| 1 | A bill to be entitled |
| 2 | An act relating to the provision of health care services; |
| 3 | specifying conditions under which a health care provider |
| 4 | must be permitted to participate as a service provider |
| 5 | under a health plan offered by a managed care |
| 6 | organization; defining the term "managed care |
| 7 | organization"; requiring that a health care provider be |
| 8 | reimbursed for providing services under specified |
| 9 | conditions; providing for civil penalties; amending s. |
| 10 | 627.419, F.S.; providing for construction of policies; |
| 11 | providing for application; providing an effective date. |
| 12 |
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| 13 | Be It Enacted by the Legislature of the State of Florida: |
| 14 |
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| 15 | Section 1. Health care provider as an authorized service |
| 16 | provider; penalties.-- |
| 17 | (1) A managed care organization must allow any health care |
| 18 | provider to participate as a service provider under a health |
| 19 | plan offered by the managed care organization if the health care |
| 20 | provider agrees to: |
| 21 | (a) Accept the reimbursement rates negotiated by the |
| 22 | managed care organization with other health care providers that |
| 23 | provide the same service under the health plan. |
| 24 | (b) Comply with all guidelines relating to quality of care |
| 25 | and utilization criteria which must be met by other employee or |
| 26 | nonemployee providers. |
| 27 | (2) A managed care organization must reimburse any health |
| 28 | care provider rendering services under the health plan if the |
| 29 | health care provider accepts the managed care organization's |
| 30 | reimbursement rates and has complied with the guidelines for |
| 31 | quality of care and utilization criteria. |
| 32 | (3) As used in this section, the term "managed care |
| 33 | organization" means a health maintenance organization or prepaid |
| 34 | health clinic certified under chapter 641, Florida Statutes, a |
| 35 | health insurer that issues an exclusive provider organization |
| 36 | policy under s. 627.6472 or s. 627.662(9), Florida Statutes, or |
| 37 | a health insurer that issues a preferred provider organization |
| 38 | policy under s. 627.6471 or s. 627.662(8), Florida Statutes. |
| 39 | (4) A managed care organization that violates subsection |
| 40 | (1) or subsection (2) is subject to a civil fine in the amount |
| 41 | of: |
| 42 | (a) Up to $25,000 for each violation; or |
| 43 | (b) If the Secretary of Health Care Administration |
| 44 | determines that the entity has engaged in a pattern of |
| 45 | violations of subsection (1) or subsection (2), up to $100,000 |
| 46 | for each violation. |
| 47 | Section 2. Subsection (10) is added to section 627.419, |
| 48 | Florida Statutes, to read: |
| 49 | 627.419 Construction of policies.-- |
| 50 | (10)(a) Any health insurance policy, health care services |
| 51 | plan, or other contract that provides for payment for medical |
| 52 | expense benefits or procedures must allow any health care |
| 53 | provider to participate as a service provider under a health |
| 54 | plan offered by the health insurance policy, health care |
| 55 | services plan, or other contract that provides for payment for |
| 56 | medical expense benefits or procedures if the health care |
| 57 | provider agrees to: |
| 58 | 1. Accept the reimbursement rates negotiated by the health |
| 59 | insurance policy, health care services plan, or other contract |
| 60 | that provides for payment for medical expense benefits or |
| 61 | procedures with other health care providers that provide the |
| 62 | same service under the health plan. |
| 63 | 2. Comply with all guidelines relating to quality of care |
| 64 | and utilization criteria which must be met by other providers |
| 65 | with whom the health insurance policy, health care services |
| 66 | plan, or other contract that provides for payment for medical |
| 67 | expense benefits or procedures has contractual arrangements for |
| 68 | those services. |
| 69 | (b) A provider of a health insurance policy, health care |
| 70 | services plan, or other contract to pay for medical expense |
| 71 | benefits must reimburse any health care provider rendering |
| 72 | services under the health plan if the health care provider |
| 73 | accepts the provider's reimbursement rates and the health care |
| 74 | provider has complied with the guidelines for quality of care |
| 75 | and utilization criteria. |
| 76 | (c) The provider of any health insurance policy, health |
| 77 | care services plan, or other contract that violates paragraph |
| 78 | (a) or paragraph (b) is subject to a civil fine in the amount |
| 79 | of: |
| 80 | 1. Up to $25,000 for each violation; or |
| 81 | 2. If the Office of Insurance Regulation determines that |
| 82 | the provider has engaged in a pattern of violations of paragraph |
| 83 | (a) or paragraph (b), up to $100,000 for each violation. |
| 84 | Section 3. Sections 1 and 2 of this act do not apply to |
| 85 | any health insurance policy that is in force before October 1, |
| 86 | 2005, but do apply to such policies at the next renewal period |
| 87 | immediately following October 1, 2005. |
| 88 | Section 4. This act shall take effect October 1, 2005. |