premium surcharges
3 based upon the insured's income may apply to all enrollees
4 except those obtaining coverage in accordance with s.
5 627.6487, provided that such premiums do not exceed 300
6 percent of the standard risk rate.
7 (b) Sources of additional revenue.--Any deficit
8 incurred by the plan shall be primarily funded through amounts
9 appropriated by the Legislature from general revenue sources,
10 including, but not limited to, a portion of the annual growth
11 in existing net insurance premium taxes. The board shall
12 operate the plan in such a manner that the estimated cost of
13 providing health insurance during any fiscal year will not
14 exceed total income the plan expects to receive from policy
15 premiums and funds appropriated by the Legislature, including
16 any interest on investments. After determining the amount of
17 funds appropriated to the board for a fiscal year, the board
18 shall estimate the number of new policies it believes the plan
19 has the financial capacity to insure during that year so that
20 costs do not exceed income. The board shall take steps
21 necessary to ensure that plan enrollment does not exceed the
22 number of residents it has estimated it has the financial
23 capacity to insure.
24 (16) BENEFITS.--
25 (a) The benefits provided shall be the same as the
26 standard and basic plans for small employers as outlined in s.
27 627.6699. The board shall also establish an option of
28 alternative coverage such as catastrophic coverage that
29 includes a minimum level of primary care coverage and a high
30 deductible plan that meets the federal requirements of a
31 health savings account.
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1 (b) In establishing the plan coverage, the board shall
2 take into consideration the levels of health insurance
3 provided in the state and such medical economic factors as may
4 be deemed appropriate and adopt benefit levels, deductibles,
5 copayments, coinsurance factors, exclusions, and limitations
6 determined to be generally reflective of and commensurate with
7 health insurance provided through a representative number of
8 large employers in the state.
9 (c) The board may adjust any deductibles and
10 coinsurance factors annually according to the medical
11 component of the Consumer Price Index.
12 (d)1. Plan coverage shall exclude charges or expenses
13 incurred during the first 6 months following the effective
14 date of coverage for any condition for which medical advice,
15 care, or treatment was recommended or received for such
16 condition during the 6-month period immediately preceding the
17 effective date of coverage.
18 2. Such preexisting condition exclusions shall be
19 waived to the extent that similar exclusions, if any, have
20 been satisfied under any prior health insurance coverage which
21 was involuntarily terminated, provided application for pool
22 coverage is made not later than 63 days following such
23 involuntary termination. In such case, coverage under the plan
24 shall be effective from the date on which such prior coverage
25 was terminated and the applicant is not eligible for
26 continuation or conversion rights that would provide coverage
27 substantially similar to plan coverage.
28 (17) NONDUPLICATION OF BENEFITS.--
29 (a) The plan shall be payor of last resort of benefits
30 whenever any other benefit or source of third-party payment is
31 available. Benefits otherwise payable under plan coverage
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1 shall be reduced by all amounts paid or payable through any
2 other health insurance, by all hospital and medical expense
3 benefits paid or payable under any workers' compensation
4 coverage, automobile medical payment, or liability insurance,
5 whether provided on the basis of fault or nonfault, and by any
6 hospital or medical benefits paid or payable under or provided
7 pursuant to any state or federal law or program.
8 (b) The plan shall have a cause of action against an
9 eligible person for the recovery of the amount of benefits
10 paid that are not for covered expenses. Benefits due from the
11 plan may be reduced or refused as a setoff against any amount
12 recoverable under this paragraph.
13 (18) ANNUAL AND MAXIMUM BENEFITS.--Maximum benefits
14 under the plan shall be determined by the board.
15 (19) TAXATION.--The plan is exempt from any tax
16 imposed by this state. The plan shall apply for federal tax
17 exemption status.
18 (20) COMBINING MEMBERSHIP OF THE FLORIDA COMPREHENSIVE
19 HEALTH ASSOCIATION.--
20 (a)1. Upon implementation of the plan, the Florida
21 Comprehensive Health Association is abolished and all
22 high-risk individuals actively enrolled in the Florida
23 Comprehensive Health Association shall be enrolled in the plan
24 subject to its rules and requirements.
25 2. Persons formerly enrolled in the Florida
26 Comprehensive Health Association are only eligible for the
27 benefits authorized under subsection (18). Maximum lifetime
28 benefits paid to an individual in the plan shall not exceed
29 the amount established under subsection (18), and benefits
30 previously paid for any individual by the Florida
31
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1 Comprehensive Health Association shall be used in determining
2 the total lifetime benefits paid under the plan.
3 3. Except as otherwise provided in this section, the
4 Florida Comprehensive Health Association shall operate under
5 the existing plan of operation without modification until the
6 adoption of the new plan of operation for the Florida Health
7 Insurance Plan.
8 (b)1. As a condition of doing business in this state,
9 an insurer shall pay an assessment to the board in the amount
10 prescribed by this paragraph. For operating losses incurred on
11 or after July 1, 2004, by persons previously enrolled in the
12 Florida Comprehensive Health Association, each insurer shall
13 annually be assessed by the board in the following calendar
14 year a portion of such incurred operating losses of the plan.
15 Such portion shall be determined by multiplying such operating
16 losses by a fraction, the numerator of which equals the
17 insurer's earned premium pertaining to direct writings of
18 health insurance in the state during the calendar year
19 proceeding that for which the assessment is levied, and the
20 denominator of which equals the total of all such premiums
21 earned by participating insurers in the state during such
22 calendar year.
23 2. The total of all assessments under this paragraph
24 upon a participating insurer shall not exceed 1 percent of
25 such insurer's health insurance premium earned in this state
26 during the calendar year preceding the year for which the
27 assessments were levied.
28 3. All rights, title, and interest in the assessment
29 funds collected under this paragraph shall vest in this state.
30 However, all of such funds and interest earned shall be used
31 by the plan to pay claims and administrative expenses.
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1 (c) If assessments and other receipts by the plan,
2 board, or plan administrator exceed the actual losses and
3 administrative expenses of the plan, the excess shall be held
4 in interest and used by the board to offset future losses. As
5 used in this subsection, the term "future losses" includes
6 reserves for claims incurred but not reported.
7 (d) Each insurer's assessment shall be determined
8 annually by the board or plan administrator based on annual
9 statements and other reports deemed necessary by the board or
10 plan administrator and filed with the board or plan
11 administrator by the insurer. Any deficit incurred under the
12 plan by persons previously enrolled in the Florida
13 Comprehensive Health Association shall be recouped by the
14 assessments against participating insurers by the board or
15 plan administrator in the manner provided in paragraph (b),
16 and the insurers may recover the assessment in the normal
17 course of their respective businesses without time limitation.
18 (e) If a person enrolled in the Florida Comprehensive
19 Health Association as of July 1, 2004, loses eligibility for
20 participation in the plan, such person shall not be included
21 in the calculation of incurred operational losses as described
22 in paragraph (b) if the person later regains eligibility for
23 participation in the plan.
24 (f) After all persons enrolled in the Florida
25 Comprehensive Health Association as of July 1, 2004, are no
26 longer eligible for participation in the plan, the plan,
27 board, or plan administrator shall no longer be allowed to
28 assess insurers in this state for incurred losses as described
29 in paragraph (b).
30 Section 24. Upon implementation, as defined in section
31 627.64872(2), Florida Statutes, and provided in section
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1 627.64872(20), Florida Statutes, of the Florida Health Benefit
2 Plan created under section 627.64872, Florida Statutes,
3 sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494,
4 627.6496, and 627.6498, Florida Statutes, are repealed.
5 Section 25. Subsections (12) and (13) are added to
6 section 627.662, Florida Statutes, to read:
7 627.662 Other provisions applicable.--The following
8 provisions apply to group health insurance, blanket health
9 insurance, and franchise health insurance:
10 (12) Section 627.6044, relating to the use of specific
11 methodology for payment of claims.
12 (13) Section 627.6405, relating to inappropriate
13 utilization of emergency care.
14 Section 26. Paragraphs (c) and (d) of subsection (5),
15 subsection (6), and subsection (12) of section 627.6699,
16 Florida Statutes, are amended, subsections (15) and (16) of
17 that section are renumbered as subsections (16) and (17),
18 respectively, present subsection (15) of that section is
19 amended, and new subsections (15) and (18) are added to that
20 section, to read:
21 627.6699 Employee Health Care Access Act.--
22 (5) AVAILABILITY OF COVERAGE.--
23 (c) Every small employer carrier must, as a condition
24 of transacting business in this state:
25 1. Offer and issue all small employer health benefit
26 plans on a guaranteed-issue basis to every eligible small
27 employer, with 2 to 50 eligible employees, that elects to be
28 covered under such plan, agrees to make the required premium
29 payments, and satisfies the other provisions of the plan. A
30 rider for additional or increased benefits may be medically
31 underwritten and may only be added to the standard health
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1 benefit plan. The increased rate charged for the additional or
2 increased benefit must be rated in accordance with this
3 section.
4 2. In the absence of enrollment availability in the
5 Florida Health Insurance Plan, offer and issue basic and
6 standard small employer health benefit plans on a
7 guaranteed-issue basis, during a 31-day open enrollment period
8 of August 1 through August 31 of each year, to every eligible
9 small employer, with fewer than two eligible employees, which
10 small employer is not formed primarily for the purpose of
11 buying health insurance and which elects to be covered under
12 such plan, agrees to make the required premium payments, and
13 satisfies the other provisions of the plan. Coverage provided
14 under this subparagraph shall begin on October 1 of the same
15 year as the date of enrollment, unless the small employer
16 carrier and the small employer agree to a different date. A
17 rider for additional or increased benefits may be medically
18 underwritten and may only be added to the standard health
19 benefit plan. The increased rate charged for the additional or
20 increased benefit must be rated in accordance with this
21 section. For purposes of this subparagraph, a person, his or
22 her spouse, and his or her dependent children constitute a
23 single eligible employee if that person and spouse are
24 employed by the same small employer and either that person or
25 his or her spouse has a normal work week of less than 25
26 hours. Any right to an open enrollment of health benefit
27 coverage for groups of fewer than two employees, pursuant to
28 this section, shall remain in full force and effect in the
29 absence of the availability of new enrollment into the Florida
30 Health Insurance Plan.
31
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1 3. This paragraph does not limit a carrier's ability
2 to offer other health benefit plans to small employers if the
3 standard and basic health benefit plans are offered and
4 rejected.
5 (d) A small employer carrier must file with the
6 office, in a format and manner prescribed by the committee, a
7 standard health care plan, a high deductible plan that meets
8 the federal requirements of a health savings account plan, and
9 a basic health care plan to be used by the carrier.
10 (6) RESTRICTIONS RELATING TO PREMIUM RATES.--
11 (a) The commission may, by rule, establish regulations
12 to administer this section and to assure that rating practices
13 used by small employer carriers are consistent with the
14 purpose of this section, including assuring that differences
15 in rates charged for health benefit plans by small employer
16 carriers are reasonable and reflect objective differences in
17 plan design, not including differences due to the nature of
18 the groups assumed to select particular health benefit plans.
19 (b) For all small employer health benefit plans that
20 are subject to this section and are issued by small employer
21 carriers to small employer groups with 2-25 eligible employees
22 on or after January 1, 1994, premium rates for health benefit
23 plans subject to this section are subject to the following:
24 1. Small employer carriers must use a modified
25 community rating methodology in which the premium for each
26 small employer must be determined solely on the basis of the
27 eligible employee's and eligible dependent's gender, age,
28 family composition, tobacco use, or geographic area as
29 determined under paragraph (5)(j) and in which the premium may
30 be adjusted as permitted by this paragraph.
31
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1 2. Rating factors related to age, gender, family
2 composition, tobacco use, or geographic location may be
3 developed by each carrier to reflect the carrier's experience.
4 The factors used by carriers are subject to office review and
5 approval.
6 3. Small employer carriers may not modify the rate for
7 a small employer for 12 months from the initial issue date or
8 renewal date, unless the composition of the group changes or
9 benefits are changed. However, a small employer carrier may
10 modify the rate one time prior to 12 months after the initial
11 issue date for a small employer who enrolls under a previously
12 issued group policy that has a common anniversary date for all
13 employers covered under the policy if:
14 a. The carrier discloses to the employer in a clear
15 and conspicuous manner the date of the first renewal and the
16 fact that the premium may increase on or after that date.
17 b. The insurer demonstrates to the office that
18 efficiencies in administration are achieved and reflected in
19 the rates charged to small employers covered under the policy.
20 4. A carrier may issue a group health insurance policy
21 to a small employer health alliance or other group association
22 with rates that reflect a premium credit for expense savings
23 attributable to administrative activities being performed by
24 the alliance or group association if such expense savings are
25 specifically documented in the insurer's rate filing and are
26 approved by the office. Any such credit may not be based on
27 different morbidity assumptions or on any other factor related
28 to the health status or claims experience of any person
29 covered under the policy. Nothing in this subparagraph exempts
30 an alliance or group association from licensure for any
31 activities that require licensure under the insurance code. A
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1 carrier issuing a group health insurance policy to a small
2 employer health alliance or other group association shall
3 allow any properly licensed and appointed agent of that
4 carrier to market and sell the small employer health alliance
5 or other group association policy. Such agent shall be paid
6 the usual and customary commission paid to any agent selling
7 the policy.
8 5. Any adjustments in rates for claims experience,
9 health status, or duration of coverage may not be charged to
10 individual employees or dependents. For a small employer's
11 policy, such adjustments may not result in a rate for the
12 small employer which deviates more than 15 percent from the
13 carrier's approved rate. Any such adjustment must be applied
14 uniformly to the rates charged for all employees and
15 dependents of the small employer. A small employer carrier may
16 make an adjustment to a small employer's renewal premium, not
17 to exceed 10 percent annually, due to the claims experience,
18 health status, or duration of coverage of the employees or
19 dependents of the small employer. Semiannually, small group
20 carriers shall report information on forms adopted by rule by
21 the commission, to enable the office to monitor the
22 relationship of aggregate adjusted premiums actually charged
23 policyholders by each carrier to the premiums that would have
24 been charged by application of the carrier's approved modified
25 community rates. If the aggregate resulting from the
26 application of such adjustment exceeds the premium that would
27 have been charged by application of the approved modified
28 community rate by 4 5 percent for the current reporting
29 period, the carrier shall limit the application of such
30 adjustments only to minus adjustments beginning not more than
31 60 days after the report is sent to the office. For any
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1 subsequent reporting period, if the total aggregate adjusted
2 premium actually charged does not exceed the premium that
3 would have been charged by application of the approved
4 modified community rate by 4 5 percent, the carrier may apply
5 both plus and minus adjustments. A small employer carrier may
6 provide a credit to a small employer's premium based on
7 administrative and acquisition expense differences resulting
8 from the size of the group. Group size administrative and
9 acquisition expense factors may be developed by each carrier
10 to reflect the carrier's experience and are subject to office
11 review and approval.
12 6. A small employer carrier rating methodology may
13 include separate rating categories for one dependent child,
14 for two dependent children, and for three or more dependent
15 children for family coverage of employees having a spouse and
16 dependent children or employees having dependent children
17 only. A small employer carrier may have fewer, but not
18 greater, numbers of categories for dependent children than
19 those specified in this subparagraph.
20 7. Small employer carriers may not use a composite
21 rating methodology to rate a small employer with fewer than 10
22 employees. For the purposes of this subparagraph, a "composite
23 rating methodology" means a rating methodology that averages
24 the impact of the rating factors for age and gender in the
25 premiums charged to all of the employees of a small employer.
26 8.a. A carrier may separate the experience of small
27 employer groups with fewer less than 2 eligible employees from
28 the experience of small employer groups with 2-25 2-50
29 eligible employees for purposes of determining an alternative
30 modified community rating.
31
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1 b. If a carrier separates the experience of small
2 employer groups as provided in sub-subparagraph a., the rate
3 to be charged to small employer groups of fewer less than 2
4 eligible employees may not exceed 150 percent of the rate
5 determined for small employer groups of 2-25 2-50 eligible
6 employees. However, the carrier may charge excess losses of
7 the experience pool consisting of small employer groups with
8 fewer less than 2 eligible employees to the experience pool
9 consisting of small employer groups with 2-25 2-50 eligible
10 employees so that all losses are allocated and the 150-percent
11 rate limit on the experience pool consisting of small employer
12 groups with fewer less than 2 eligible employees is
13 maintained. Notwithstanding s. 627.411(1), the rate to be
14 charged to a small employer group of fewer than 2 eligible
15 employees, insured as of July 1, 2002, may be up to 125
16 percent of the rate determined for small employer groups of
17 2-25 2-50 eligible employees for the first annual renewal and
18 150 percent for subsequent annual renewals.
19 (c) For all small employer health benefit plans that
20 are subject to this section, that are issued by small employer
21 carriers before January 1, 1994, and that are renewed on or
22 after January 1, 1995, renewal rates must be based on the same
23 modified community rating standard applied to new business.
24 (d) Notwithstanding s. 627.401(2), this section and
25 ss. 627.410 and 627.411 apply to any health benefit plan
26 provided by a small employer carrier that is an insurer, and
27 this section and s. 641.31 apply to any health benefit
28 provided by a small employer carrier that is a health
29 maintenance organization, that provides coverage to one or
30 more employees of a small employer regardless of where the
31 policy, certificate, or contract is issued or delivered, if
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1 the health benefit plan covers employees or their covered
2 dependents who are residents of this state.
3 (12) STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED
4 HEALTH BENEFIT PLANS.--
5 (a)1. The Chief Financial Officer shall appoint a
6 health benefit plan committee composed of four representatives
7 of carriers which shall include at least two representatives
8 of HMOs, at least one of which is a staff model HMO, two
9 representatives of agents, four representatives of small
10 employers, and one employee of a small employer. The carrier
11 members shall be selected from a list of individuals
12 recommended by the board. The Chief Financial Officer may
13 require the board to submit additional recommendations of
14 individuals for appointment.
15 2. The plans shall comply with all of the requirements
16 of this subsection.
17 3. The plans must be filed with and approved by the
18 office prior to issuance or delivery by any small employer
19 carrier.
20 4. After approval of the revised health benefit plans,
21 if the office determines that modifications to a plan might be
22 appropriate, the Chief Financial Officer shall appoint a new
23 health benefit plan committee in the manner provided in
24 subparagraph 1. to submit recommended modifications to the
25 office for approval.
26 (b)1. Each small employer carrier issuing new health
27 benefit plans shall offer to any small employer, upon request,
28 a standard health benefit plan, and a basic health benefit
29 plan, and a high deductible plan that meets the requirements
30 of a health savings account plan as defined by federal law,
31 that meet meets the criteria set forth in this section.
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1 2. For purposes of this subsection, the terms
2 "standard health benefit plan," and "basic health benefit
3 plan," and "high deductible plan" mean policies or contracts
4 that a small employer carrier offers to eligible small
5 employers that contain:
6 a. An exclusion for services that are not medically
7 necessary or that are not covered preventive health services;
8 and
9 b. A procedure for preauthorization by the small
10 employer carrier, or its designees.
11 3. A small employer carrier may include the following
12 managed care provisions in the policy or contract to control
13 costs:
14 a. A preferred provider arrangement or exclusive
15 provider organization or any combination thereof, in which a
16 small employer carrier enters into a written agreement with
17 the provider to provide services at specified levels of
18 reimbursement or to provide reimbursement to specified
19 providers. Any such written agreement between a provider and a
20 small employer carrier must contain a provision under which
21 the parties agree that the insured individual or covered
22 member has no obligation to make payment for any medical
23 service rendered by the provider which is determined not to be
24 medically necessary. A carrier may use preferred provider
25 arrangements or exclusive provider arrangements to the same
26 extent as allowed in group products that are not issued to
27 small employers.
28 b. A procedure for utilization review by the small
29 employer carrier or its designees.
30
31
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1 This subparagraph does not prohibit a small employer carrier
2 from including in its policy or contract additional managed
3 care and cost containment provisions, subject to the approval
4 of the office, which have potential for controlling costs in a
5 manner that does not result in inequitable treatment of
6 insureds or subscribers. The carrier may use such provisions
7 to the same extent as authorized for group products that are
8 not issued to small employers.
9 4. The standard health benefit plan shall include:
10 a. Coverage for inpatient hospitalization;
11 b. Coverage for outpatient services;
12 c. Coverage for newborn children pursuant to s.
13 627.6575;
14 d. Coverage for child care supervision services
15 pursuant to s. 627.6579;
16 e. Coverage for adopted children upon placement in the
17 residence pursuant to s. 627.6578;
18 f. Coverage for mammograms pursuant to s. 627.6613;
19 g. Coverage for handicapped children pursuant to s.
20 627.6615;
21 h. Emergency or urgent care out of the geographic
22 service area; and
23 i. Coverage for services provided by a hospice
24 licensed under s. 400.602 in cases where such coverage would
25 be the most appropriate and the most cost-effective method for
26 treating a covered illness.
27 5. The standard health benefit plan and the basic
28 health benefit plan may include a schedule of benefit
29 limitations for specified services and procedures. If the
30 committee develops such a schedule of benefits limitation for
31 the standard health benefit plan or the basic health benefit
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1 plan, a small employer carrier offering the plan must offer
2 the employer an option for increasing the benefit schedule
3 amounts by 4 percent annually.
4 6. The basic health benefit plan shall include all of
5 the benefits specified in subparagraph 4.; however, the basic
6 health benefit plan shall place additional restrictions on the
7 benefits and utilization and may also impose additional cost
8 containment measures.
9 7. Sections 627.419(2), (3), and (4), 627.6574,
10 627.6612, 627.66121, 627.66122, 627.6616, 627.6618, 627.668,
11 and 627.66911 apply to the standard health benefit plan and to
12 the basic health benefit plan. However, notwithstanding said
13 provisions, the plans may specify limits on the number of
14 authorized treatments, if such limits are reasonable and do
15 not discriminate against any type of provider.
16 8. The plan associated with a health savings account
17 shall include all the benefits specified in subparagraph 4.
18 9.8. Each small employer carrier that provides for
19 inpatient and outpatient services by allopathic hospitals may
20 provide as an option of the insured similar inpatient and
21 outpatient services by hospitals accredited by the American
22 Osteopathic Association when such services are available and
23 the osteopathic hospital agrees to provide the service.
24 (c) If a small employer rejects, in writing, the
25 standard health benefit plan, and the basic health benefit
26 plan, and the high deductible health savings account plan, the
27 small employer carrier may offer the small employer a limited
28 benefit policy or contract.
29 (d)1. Upon offering coverage under a standard health
30 benefit plan, a basic health benefit plan, or a limited
31 benefit policy or contract for any small employer, the small
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1 employer carrier shall provide such employer group with a
2 written statement that contains, at a minimum:
3 a. An explanation of those mandated benefits and
4 providers that are not covered by the policy or contract;
5 b. An explanation of the managed care and cost control
6 features of the policy or contract, along with all appropriate
7 mailing addresses and telephone numbers to be used by insureds
8 in seeking information or authorization; and
9 c. An explanation of the primary and preventive care
10 features of the policy or contract.
11
12 Such disclosure statement must be presented in a clear and
13 understandable form and format and must be separate from the
14 policy or certificate or evidence of coverage provided to the
15 employer group.
16 2. Before a small employer carrier issues a standard
17 health benefit plan, a basic health benefit plan, or a limited
18 benefit policy or contract, it must obtain from the
19 prospective policyholder a signed written statement in which
20 the prospective policyholder:
21 a. Certifies as to eligibility for coverage under the
22 standard health benefit plan, basic health benefit plan, or
23 limited benefit policy or contract;
24 b. Acknowledges the limited nature of the coverage and
25 an understanding of the managed care and cost control features
26 of the policy or contract;
27 c. Acknowledges that if misrepresentations are made
28 regarding eligibility for coverage under a standard health
29 benefit plan, a basic health benefit plan, or a limited
30 benefit policy or contract, the person making such
31
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1 misrepresentations forfeits coverage provided by the policy or
2 contract; and
3 d. If a limited plan is requested, acknowledges that
4 the prospective policyholder had been offered, at the time of
5 application for the insurance policy or contract, the
6 opportunity to purchase any health benefit plan offered by the
7 carrier and that the prospective policyholder had rejected
8 that coverage.
9
10 A copy of such written statement shall be provided to the
11 prospective policyholder no later than at the time of delivery
12 of the policy or contract, and the original of such written
13 statement shall be retained in the files of the small employer
14 carrier for the period of time that the policy or contract
15 remains in effect or for 5 years, whichever period is longer.
16 3. Any material statement made by an applicant for
17 coverage under a health benefit plan which falsely certifies
18 as to the applicant's eligibility for coverage serves as the
19 basis for terminating coverage under the policy or contract.
20 4. Each marketing communication that is intended to be
21 used in the marketing of a health benefit plan in this state
22 must be submitted for review by the office prior to use and
23 must contain the disclosures stated in this subsection.
24 (e) A small employer carrier may not use any policy,
25 contract, form, or rate under this section, including
26 applications, enrollment forms, policies, contracts,
27 certificates, evidences of coverage, riders, amendments,
28 endorsements, and disclosure forms, until the insurer has
29 filed it with the office and the office has approved it under
30 ss. 627.410 and 627.411 and this section.
31 (15) SMALL EMPLOYERS ACCESS PROGRAM.--
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1 (a) Popular name.--This subsection may be referred to
2 by the popular name "The Small Employers Access Program."
3 (b) Intent.--The Legislature finds that increased
4 access to health care coverage for small employers with up to
5 25 employees could improve employees' health and reduce the
6 incidence and costs of illness and disabilities among
7 residents in this state. Many employers do not offer health
8 care benefits to their employees citing the increased cost of
9 this benefit. It is the intent of the Legislature to create
10 the Small Business Health Plan to provide small employers the
11 option and ability to provide health care benefits to their
12 employees at an affordable cost through the creation of
13 purchasing pools for employers with up to 25 employees, and
14 rural hospital employers and nursing home employers regardless
15 of the number of employees.
16 (c) Definitions.--For purposes of this subsection, the
17 term:
18 1. "Fair commission" means a commission structure
19 determined by the insurers and reflected in the insurers' rate
20 filings made pursuant to this subsection.
21 2. "Insurer" means any entity that provides health
22 insurance in this state. For purposes of this subsection,
23 insurer includes an insurance company holding a certificate of
24 authority pursuant to chapter 624 or a health maintenance
25 organization holding a certificate of authority pursuant to
26 chapter 641, which qualifies to provide coverage to small
27 employer groups pursuant to this section.
28 3. "Mutually supported benefit plan" means an optional
29 alternative coverage plan developed within a defined
30 geographic region which may include, but is not limited to, a
31 minimum level of primary care coverage in which the percentage
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1 of the premium is distributed among the employer, the
2 employee, and community-generated revenue either alone or in
3 conjunction with federal matching funds.
4 4. "Office" means the Office of Insurance Regulation
5 of the Department of Financial Services.
6 5. "Participating insurer" means any insurer providing
7 health insurance to small employers that has been selected by
8 the office in accordance with this subsection for its
9 designated region.
10 6. "Program" means the Small Employer Access Program
11 as created by this subsection.
12 (d) Eligibility.--
13 1. Any small employer group of up to 25 employees.
14 2. Any municipality, county, school district, or
15 hospital located in a rural community as defined in s.
16 288.0636(2)(b).
17 3. Nursing home employers may participate.
18 4. Each dependent of a person eligible for coverage is
19 also eligible to participate.
20 5. Any small employer that is actively engaged in
21 business, has its principal place of business in this state,
22 employed up to 25 eligible employees on business days during
23 the preceding calendar year, and employs at least 2 employees
24 on the first day of the plan year may participate.
25
26 Coverage for a small employer group that ceases to meet the
27 eligibility requirements of this section may be terminated at
28 the end of the policy period for which the necessary premiums
29 have been paid.
30 (e) Administration.--
31
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1 1. The office shall by competitive bid, in accordance
2 with current state law, select an insurer to provide coverage
3 through the program to eligible small employers within an
4 established geographical area of this state. The office may
5 develop exclusive regions for the program similar to those
6 used by the Healthy Kids Corporation. However the office is
7 not precluded from developing, in conjunction with insurers,
8 regions different from those used by the Healthy Kids
9 Corporation if the office deems that such a region will carry
10 out the intentions of this subsection.
11 2. The office shall evaluate bids submitted based upon
12 criteria established by the office, which shall include, but
13 not be limited to:
14 a. The insurer's proven ability to handle health
15 insurance coverage to small employer groups.
16 b. The efficiency and timeliness of the insurer's
17 claim processing procedures.
18 c. The insurer's ability to apply effective
19 cost-containment programs and procedures and to administer the
20 program in a cost-efficient manner.
21 d. The financial condition and stability of the
22 insurer.
23 e. The insurer's ability to develop an optional
24 mutually supported benefit plan.
25
26 The office may use any financial information available to it
27 through its regulatory duties to make this evaluation.
28 (f) Insurer qualifications.--The insurer shall be a
29 duly authorized insurer or health maintenance organization.
30 (g) Duties of the insurer.--The insurer shall:
31
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1 1. Develop and implement a program to publicize the
2 existence of the program, program eligibility requirements,
3 and procedures for enrollment and maintain public awareness of
4 the program.
5 2. Maintain employer awareness of the program.
6 3. Demonstrate the ability to use delivery of
7 cost-effective health care services.
8 4. Encourage, educate, advise, and administer the
9 effective use of health savings accounts by covered employees
10 and dependents.
11 5. Serve for a period specified in the contract
12 between the office and the insurer, subject to removal for
13 cause and subject to any terms, conditions, and limitations of
14 the contract between the office and the insurer as may be
15 specified in the request for proposal.
16 (h) Contract term.--The contract term shall not exceed
17 3 years. At least 6 months prior to the expiration of each
18 contract period, the office shall invite eligible entities,
19 including the current insurer, to submit bids to serve as the
20 insurer for a designated geographic area. Selection of the
21 insurer for the succeeding period shall be made at least 3
22 months prior to the end of the current period. If a protest is
23 filed and not resolved by the end of the contract period, the
24 contract with the existing administrator may be extended for a
25 period not to exceed 6 months. During the contract extension
26 period, the administrator shall be paid at a rate to be
27 negotiated by the office.
28 (i) Insurer reporting requirements.--On March 1
29 following the close of each calendar year, the insurer shall
30 determine net written and earned premiums, the expense of
31 administration, and the paid and incurred losses for the year
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1 and report this information to the office on a form prescribed
2 by the office.
3 (j) Application requirements.--The insurer shall
4 permit or allow any licensed and duly appointed health
5 insurance agent residing in the designated region to submit
6 applications for coverage, and such agent shall be paid a fair
7 commission if coverage is written. The agent must be appointed
8 to at least one insurer.
9 (k) Benefits.--The benefits provided by the plan shall
10 be the same as the coverage required for small employers under
11 subsection (12). Upon the approval of the office, the insurer
12 may also establish an optional mutually supported benefit plan
13 which is an alternative plan developed within a defined
14 geographic region of this state or any other such alternative
15 plan which will carry out the intent of this subsection. Any
16 small employer carrier issuing new health benefit plans may
17 offer a benefit plan with coverages similar to, but not less
18 than, any alternative coverage plan developed pursuant to this
19 subsection.
20 (l) Annual reporting.--The office shall make an annual
21 report to the Governor, the President of the Senate, and the
22 Speaker of the House of Representatives. The report shall
23 summarize the activities of the program in the preceding
24 calendar year, including the net written and earned premiums,
25 program enrollment, the expense of administration, and the
26 paid and incurred losses. The report shall be submitted no
27 later than March 15 following the close of the prior calendar
28 year.
29 (16)(15) APPLICABILITY OF OTHER STATE LAWS.--
30 (a) Except as expressly provided in this section, a
31 law requiring coverage for a specific health care service or
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1 benefit, or a law requiring reimbursement, utilization, or
2 consideration of a specific category of licensed health care
3 practitioner, does not apply to a standard or basic health
4 benefit plan policy or contract or a limited benefit policy or
5 contract offered or delivered to a small employer unless that
6 law is made expressly applicable to such policies or
7 contracts. A law restricting or limiting deductibles,
8 coinsurance, copayments, or annual or lifetime maximum
9 payments does not apply to any health plan policy, including a
10 standard or basic health benefit plan policy or contract,
11 offered or delivered to a small employer unless such law is
12 made expressly applicable to such policy or contract. However,
13 every small employer carrier must offer to eligible small
14 employers the standard benefit plan and the basic benefit
15 plan, as required by subsection (5), as such plans have been
16 approved by the office pursuant to subsection (12).
17 (b) Except as provided in this section, a standard or
18 basic health benefit plan policy or contract or limited
19 benefit policy or contract offered to a small employer is not
20 subject to any provision of this code which:
21 1. Inhibits a small employer carrier from contracting
22 with providers or groups of providers with respect to health
23 care services or benefits;
24 2. Imposes any restriction on a small employer
25 carrier's ability to negotiate with providers regarding the
26 level or method of reimbursing care or services provided under
27 a health benefit plan; or
28 3. Requires a small employer carrier to either include
29 a specific provider or class of providers when contracting for
30 health care services or benefits or to exclude any class of
31
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1 providers that is generally authorized by statute to provide
2 such care.
3 (c) Any second tier assessment paid by a carrier
4 pursuant to paragraph (11)(j) may be credited against
5 assessments levied against the carrier pursuant to s.
6 627.6494.
7 (d) Notwithstanding chapter 641, a health maintenance
8 organization is authorized to issue contracts providing
9 benefits equal to the standard health benefit plan, the basic
10 health benefit plan, and the limited benefit policy authorized
11 by this section.
12 (17)(16) RULEMAKING AUTHORITY.--The commission may
13 adopt rules to administer this section, including rules
14 governing compliance by small employer carriers and small
15 employers.
16 Section 27. Section 627.9175, Florida Statutes, is
17 amended to read:
18 627.9175 Reports of information on health and accident
19 insurance.--
20 (1) Each health insurer, prepaid limited health
21 services organization, and health maintenance organization
22 shall submit, no later than April 1 of each year, annually to
23 the office information concerning health and accident
24 insurance coverage and medical plans being marketed and
25 currently in force in this state. The required information
26 shall be described by market segment, including, but not
27 limited to:
28 (a) Issuing, servicing company, and entity contact
29 information.
30 (b) Information on all health and accident insurance
31 policies and prepaid limited health service organizations and
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1 health maintenance organization contracts in force and issued
2 in the previous year. Such information shall include, but not
3 be limited to, direct premiums earned, direct losses incurred,
4 number of policies, number of certificates, number of covered
5 lives, number or the percentage of claims denied and claims
6 meeting prompt pay requirements, and the average number of
7 days taken to pay claims. as to policies of individual health
8 insurance:
9 (a) A summary of typical benefits, exclusions, and
10 limitations for each type of individual policy form currently
11 being issued in the state. The summary shall include, as
12 appropriate:
13 1. The deductible amount;
14 2. The coinsurance percentage;
15 3. The out-of-pocket maximum;
16 4. Outpatient benefits;
17 5. Inpatient benefits; and
18 6. Any exclusions for preexisting conditions.
19
20 The commission shall determine other appropriate benefits,
21 exclusions, and limitations to be reported for inclusion in
22 the consumer's guide published pursuant to this section.
23 (b) A schedule of rates for each type of individual
24 policy form reflecting typical variations by age, sex, region
25 of the state, or any other applicable factor which is in use
26 and is determined to be appropriate for inclusion by the
27 commission.
28
29 The commission may establish rules governing shall provide by
30 rule a uniform format for the submission of this information
31 described in this section, including the use of uniform
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1 formats and electronic data transmission order to allow for
2 meaningful comparisons of premiums charged for comparable
3 benefits. The office shall provide this information to the
4 department, which shall publish annually a consumer's guide
5 which summarizes and compares the information required to be
6 reported under this subsection.
7 (2)(a) Every insurer transacting health insurance in
8 this state shall report annually to the office, not later than
9 April 1, information relating to any measure the insurer has
10 implemented or proposes to implement during the next calendar
11 year for the purpose of containing health insurance costs or
12 cost increases. The reports shall identify each measure and
13 the forms to which the measure is applied, shall provide an
14 explanation as to how the measure is used, and shall provide
15 an estimate of the cost effect of the measure.
16 (b) The commission shall promulgate forms to be used
17 by insurers in reporting information pursuant to this
18 subsection and shall utilize such forms to analyze the effects
19 of health care cost containment programs used by health
20 insurers in this state.
21 (c) The office shall analyze the data reported under
22 this subsection and shall annually make available to the
23 department which shall provide to the public a summary of its
24 findings as to the types of cost containment measures reported
25 and the estimated effect of these measures.
26 Section 28. (1) Effective January 1, 2005, chapter
27 636, Florida Statutes, is redesignated as "Prepaid Limited
28 Health Service Organizations and Discount Medical Plan
29 Organizations."
30 (2) Effective January 1, 2005, sections
31 636.002-636.067, Florida Statutes, are designated as part I of
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1 chapter 636, Florida Statutes, entitled "Prepaid Limited
2 Health Service Organizations."
3 Section 29. Effective January 1, 2005, section
4 636.002, Florida Statutes, is amended to read:
5 636.002 Short title.--This part Sections 1-57, chapter
6 93-148, Laws of Florida, may be cited as the "Prepaid Limited
7 Health Service Organization Act of Florida."
8 Section 30. Effective January 1, 2005, subsection (7)
9 of section 636.003, Florida Statutes, is amended to read:
10 636.003 Definitions.--As used in this act, the term:
11 (7) "Prepaid limited health service organization"
12 means any person, corporation, partnership, or any other
13 entity which, in return for a prepayment, undertakes to
14 provide or arrange for, or provide access to, the provision of
15 a limited health service to enrollees through an exclusive
16 panel of providers. Prepaid limited health service
17 organization does not include:
18 (a) An entity otherwise authorized pursuant to the
19 laws of this state to indemnify for any limited health
20 service;
21 (b) A provider or entity when providing limited health
22 services pursuant to a contract with a prepaid limited health
23 service organization, a health maintenance organization, a
24 health insurer, or a self-insurance plan; or
25 (c) Any person who is licensed pursuant to part II of
26 this chapter as a discount medical plan organization, in
27 exchange for fees, dues, charges or other consideration,
28 provides access to a limited health service provider without
29 assuming any responsibility for payment for the limited health
30 service or any portion thereof.
31
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1 Section 31. Effective January 1, 2005, part II of
2 chapter 636, Florida Statutes, consisting of sections 636.202,
3 636.204, 636.206, 636.208, 636.210, 636.212, 636.214, 636.216,
4 636.218, 636.220, 636.222, 636.224, 636.226, 636.228, 636.230,
5 636.232, 636.234, 636.236, 636.238, 636.240, 636.242, and
6 636.244, is created to read:
7 Part II
8 Discount Medical Plan Organizations
9 636.202 Definitions.--As used in this part, the term:
10 (1) "Commission" means the Financial Services
11 Commission.
12 (2) "Discount medical plan" means a business
13 arrangement or contract in which a person, in exchange for
14 fees, dues, charges, or other consideration, provides access
15 for plan members to providers of medical services and the
16 right to receive medical services from those providers at a
17 discount.
18 (3) "Discount medical plan organization" means a
19 person who, in exchange for fees, dues, charges, or other
20 consideration, provides members a discount medical plan.
21 (4) "Marketer" means a person that markets, promotes,
22 sells, or distributes a discount medical plan, including a
23 private label entity which places its name on and markets or
24 distributes a discount medical plan, but does not operate a
25 discount medical plan.
26 (5) "Medical services" means any care, service, or
27 treatment of an illness or a dysfunction of, or injury to, the
28 human body, including, but not limited to, physician care,
29 inpatient care, hospital surgical services, emergency
30 services, ambulance services, dental care services, vision
31 care services, mental health services, substance abuse
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1 services, chiropractic services, podiatric care services,
2 laboratory services, medical equipment and supplies. The term
3 does not include pharmaceutical supplies or prescriptions.
4 (6) "Member" means any person who pays fees, dues,
5 charges, or other consideration for the right to receive the
6 benefits of a discount medical plan.
7 (7) "Office" means the Office of Insurance Regulation
8 of the Financial Services Commission.
9 (8) "Provider" means any person that contracts,
10 directly or indirectly, with a discount medical plan
11 organization to provide medical services to members.
12 (9) "Provider network" means an entity that negotiates
13 on behalf of more than one provider with a discount medical
14 plan organization to provide medical services to members.
15 636.204 License.--
16 (1) A person may not conduct business in this state as
17 a discount medical plan organization unless the person:
18 (a) Is a corporation, either incorporated under the
19 laws of this state, or, if a foreign corporation, is
20 authorized to transact business in this state; and
21 (b) Is licensed as a discount medical plan
22 organization by the office.
23 (2) An application for a license to operate as a
24 discount medical plan organization must be filed with the
25 office on a form prescribed by the commission. The application
26 must be sworn to by an officer or authorized representative of
27 the applicant and must be accompanied by the following:
28 (a) A copy of the applicant's articles of
29 incorporation, including all amendments.
30 (b) A copy of the corporate bylaws.
31
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1 (c) A list of the names, addresses, official
2 positions, and biographical information of the individuals
3 responsible for conducting the applicant's affairs, including,
4 but not limited to, all members of the board of directors,
5 board of trustees, executive committee, or other governing
6 board or committee, the officers, contracted management
7 company personnel, and any person or entity owning or having
8 the right to acquire 10 percent or more of the voting
9 securities of the applicant. The list must fully disclose the
10 extent and nature of any contract or arrangement between any
11 individual who is responsible for conducting the applicant's
12 affairs and the discount medical plan organization, including
13 any possible conflicts of interest.
14 (d) A complete biographical statement, on forms
15 prescribed by the commission, an independent investigation
16 report, and a set of fingerprints, as provided in chapter 624,
17 from each individual identified in subsection (c).
18 (e) A statement describing the applicant, its
19 facilities, and personnel and the medical services it proposes
20 to offer.
21 (f) A copy of any form contract used by the applicant
22 with any provider or provider network regarding the provision
23 of medical services to members.
24 (g) A copy of any form contract used by the applicant
25 with any person listed in subsection (c).
26 (h) A copy of any form contract used by the applicant
27 with any person, corporation, partnership, or other entity for
28 the performance on the applicant's behalf of any function,
29 including, but not limited to, marketing, administration,
30 enrollment, investment management, and subcontracting for the
31 provision of health services to members.
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1 (i) A copy of the applicant's most recent financial
2 statements that have been audited by an independent certified
3 public accountant.
4 (j) A description of the applicant's proposed method
5 of marketing.
6 (k) A description of the member's complaint procedures
7 to be established and maintained by the applicant.
8 (l) The fee for issuance of a license.
9 (m) Such other information as the commission or office
10 may request from the applicant.
11 (3) The office shall issue a license that expires 1
12 year after the date of issuance, and each year on that date
13 thereafter. The office shall renew the license if the licensee
14 pays the annual license fee of $50 and if the licensee is in
15 compliance with this part.
16 (4) Before the office issues a license, each medical
17 discount plan organization must establish a website in order
18 to conform with the requirements of s. 636.226.
19 (5) The license fee under this section is $50 per
20 year, per licensee. All amounts collected shall be deposited
21 in the General Revenue Fund.
22 (6) This part does not require a provider who provides
23 discounts to his or her own patients to obtain and maintain a
24 license as a discount medical plan organization.
25 636.206 Examinations and investigations.--
26 (1) The office may examine or investigate any discount
27 medical plan organization. The office may order any discount
28 medical plan organization or applicant to produce any records,
29 books, files, advertising and solicitation materials, or other
30 information and may take statements under oath to determine
31 whether the discount medical plan organization or applicant is
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1 in violation of the law or is acting contrary to the public
2 interest. The expenses incurred in conducting an examination
3 or investigation must be paid by the discount medical plan
4 organization or applicant. Examinations and investigations
5 must be conducted as provided in chapter 624 and a discount
6 medical plan organization is subject to all applicable
7 provisions of the Florida Insurance Code.
8 (2) Failure by a discount medical plan organization to
9 pay the costs incurred under this section is grounds for
10 denial or revocation of a license.
11 636.208 Permitted activities of a discount medical
12 plan.--A discount medical plan organization may engage in the
13 following activities:
14 (1) Charge a monthly fee to its members. However, if a
15 discount medical plan charges a fee for a time period
16 exceeding 1 month, it must, in the event of cancellation of
17 the membership by either party, make a pro rata reimbursement
18 of the fee to the member.
19 (2) Enter into contracts with a provider or provider
20 network in which the provider or provider network agrees to
21 provide medical services at a discount to plan members.
22 636.210 Prohibited activities of a discount medical
23 plan.--
24 (1) A discount medical plan organization may not:
25 (a) Use in its advertisements, marketing material,
26 brochures, or discount cards the term "insurance" except as
27 otherwise authorized in this part;
28 (b) Use in its advertisements, marketing material,
29 brochures, or discount cards the terms "affordable
30 healthcare", "health plan", "coverage", "co-pay",
31 "co-payments", "pre-existing conditions", "guaranteed issue",
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1 "premium" or other terms that could reasonably mislead a
2 person into believing the discount medical plan was health
3 insurance;
4 (c) Have restrictions on free access to plan
5 providers, including, but not limited to, waiting periods and
6 notification periods; or
7 (d) Pay providers any fees for medical services.
8 (2) A discount medical plan organization is prohibited
9 from collecting or accepting money from a member for payment
10 to a provider for specific medical services furnished or to be
11 furnished to the member unless it has an active certificate of
12 authority from the office to act as an administrator.
13 636.212 Disclosures.--The following disclosures must
14 be made in writing to any prospective member, and must be on
15 the first page of any advertisements, marketing material, or
16 brochures relating to a discount medical plan. The disclosures
17 must be printed in not less than 10-point type or no smaller
18 than the largest type on the page if larger than 10-point
19 type, and must state that:
20 (1) The plan is not insurance;
21 (2) The plan does not make payments directly to
22 providers of medical services;
23 (3) The plan member is obligated to pay to the
24 provider the full amount of the discounted fees; and
25 (4) The corporate name and the locations of the
26 licensed discount medical plan organization.
27 636.214 Provider agreements.--
28 (1) A provider offering medical services to a member
29 under a discount medical plan must provide the service under a
30 written agreement with the organization. The agreement may be
31
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1 entered into directly by the provider or by a provider network
2 to which the provider belongs.
3 (2) A provider agreement must contain the following:
4 (a) A list of the services and products to be
5 delivered at a discount;
6 (b) A statement specifying the amount of the discounts
7 offered or, alternatively, a fee schedule that reflects the
8 provider's discounted rates; and
9 (c) A statement that the provider will not charge
10 members more than the discounted rates.
11 (3) A provider agreement between a discount medical
12 plan organization and a provider network shall require the
13 provider network to have written agreements with each
14 provider. An agreement must:
15 (a) Contain the elements described in subsection (2);
16 (b) Authorize the provider network to contract with
17 the medical discount medical plan organization on behalf of
18 the provider; and
19 (c) Require the provider network to maintain an
20 up-to-date list of the providers with whom it has a contract
21 and to deliver that list to the discount medical plan
22 organization each month.
23 (4) The discount medical plan organization shall
24 maintain a copy of each active provider agreement.
25 636.216 Form and rate filings.--
26 (1) All fees charged to members must be filed with the
27 office and must be approved by the office before they can be
28 imposed on a member. The discount medical plan organization
29 has the burden of proof that the fees charged bear a
30 reasonable relation to the benefits received by the member.
31
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1 (2) There must be a written agreement between the
2 discount medical plan organization and the member specifying
3 the benefits under the discount medical plan and complying
4 with the disclosure requirements of this part.
5 (3) Any form used by the discount medical plan
6 organization, including the written agreement between the
7 organization and the member, must first be filed with and
8 approved by the office. Every form filed shall be identified
9 by a unique form number placed in the lower left corner of
10 each form.
11 (4) If the office disapproves any filing, the office
12 shall notify the discount medical plan organization in writing
13 and must specify the reasons why the office disapproved the
14 filing. The discount medical plan organization has 21 days
15 from the date it receives the disapproval notice to request a
16 hearing before the office under chapter 120.
17 636.218 Annual reports.--
18 (1) Each discount medical plan organization must file
19 with the office an annual report no later than 3 months after
20 the end of the organization's fiscal year.
21 (2) The report must be on a form and in a format
22 prescribed by the commission and must include:
23 (a) Audited financial statements prepared in
24 accordance with generally accepted accounting principles and
25 certified by an independent certified public accountant. The
26 financial statements shall include the organization's balance
27 sheet, income statement, and statement of changes in cash flow
28 for the preceding year.
29 (b) A list of the names and residence addresses of all
30 persons responsible for the conduct of its affairs, together
31 with a disclosure of the extent and nature of any contracts or
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1 arrangements between these persons and the discount medical
2 plan organization, including any possible conflicts of
3 interest.
4 (c) The number of discount medical plan members.
5 (d) Such other information relating to the performance
6 of the discount medical plan organization that is required by
7 the commission or office.
8 (3) A discount medical plan organization that fails to
9 file an annual report in the form and within the time required
10 by this section shall forfeit up to $500 for each day for the
11 first 10 days during which the report is delinquent and shall
12 forfeit up to $1,000 for each day after the first 10 days
13 during which the report is delinquent. Upon notice by the
14 office, the organization may no longer enroll new members or
15 do business in this state until the organization complies with
16 this section. The office shall deposit all sums collected by
17 it under this section to the credit of the Insurance
18 Regulatory Trust Fund. The office may not collect more than
19 $50,000 for each delinquent report.
20 636.220 Minimum capital requirements.--
21 (1) Each discount medical plan organization must at
22 all times maintain a net worth of at least $150,000.
23 (2) The office may not issue a license unless the
24 medical discount medical plan organization has a net worth of
25 at least $150,000.
26 636.222 Suspension or revocation of license;
27 suspension of enrollment of new members; terms of
28 suspension.--
29 (1) The office may suspend the authority of a discount
30 medical plan organization to enroll new members, may revoke a
31 license issued to a discount medical plan organization, or may
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1 order compliance if it finds that any of the following
2 conditions exist:
3 (a) The organization is not operating in compliance
4 with this part.
5 (b) The discount medical plan organization does not
6 have the minimum net worth as required by this part.
7 (c) The organization has advertised, merchandised, or
8 attempted to merchandise its services in a manner as to
9 misrepresent its services or capacity for service or has
10 engaged in deceptive, misleading, or unfair practices with
11 respect to advertising or merchandising.
12 (d) The discount medical plan organization is not
13 fulfilling its obligations as a discount medical plan
14 organization.
15 (e) The continued operation of the discount medical
16 plan organization would be hazardous to its members.
17 (2) If the office has cause to believe that grounds
18 for the suspension or revocation of a license exist, it shall
19 notify the discount medical plan organization in writing
20 specifically stating the grounds for suspension or revocation
21 and shall pursue a hearing on the matter in accordance with
22 chapter 120.
23 (3) If the license of a discount medical plan
24 organization is surrendered or revoked, the organization must
25 proceed, immediately following the effective date of the order
26 of revocation, to wind up its affairs transacted under the
27 license. It may not engage in any further advertising,
28 solicitation, collecting of fees, or renewal of contracts.
29 (4) The office shall, in its order suspending the
30 authority of a discount medical plan organization to enroll
31 new members, specify the period during which the suspension is
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1 to be in effect and the conditions, if any, which must be met
2 by the discount medical plan organization before reinstatement
3 of its license to enroll new members. The order of suspension
4 is subject to rescission or modification by further order of
5 the office before expiration of the suspension period.
6 Reinstatement may not be made unless requested by the discount
7 medical plan organization. However, the office may not grant
8 reinstatement if it finds that the circumstances for which the
9 suspension occurred still exist or are likely to recur.
10 636.224 Notice of change of name or address of
11 discount medical plan organization.--Each discount medical
12 plan organization must notify the office at least 30 days in
13 advance of any change in the discount medical plan
14 organization's name, address, principal business address, or
15 mailing address.
16 636.226 Provider name listing.--
17 (1) Each discount medical plan organization must
18 maintain an up-to-date list of the names and addresses of the
19 providers with whom it has a contract to deliver medical
20 services. The list must be stored on its website, the Internet
21 address of which must be prominently displayed on all its
22 advertisements, marketing material, brochures, and discount
23 cards.
24 (2) This section applies to providers with whom the
25 discount medical plan organization has contracted directly and
26 to those who are members of a provider network with which the
27 discount medical plan organization has a contract to deliver
28 medical services.
29 636.228 Marketing of discount medical plans.--
30
31
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1 (1) All advertisements, marketing material, brochures,
2 and discount cards used by marketers must be approved in
3 writing for use by the discount medical plan organization.
4 (2) The discount medical plan organization shall have
5 an executed written agreement with a marketer before the
6 marketer marketing, promoting, selling, or distributing the
7 discount medical plan.
8 (3) A person may not act in the capacity of a marketer
9 unless licensed as an agent as defined in s. 626.015(2).
10 (4) A person may not act as a marketer for a discount
11 medical plan program unless appointed by the discount medical
12 plan program, using a form prescribed by the commission.
13 636.230 Bundling discount medical plans with other
14 insurance products.--When a marketer or discount medical plan
15 organization sells a discount medical plan along with any
16 other product, the fees for each product must be itemized
17 separately and provided to the members in writing.
18 636.232 Rules.--The commission may adopt rules to
19 administer this part, including rules for the licensing of
20 discount medical plan organizations; establishing standards
21 for evaluating forms, advertisements, marketing material,
22 brochures, and discount cards; the collection of data;
23 disclosures to plan members; and rules defining terms used in
24 this act.
25 636.234 Service of process on a discount medical plan
26 organization.--Sections 624.422 and 624.423 apply to a
27 discount medical plan organization as if a discount medical
28 plan organization were an insurer.
29 636.236 Security deposit.--
30 (1) A licensed discount medical plan organization must
31 deposit, and maintain deposited in trust with the department,
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1 securities eligible for deposit under s. 625.52, in order that
2 the office might protect plan members. The securities must, at
3 all times, have a value of not less than $35,000.
4 (2) A judgment creditor or other claimant of a
5 discount medical plan organization, other than the office or
6 the Department of Financial Services, does not have the right
7 to levy upon any of the assets or securities held in this
8 state as a deposit under this section.
9 636.238 Penalties for violation of this part.--
10 (1) Except as provided in subsection (2), a person who
11 violates this part commits a misdemeanor of the second degree,
12 punishable as provided in s. 775.082 or s. 775.083.
13 (2) A person who operates as or aids and abets another
14 operating as a discount medical plan organization in violation
15 of s. 636.204(1) commits a felony punishable as provided for
16 in s. 624.401(4)(b), as if the unlicensed discount medical
17 plan organization were an unauthorized insurer, and the fees,
18 dues, charges, or other consideration collected from the
19 members by the unlicensed discount medical plan organization
20 or marketer were insurance premium.
21 (3) A person who collects fees for purported
22 membership in a discount medical plan but fails to provide the
23 promised benefits commits a theft punishable as provided in s.
24 812.014.
25 636.240 Injunction.--
26 (1) In addition to the penalties and other enforcement
27 provisions of this act, the office may commence an action for
28 temporary and permanent injunctive relief if:
29 (a) A discount medical plan is operated by a person
30 that is not licensed under this part.
31
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1 (b) A person, entity, or discount medical plan
2 organization has engaged in any activity prohibited by this
3 act or any rule adopted under this act.
4 (2) Venue for any proceeding bought under this section
5 shall be in the Circuit Court for Leon County.
6 (3) The office's authority to seek injunctive relief
7 is not conditioned on having conducted any proceeding under
8 chapter 120.
9 636.242 Civil remedies.--Any person injured by a
10 person acting in violation of this part may bring a civil
11 action against the person committing the violation in the
12 circuit court of the county in which the alleged violator
13 resides or has a principal place of business or in the county
14 where the alleged violation occurred. If the defendant is
15 found to have injured the plaintiff, the defendant is liable
16 for damages and the court may also award the prevailing
17 plaintiff court costs and reasonable attorney's fees. If so
18 awarded, the court costs and attorney's fees must be included
19 in the judgment or decree rendered in the case. If it appears
20 to the court that the suit brought by the plaintiff is
21 frivolous or brought for purposes of harassment, the court may
22 award the defendant court costs and reasonable attorney's fees
23 and may apply sanctions against the plaintiff in accordance
24 with chapter 57.
25 636.244 Unlicensed discount medical plan
26 organizations.--Sections 626.901 through 626.912 apply to the
27 activities of an unlicensed discount medical plan organization
28 as if an unlicensed discount medical plan organization were an
29 unauthorized insurer.
30 Section 32. Section 627.65626, Florida Statutes, is
31 created to read:
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1 627.65626 Insurance rebates for healthy lifestyles.--
2 (1) Any rate, rating schedule, or rating manual for a
3 health insurance policy filed with the office shall provide
4 for an appropriate rebate of premiums paid in the last
5 calendar year when the majority of members of a health plan
6 have enrolled and maintained participation in any health
7 wellness, maintenance, or improvement program offered by the
8 employer. The employer must provide evidence of demonstrative
9 maintenance or improvement of the enrollees' health status as
10 determined by assessments of agreed-upon health status
11 indicators between the employer and the health insurer,
12 including, but not limited to, reduction in weight, body mass
13 index, and smoking cessation. Any rebate provided by the
14 health insurer is presumed to be appropriate unless credible
15 data demonstrates otherwise, but shall not exceed 10 percent
16 of paid premiums.
17 (2) The premium rebate authorized by this section
18 shall be effective for an insured on an annual basis, unless
19 the number of participating employees becomes less than the
20 majority of the employees eligible for participation in the
21 wellness program.
22 Section 33. Section 627.6402, Florida Statutes, is
23 created to read:
24 627.6402 Insurance rebates for healthy lifestyles.--
25 (1) Any rate, rating schedule, or rating manual for an
26 individual health insurance policy filed with the office shall
27 provide for an appropriate rebate of premiums paid in the last
28 calendar year when the individual covered by such plan is
29 enrolled in and maintains participation in any health
30 wellness, maintenance, or improvement program approved by the
31 health plan. The individual must provide evidence of
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1 demonstrative maintenance or improvement of the individual's
2 health status as determined by assessments of agreed-upon
3 health status indicators between the individual and the health
4 insurer, including, but not limited to, reduction in weight,
5 body mass index, and smoking cessation. Any rebate provided by
6 the health insurer is presumed to be appropriate unless
7 credible data demonstrates otherwise, but shall not exceed 10
8 percent of paid premiums.
9 (2) The premium rebate authorized by this section
10 shall be effective for an insured on an annual basis, unless
11 the individual fails to maintain or improve his or her health
12 status while participating in an approved wellness program, or
13 credible evidence demonstrates that the individual is not
14 participating in the approved wellness program.
15 Section 34. Subsection (38) of section 641.31, Florida
16 Statutes, is amended, and subsection (40) is added to that
17 section, to read:
18 641.31 Health maintenance contracts.--
19 (38)(a) Notwithstanding any other provision of this
20 part, a health maintenance organization that meets the
21 requirements of paragraph (b) may, through a point-of-service
22 rider to its contract providing comprehensive health care
23 services, include a point-of-service benefit. Under such a
24 rider, a subscriber or other covered person of the health
25 maintenance organization may choose, at the time of covered
26 service, a provider with whom the health maintenance
27 organization does not have a health maintenance organization
28 provider contract. The rider may not require a referral from
29 the health maintenance organization for the point-of-service
30 benefits.
31
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1 (b) A health maintenance organization offering a
2 point-of-service rider under this subsection must have a valid
3 certificate of authority issued under the provisions of the
4 chapter, must have been licensed under this chapter for a
5 minimum of 3 years, and must at all times that it has riders
6 in effect maintain a minimum surplus of $5 million. A health
7 maintenance organization offering a point-of-service rider to
8 its contract providing comprehensive health care services may
9 offer the rider to employers who have employees living and
10 working outside the health maintenance organization's approved
11 geographic service area without having to obtain a health care
12 provider certificate, as long as the master group contract is
13 issued to an employer that maintains its primary place of
14 business within the health maintenance organization's approved
15 service area. Any member or subscriber that lives and works
16 outside the health maintenance organization's service area and
17 elects coverage under the health maintenance organization's
18 point-of-service rider must provide a statement to the health
19 maintenance organization which indicates that the member or
20 subscriber understands the limitations of his or her policy
21 and that only those benefits under the point-of-service rider
22 will be covered when services are provided outside the service
23 area.
24 (c) Premiums paid in for the point-of-service riders
25 may not exceed 15 percent of total premiums for all health
26 plan products sold by the health maintenance organization
27 offering the rider. If the premiums paid for point-of-service
28 riders exceed 15 percent, the health maintenance organization
29 must notify the office and, once this fact is known, must
30 immediately cease offering such a rider until it is in
31 compliance with the rider premium cap.
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1 (d) Notwithstanding the limitations of deductibles and
2 copayment provisions in this part, a point-of-service rider
3 may require the subscriber to pay a reasonable copayment for
4 each visit for services provided by a noncontracted provider
5 chosen at the time of the service. The copayment by the
6 subscriber may either be a specific dollar amount or a
7 percentage of the reimbursable provider charges covered by the
8 contract and must be paid by the subscriber to the
9 noncontracted provider upon receipt of covered services. The
10 point-of-service rider may require that a reasonable annual
11 deductible for the expenses associated with the
12 point-of-service rider be met and may include a lifetime
13 maximum benefit amount. The rider must include the language
14 required by s. 627.6044 and must comply with copayment limits
15 described in s. 627.6471. Section 641.3154 does not apply to a
16 point-of-service rider authorized under this subsection.
17 (e) The point-of-service rider must contain provisions
18 that comply with s. 627.6044.
19 (f)(e) The term "point of service" may not be used by
20 a health maintenance organization except with riders permitted
21 under this section or with forms approved by the office in
22 which a point-of-service product is offered with an indemnity
23 carrier.
24 (g)(f) A point-of-service rider must be filed and
25 approved under ss. 627.410 and 627.411.
26 (40)(a) Any rate, rating schedule, or rating manual
27 for a health maintenance organization policy filed with the
28 office shall provide for an appropriate rebate of premiums
29 paid in the last calendar year when the individual covered by
30 such plan is enrolled in and maintains participation in any
31 health wellness, maintenance, or improvement program approved
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1 by the health plan. The individual must provide evidence of
2 demonstrative maintenance or improvement of his or her health
3 status as determined by assessments of agreed-upon health
4 status indicators between the individual and the health
5 insurer, including, but not limited to, reduction in weight,
6 body mass index, and smoking cessation. Any rebate provided by
7 the health insurer is presumed to be appropriate unless
8 credible data demonstrates otherwise, but shall not exceed 10
9 percent of paid premiums.
10 (b) The premium rebate authorized by this section
11 shall be effective for an insured on an annual basis, unless
12 the individual fails to maintain or improve his or her health
13 status while participating in an approved wellness program, or
14 credible evidence demonstrates that the individual is not
15 participating in the approved wellness program.
16 Section 35. Notwithstanding the amendment to section
17 627.6699(5)(c), Florida Statutes, by this act, any right to an
18 open enrollment offer of health benefit coverage for groups of
19 fewer than two employees, pursuant to section 627.6699(5)(c),
20 Florida Statutes, as it existed immediately before the
21 effective date of this act, shall remain in full force and
22 effect until the enactment of section 627.64872, Florida
23 Statutes, and the subsequent date upon which such plan begins
24 to accept new risks or members.
25 Section 36. Section 465.0244, Florida Statutes, is
26 created to read:
27 465.0244 Information disclosure.--Every pharmacy shall
28 make available on its Internet website a link to the
29 performance outcome and financial data that is published by
30 the Agency for Health Care Administration pursuant to s.
31 408.05(3)(l) and shall place in the area where customers
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1 receive filled prescriptions notice that such information is
2 available electronically and the address of its Internet
3 website.
4 Section 37. Section 627.6499, Florida Statutes, is
5 amended to read:
6 627.6499 Reporting by insurers and third-party
7 administrators.--
8 (1) The office may require any insurer, third-party
9 administrator, or service company to report any information
10 reasonably required to assist the board in assessing insurers
11 as required by this act.
12 (2) Each health insurance issuer shall make available
13 on its Internet website a link to the performance outcome and
14 financial data that is published by the Agency for Health Care
15 Administration pursuant to s. 408.05(3)(l) and shall include
16 in every policy delivered or issued for delivery to any person
17 in the state or any materials provided as required by s.
18 627.64725 notice that such information is available
19 electronically and the address of its Internet website.
20 Section 38. Subsections (6) and (7) are added to
21 section 641.54, Florida Statutes, to read:
22 641.54 Information disclosure.--
23 (6) Each health maintenance organization shall make
24 available to its subscribers the estimated co-pay,
25 coinsurance, or deductible, whichever is applicable, for any
26 covered services, the status of the subscriber's maximum
27 annual out-of-pocket payments for a covered individual or
28 family, and the status of the subscriber's maximum lifetime
29 benefit. Such estimate shall not preclude the actual co-pay,
30 coinsurance, or deductible, whichever is applicable, from
31 exceeding the estimate.
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1 (7) Each health maintenance organization shall make
2 available on its Internet website a link to the performance
3 outcome and financial data that is published by the Agency for
4 Health Care Administration pursuant to s. 408.05(3)(l) and
5 shall include in every policy delivered or issued for delivery
6 to any person in the state or any materials provided as
7 required by s. 627.64725 notice that such information is
8 available electronically and the address of its Internet
9 website.
10 Section 39. Section 408.02, Florida Statutes, is
11 repealed.
12 Section 40. Subsection (3) of section 766.1016,
13 Florida Statutes, is repealed.
14 Section 41. The sum of $250,000 is appropriated from
15 the Insurance Regulatory Trust Fund in the Department of
16 Financial Services to the Office of Insurance Regulation for
17 the purpose of implementing the provisions in this act
18 relating to the Small Employers Access Program.
19 Section 42. The sum of $350,000 in nonrecurring
20 general revenue funds is appropriated to the Agency for Health
21 Care Administration to support the establishment of and to
22 contract with the Florida Patient Safety Corporation to
23 implement the provisions of section 16 of this act during the
24 2004-2005 fiscal year.
25 Section 43. The sum of $113,500 in nonrecurring
26 general revenue funds is appropriated to the Florida State
27 University College of Medicine for the purpose of conducting
28 the study required in section 17 of this act during the
29 2004-2005 fiscal year.
30 Section 44. The sum of $250,000 in nonrecurring
31 general funds is appropriated to the board of the Florida
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1 Health Insurance Plan to contract for an independent actuarial
2 study for the interim report that the board is required to
3 submit pursuant to section 627.64872, Florida Statutes, as
4 created by this act.
5 Section 45. The sum of $2 million in nonrecurring
6 general revenue funds is appropriated to the Agency for Health
7 Care Administration for its activities during the 2004-2005
8 fiscal year related to developing and implementing a strategy
9 for the adoption and use of electronic health records.
10 Section 46. Except as otherwise expressly provided in
11 this act, this act shall take effect July 1, 2004.
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1 STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
COMMITTEE SUBSTITUTE FOR
2 CS for SB 2910
3
4 Revises requirements for health care facilities to publish the
average cost of certain services.
5
Requires health care facilities, providers, and health
6 insurers to submit data to the Agency for Health Care
Administration (AHCA) and for AHCA to make performance outcome
7 and financial data available to consumers.
8 Revises the requirements for the Florida Health Insurance
Plan.
9
Revises requirements for the Health Flex Program, which is
10 expanded statewide.
11 Provides that policies for small employers with 26 to 50
employees would no longer be subject to the modified community
12 rating requirements and the rates for such policies would not
be required to be filed with or approved by the Office of
13 Insurance Regulation.
14 Revises requirements for small group policies.
15 Requires persons who provide access to any discounted medical
services to be licensed by the Office of Insurance Regulation.
16
Require health insurers to provide for a rebate of premiums
17 when the majority of members of a health plan have maintained
participation in a wellness program.
18
Creates the Florida Patient Safety Corporation to assist
19 health care providers to improve the quality and safety of
health care rendered and to reduce harm to patients.
20
Requires the Patient Safety Center at the Florida State
21 University College of Medicine to conduct a study on
hospitals.
22
Requires patient safety officers and patient safety committees
23 at licensed facilities to recommend improvements in the
patient safety measures.
24
Requires AHCA to develop and implement a strategy for the
25 adoption and use of electronic health records.
26 Allows hospitals and federally quality health centers to
develop emergency room diversion programs.
27
Renames the Statewide Provider and Subscriber Assistance
28 Program as the Subscriber Assistance Program and revises
requirements for the program.
29
Makes appropriations.
30
31
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