The Florida Senate

408.7056  Statewide Provider and Subscriber Assistance Program.--

(1)  The Agency for Health Care Administration shall adopt and implement a program to provide assistance to subscribers and providers, including those whose grievances are not resolved by the accountable health partnership, health maintenance organization, prepaid health clinic, prepaid health plan authorized pursuant to s. 409.912, or exclusive provider organization to the satisfaction of the subscriber or provider. The panel shall not consider grievances which:

(a)  Relate to an accountable health partnership's, health maintenance organization's, prepaid health clinic's, prepaid health plan's, or exclusive provider organization's refusal to accept a provider into its network of providers;

(b)  Are a part of a reconsideration appeal through the Medicare appeals process;

(c)  Are related to a health plan not regulated by the state such as an administrative services organization, third-party administrator, or federal employee health benefit program;

(d)  Are related to appeals by in-plan suppliers and providers, unless related to quality of care provided by the plan; or

(e)  Are part of a Medicaid fair hearing pursued pursuant to 42 C.F.R. ss. 431.220 et seq.

(2)  The program shall include the following:

(a)  A review panel which may periodically review, consider, and recommend to the agency any actions the agency or the Department of Insurance should take concerning individual cases heard by the panel, as well as the types of grievances which have not been satisfactorily resolved after subscribers or providers have followed the full grievance procedures of the accountable health partnership, health maintenance organization, prepaid health clinic, prepaid health plan, or exclusive provider organization. The proceedings of the grievance panel shall not be subject to the provisions of chapter 120. The review panel shall consist of members employed by the agency and members employed by the Department of Insurance, chosen by their respective agencies. The agency may contract with a medical director and a primary care physician who shall provide additional technical expertise to the review panel. The medical director shall be selected from a health maintenance organization with a current certificate of authority to operate in Florida.

(b)  A plan to disseminate information concerning the program to the general public as widely as possible.

(3)  Every accountable health partnership, health maintenance organization, prepaid health clinic, prepaid health plan authorized pursuant to s. 409.912, or exclusive provider organization shall submit a quarterly report to the agency and the Department of Insurance listing the number and the nature of all subscribers' and providers' grievances which have not been resolved to the satisfaction of the subscriber or provider after the subscriber or provider follows the full grievance procedure of the organization.

(4)

(a)  The Agency for Health Care Administration may impose an administrative fine, after a formal investigation has been conducted on the accountable health partnership's, health maintenance organization's, prepaid health clinic's, prepaid health plan's, or exclusive provider organization's failure to comply with quality of health services standards set forth in statute or rule. The Agency for Health Care Administration may initiate such an investigation based on the recommendations related to the quality of health services received from the Statewide Provider and Subscriber Assistance Panel pursuant to paragraph (2)(a). The fine shall not exceed $2,500 per violation and in no event shall such fine exceed an aggregate amount of $10,000 for noncompliance arising out of the same action.

(b)  In determining the amount to be levied for noncompliance under paragraph (a), the following factors shall be considered:

1.  The severity of the noncompliance, including the probability that death or serious harm to the health or safety of the subscriber will result or has resulted, the severity of actual or potential harm and the extent to which provisions of this part were violated.

2.  Actions taken by the accountable health partnership, health maintenance organization, prepaid health clinic, prepaid health plan, or exclusive provider organization to resolve or remedy any quality of care grievance.

3.  Any previous incidences of noncompliance by the accountable health partnership, health maintenance organization, prepaid health clinic, prepaid health plan, or exclusive provider organization.

(c)  All amounts collected pursuant to this subsection shall be deposited into the Health Care Trust Fund.

(5)  Any information which would identify a subscriber or the spouse, relative, or guardian of a subscriber and which is contained in a report obtained by the Department of Insurance pursuant to this section is confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

History.--ss. 1, 32, 47, ch. 85-177; s. 15, ch. 88-388; ss. 123, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 76, ch. 93-129; s. 23, ch. 95-398; s. 3, ch. 96-199; s. 250, ch. 96-406; s. 24, ch. 96-418.

Note.--Former s. 641.311; (4) former s. 119.07(3)(s).