September 23, 2020
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HB 1629CS

CHAMBER ACTION




1The Committee on Appropriations recommends the following:
2
3     Committee Substitute
4     Remove the entire bill and insert:
5
A bill to be entitled
6An act relating to affordable health care; providing a
7popular name; providing purpose; amending s. 381.026,
8F.S.; requiring certain licensed facilities to provide
9public Internet access to certain financial information;
10providing a definition; amending s. 381.734, F.S.;
11including participation by health care providers, small
12businesses, and health insurers in the Healthy
13Communities, Healthy People Program; requiring the
14Department of Health to provide public Internet access to
15certain public health programs; requiring the department
16to monitor and assess the effectiveness of such programs;
17requiring a report; requiring the Office of Program Policy
18and Government Accountability to evaluate the
19effectiveness of such programs; requiring a report;
20amending s. 395.1041, F.S.; authorizing hospitals to
21develop certain emergency room diversion programs;
22amending s. 395.1055, F.S.; requiring licensed facilities
23to make certain patient charge and performance outcome
24data available on Internet websites; amending s. 395.1065,
25F.S.; authorizing the Agency for Health Care
26Administration to charge a fine for failure to provide
27such information; amending s. 395.301, F.S.; requiring
28certain licensed facilities to provide prospective
29patients certain estimates of charges for services;
30requiring such facilities to provide patients with certain
31bill verification information; providing for a fine for
32failure to provide such information; providing charge
33limitations; requiring such facilities to establish a
34patient question review and response methodology;
35providing requirements; requiring certain licensed
36facilities to provide public Internet access to certain
37financial information; requiring posting of a notice of
38the availability of such information; amending s. 408.061,
39F.S.; requiring the Agency for Health Care Administration
40to require health care facilities, health care providers,
41and health insurers to submit certain information;
42providing requirements; requiring the agency to adopt
43certain risk and severity adjustment methodologies;
44requiring the agency to adopt certain rules; requiring
45certain information to be certified; amending s. 408.062,
46F.S.; requiring the agency to conduct certain health care
47costs and access research, analyses, and studies;
48expanding the scope of such studies to include collection
49of pharmacy retail price data, use of emergency
50departments, physician information, and Internet patient
51charge information availability; requiring a report;
52requiring the agency to conduct additional data-based
53studies and make recommendations to the Legislature;
54requiring the agency to develop and implement a strategy
55to adopt and use electronic health records; authorizing
56the agency to develop rules to protect electronic records
57confidentiality; requiring a report to the Governor and
58Legislature; amending s. 408.05, F.S.; requiring the
59agency to develop a plan to make performance outcome and
60financial data available to consumers for health care
61services comparison purposes; requiring submittal of the
62plan to the Governor and Legislature; requiring the agency
63to update the plan; requiring the agency to make the plan
64available electronically; providing plan requirements;
65amending s. 409.9066, F.S.; requiring the agency to
66provide certain information relating to the Medicare
67prescription discount program; amending s. 408.7056, F.S.;
68renaming the Statewide Provider and Subscriber Assistance
69Program as the Subscriber Assistance Program; revising
70provisions to conform; expanding certain records
71availability provisions; revising membership provisions
72relating to a subscriber grievance hearing panel; revising
73a list of grievances the panel may consider; providing
74hearing procedures; amending s. 641.3154, F.S., to conform
75to the renaming of the Subscriber Assistance Program;
76amending s. 641.511, F.S., to conform to the renaming of
77the Subscriber Assistance Program; adopting and
78incorporating by reference the Employee Retirement Income
79Security Act of 1974, as implemented by federal
80regulations; amending s. 641.58, F.S., to conform to the
81renaming of the Subscriber Assistance Program; amending s.
82408.909, F.S.; expanding a definition of "health flex plan
83entity" to include public-private partnerships; making a
84pilot health flex plan program apply permanently
85statewide; providing additional program requirements;
86creating s. 381.0271, F.S.; providing definitions;
87creating the Florida Patient Safety Corporation;
88authorizing the corporation to create additional not-for-
89profit corporate subsidiaries for certain purposes;
90specifying application of public records and public
91meetings requirements; exempting the corporation and
92subsidiaries from public procurement provisions; providing
93purposes; providing for a board of directors; providing
94for membership; authorizing the corporation to establish
95certain advisory committees; providing for organization of
96the corporation; providing for meetings; providing powers
97and duties of the corporation; requiring the corporation
98to collect, analyze, and evaluate patient safety data and
99related information; requiring the corporation to
100establish a reporting system to identify and report near
101misses relating to patient safety; requiring the
102corporation to work with state agencies to develop
103electronic health records; providing for an active library
104of evidence-based medicine and patient safety practices;
105requiring the corporation to develop and recommend core
106competencies in patient safety and public education
107programs; requiring an annual report; providing report
108requirements; authorizing the corporation to seek funding
109and apply for grants; requiring the Office of Program
110Policy Analysis and Government Accountability, the
111Department of Health, and the Agency for Health Care
112Administration to develop performance standards to
113evaluate the corporation; amending s. 409.91255, F.S.;
114expanding assistance to certain health centers to include
115community emergency room diversion programs and urgent
116care services; amending s. 627.410, F.S.; requiring
117insurers to file certain rates with the Office of
118Insurance Regulation; creating s. 627.64872, F.S.;
119providing legislative intent; creating the Florida Health
120Insurance Plan for certain purposes; providing
121definitions; providing exclusions; providing requirements
122for operation of the plan; providing for a board of
123directors; providing for appointment of members; providing
124for terms; specifying service without compensation;
125providing for travel and per diem expenses; requiring a
126plan of operation; providing requirements; providing for
127powers of the plan; requiring reports to the Governor and
128Legislature; providing for an actuarial study; providing
129certain immunity from liability for plan obligations;
130authorizing the board to provide for indemnification of
131certain costs; requiring an annually audited financial
132statement; providing for eligibility for coverage under
133the plan; providing criteria, requirements, and
134limitations; specifying certain activity as an unfair
135trade practice; providing for a plan administrator;
136providing criteria; providing requirements; providing term
137limits for the plan administrator; providing duties;
138providing for paying the administrator; providing for
139premium rates for plan coverage; providing rate
140limitations; providing for sources of additional revenue;
141specifying benefits under the plan; providing criteria,
142requirements, and limitations; providing for
143nonduplication of benefits; providing for annual and
144maximum lifetime benefits; providing for tax exempt
145status; providing for abolition of the Florida
146Comprehensive Health Association upon implementation of
147the plan; providing for continued operation of the Florida
148Comprehensive Health Association until adoption of a plan
149of operation for the Florida Health Insurance Plan;
150providing for enrollment in the plan of persons enrolled
151in the association; requiring insurers to pay certain
152assessments to the board for certain purposes; providing
153criteria, requirements, and limitations for such
154assessments; providing for repeal of ss. 627.6488,
155627.6489, 627.649, 627.6492, 627.6494, 627.6496, and
156627.6498, F.S., relating to the Florida Comprehensive
157Health Association, upon implementation of the plan;
158amending s. 627.662, F.S.; providing for application of
159certain claim payment methodologies to certain types of
160insurance; providing for certain actions relating to
161inappropriate utilization of emergency care; amending s.
162627.6699, F.S.; revising provisions requiring small
163employer carriers to offer certain health benefit plans;
164preserving a right to open enrollment for certain small
165groups; requiring small employer carriers to file and
166provide coverage under certain high deductible plans;
167including high deductible plans and health reimbursement
168arrangements under certain required plan provisions;
169creating the Small Employers Access Program; providing
170legislative intent; providing definitions; providing
171participation eligibility requirements and criteria;
172requiring the Office of Insurance Regulation to administer
173the program by selecting an insurer through competitive
174bidding; providing requirements; specifying insurer
175qualifications; providing duties of the insurer; providing
176a contract term; providing insurer reporting requirements;
177providing application requirements; providing for benefits
178under the program; requiring the office to annually report
179to the Governor and Legislature; creating ss. 627.6405 and
180641.31097, F.S.; providing for decreasing inappropriate
181use of emergency care; providing legislative findings and
182intent; requiring health maintenance organizations and
183providers to provide certain information electronically
184and develop community emergency department diversion
185programs; authorizing health maintenance organizations to
186require higher copayments for certain uses of emergency
187departments; amending s. 627.9175, F.S.; requiring certain
188health insurers to annually report certain coverage
189information to the office; providing requirements;
190deleting certain reporting requirements; retitling ch.
191636, F.S.; designating ss. 636.002-636.067, F.S., as pt. I
192of ch. 636, F.S.; providing a part title; amending s.
193636.003, F.S.; revising the definition of "prepaid limited
194health service organization" to exclude discount medical
195plan organizations; creating pt. II of ch. 636, F.S.,
196consisting of ss. 636.202-636.244, F.S.; providing a part
197title; providing definitions; providing for regulation and
198operation of discount medical plan organizations;
199requiring corporate licensure before doing business as a
200discount medical plan; specifying application
201requirements; requiring license fees; providing for
202expiration and renewal of licenses; requiring such
203organizations to establish an Internet website; requiring
204publication of certain information on the website;
205specifying collection and deposit of the licensing fee;
206authorizing the office to examine or investigate the
207business affairs of such organizations; requiring
208examinations and investigations; authorizing the office to
209order production of documents and take statements;
210requiring organizations to pay certain expenses;
211specifying grounds for denial or revocation under certain
212circumstances; authorizing discount medical plan
213organizations to charge certain fees under certain
214circumstances; providing reimbursement requirements;
215prohibiting certain activities; requiring certain
216disclosures to prospective members; requiring provider
217agreements to provide services under a medical discount
218plan; providing agreement requirements; requiring forms
219and rates to be filed with the office; requiring annual
220reports to be filed with the office; providing
221requirements; providing for fines and administrative
222sanctions for failing to file annual reports; establishing
223minimum capital requirements; providing for suspension or
224revocation of licenses under certain circumstances;
225providing for suspension of enrollment of new members
226under certain circumstances; providing terms of
227suspensions; requiring notice of any change of an
228organization's name; requiring discount medical plan
229organizations to maintain provider names listings;
230specifying marketing requirements of discount medical
231plans; providing limitations; specifying fee disclosure
232requirements for bundling discount medical plans with
233other insurance products; authorizing the commission to
234adopt rules; applying insurer service of process
235requirements on discount medical plan organizations;
236requiring a security deposit; prohibiting levy on certain
237deposit assets or securities under certain circumstances;
238providing criminal penalties; authorizing the office to
239seek certain injunctive relief under certain
240circumstances; providing limitations; providing for civil
241actions for damages for certain violations; providing for
242awards of court costs and attorney fees; specifying
243application of unauthorized insurer provisions of law to
244unlicensed discount medical plan organizations; creating
245ss. 627.65626 and 627.6402, F.S.; providing for insurance
246rebates for healthy lifestyles; providing for rebate of
247certain premiums for participation in health wellness,
248maintenance, or improvement programs under certain
249circumstances; providing requirements; amending s. 641.31,
250F.S.; authorizing health maintenance organizations
251offering certain point-of-service riders to offer such
252riders to certain employers for certain employees;
253providing requirements and limitations; providing for
254application of certain claim payment methodologies to
255certain types of insurance; providing for rebate of
256certain premiums for participation in health wellness,
257maintenance, or improvement programs under certain
258circumstances; providing requirements; creating s.
259626.593, F.S.; providing fee and commission limitations
260for health insurance agents; requiring a written contract
261for compensation; providing contract requirements;
262requiring a rebate of commission under certain
263circumstances; amending ss. 626.191 and 626.201, F.S.;
264clarifying certain application requirements; preserving
265certain rights to enrollment in certain health benefit
266coverage programs for certain groups under certain
267circumstances; creating s. 465.0244, F.S.; requiring each
268pharmacy to make available on its Internet website a link
269to certain performance outcome and financial data of the
270Agency for Health Care Administration and a notice of the
271availability of such information; amending s. 627.6499,
272F.S.; requiring each health insurer to make available on
273its Internet website a link to certain performance outcome
274and financial data of the Agency for Health Care
275Administration and a notice in policies of the
276availability of such information; amending s. 641.54,
277F.S.; requiring health maintenance organizations to make
278certain insurance financial information available to
279subscribers; requiring health maintenance organizations to
280make available on its Internet website a link to certain
281performance outcome and financial data of the Agency for
282Health Care Administration and a notice in policies of the
283availability of such information; repealing s. 408.02,
284F.S., relating to the development, endorsement,
285implementation, and evaluation of patient management
286practice parameters by the Agency for Health Care
287Administration; providing appropriations; providing
288effective dates.
289
290     WHEREAS, according to the Kaiser Family Foundation, eight
291out of ten uninsured Americans are workers or dependents of
292workers and nearly eight out of ten uninsured Americans have
293family incomes above the poverty level, and
294     WHEREAS, fifty-five percent of those who do not have
295insurance state the reason they don't have insurance is lack of
296affordability, and
297     WHEREAS, average health insurance premium increases for the
298last two years have been in the range of ten to twenty percent
299for Florida's employers, and
300     WHEREAS, an increasing number of employers are opting to
301cease providing insurance coverage to their employees due to the
302high cost, and
303     WHEREAS, an increasing number of employers who continue
304providing coverage are forced to shift more premium cost to
305their employees, thus diminishing the value of employee wage
306increases, and
307     WHEREAS, according to studies, the rate of avoidable
308hospitalization is fifty to seventy percent lower for the
309insured versus the uninsured, and
310     WHEREAS, according to Florida Cancer Registry data, the
311uninsured have a seventy percent greater chance of a late
312diagnosis, thus decreasing the chances of a positive health
313outcome, and
314     WHEREAS, according to the Agency for Health Care
315Administration's 2002 financial data, uncompensated care in
316Florida's hospitals is growing at the rate of twelve to thirteen
317percent per year, and, at $4.3 billion in 2001, this cost, when
318shifted to Floridians who remain insured, is not sustainable,
319and
320     WHEREAS, the Florida Legislature, through the creation of
321Health Flex, has already identified the need for lower cost
322alternatives, and
323     WHEREAS, it is of vital importance and in the best
324interests of the people of the State of Florida that the issue
325of available, affordable health care insurance be addressed in a
326cohesive and meaningful manner, and
327     WHEREAS, there is general recognition that the issues
328surrounding the problem of access to affordable health insurance
329are complicated and multifaceted, and
330     WHEREAS, on August 14, 2003, Speaker Johnnie Byrd created
331the Select Committee on Affordable Health Care for Floridians in
332an effort to address the issue of affordable and accessible
333employment-based insurance, and
334     WHEREAS, the Select Committee on Affordable Health Care for
335Floridians held public hearings with predetermined themes around
336the state, specifically, in Orlando, Miami, Jacksonville, Tampa,
337Pensacola, Boca Raton, and Tallahassee, from October through
338November 2003 to effectively probe the operation of the private
339insurance marketplace, to understand the health insurance market
340trends, to learn from past policy initiatives, and to identify,
341explore, and debate new ideas for change, and
342     WHEREAS, recommendations from the Select Committee on
343Affordable Health Care were adopted on February 4, 2004, to
344address the multifaceted issues attributed to the increase in
345health care cost, and
346     WHEREAS, these recommendations were presented to the
347Speaker of the House of Representatives in a final report from
348the committee on February 18, 2004, and subsequent legislation
349was drafted creating the "The 2004 Affordable Health Care for
350Floridians Act," NOW, THEREFORE,
351
352Be It Enacted by the Legislature of the State of Florida:
353
354     Section 1.  This act may be referred to by the popular name
355"The 2004 Affordable Health Care for Floridians Act."
356     Section 2.  The purpose of this act is to address the
357underlying cause of the double-digit increases in health
358insurance premiums by mitigating the overall growth in health
359care costs.
360     Section 3.  Paragraph (c) of subsection (4) of section
361381.026, Florida Statutes, is amended to read:
362     381.026  Florida Patient's Bill of Rights and
363Responsibilities.--
364     (4)  RIGHTS OF PATIENTS.--Each health care facility or
365provider shall observe the following standards:
366     (c)  Financial information and disclosure.--
367     1.  A patient has the right to be given, upon request, by
368the responsible provider, his or her designee, or a
369representative of the health care facility full information and
370necessary counseling on the availability of known financial
371resources for the patient's health care.
372     2.  A health care provider or a health care facility shall,
373upon request, disclose to each patient who is eligible for
374Medicare, in advance of treatment, whether the health care
375provider or the health care facility in which the patient is
376receiving medical services accepts assignment under Medicare
377reimbursement as payment in full for medical services and
378treatment rendered in the health care provider's office or
379health care facility.
380     3.  A health care provider or a health care facility shall,
381upon request, furnish a person patient, prior to provision of
382medical services, a reasonable estimate of charges for such
383services. Such reasonable estimate shall not preclude the health
384care provider or health care facility from exceeding the
385estimate or making additional charges based on changes in the
386patient's condition or treatment needs.
387     4.  Each licensed facility not operated by the state shall
388make available to the public on its Internet website or by other
389electronic means a description of and a link to the performance
390outcome and financial data that is published by the agency
391pursuant to s. 408.05(3)(l). The facility shall place a notice
392in the reception area that such information is available
393electronically and the website address. The licensed facility
394may indicate that the pricing information is based on a
395compilation of charges for the average patient and that each
396patient's bill may vary from the average depending upon the
397severity of illness and individual resources consumed. The
398licensed facility may also indicate that the price of service is
399negotiable for eligible patients based upon the patient's
400ability to pay.
401     5.4.  A patient has the right to receive a copy of an
402itemized bill upon request. A patient has a right to be given an
403explanation of charges upon request.
404     Section 4.  Subsection (1) and paragraph (g) of subsection
405(3) of section 381.734, Florida Statutes, are amended, and
406subsections (4), (5), and (6) are added to said section, to
407read:
408     381.734  Healthy Communities, Healthy People Program.--
409     (1)  The department shall develop and implement the Healthy
410Communities, Healthy People Program, a comprehensive and
411community-based health promotion and wellness program. The
412program shall be designed to reduce major behavioral risk
413factors associated with chronic diseases, including those
414chronic diseases identified in chapter 385, by enhancing the
415knowledge, skills, motivation, and opportunities for
416individuals, organizations, health care providers, small
417businesses, health insurers, and communities to develop and
418maintain healthy lifestyles.
419     (3)  The program shall include:
420     (g)  The establishment of a comprehensive program to inform
421the public, health care professionals, health insurers, and
422communities about the prevalence of chronic diseases in the
423state; known and potential risks, including social and
424behavioral risks; and behavior changes that would reduce risks.
425     (4)  The department shall make available on its Internet
426website, no later than October 1, 2004, and in a hard-copy
427format upon request, a listing of age-specific, disease-
428specific, and community-specific health promotion, preventive
429care, and wellness programs offered and established under the
430Healthy Communities, Healthy People Program. The website shall
431also provide residents with information to identify behavior
432risk factors that lead to diseases that are preventable by
433maintaining a healthy lifestyle. The website shall allow
434consumers to select by county or region disease-specific
435statistical information.
436     (5)  The department shall monitor and assess the
437effectiveness of such programs. The department shall submit a
438status report based on this monitoring and assessment to the
439Governor, the Speaker of the House of Representatives, the
440President of the Senate, and the substantive committees of each
441house of the Legislature, with the first annual report due
442January 31, 2005.
443     (6)  The Office of Program Policy and Government
444Accountability shall evaluate and report to the Governor, the
445President of the Senate, and the Speaker of the House of
446Representatives, by March 1, 2005, on the effectiveness of the
447department's monitoring and assessment of the program's
448effectiveness.
449     Section 5.  Subsection (7) is added to section 395.1041,
450Florida Statutes, to read:
451     395.1041  Access to emergency services and care.--
452     (7)  EMERGENCY ROOM DIVERSION PROGRAMS.--Hospitals may
453develop emergency room diversion programs, including, but not
454limited to, an "Emergency Hotline" which allows patients to help
455determine if emergency department services are appropriate or if
456other health care settings may be more appropriate for care, and
457a "Fast Track" program allowing nonemergency patients to be
458treated at an alternative site. Alternative sites may include
459health care programs funded with local tax revenue and federally
460funded community health centers, county health departments, or
461other nonhospital providers of health care services. The program
462may include provisions for followup care and case management.
463     Section 6.  Paragraph (h) is added to subsection (1) of
464section 395.1055, Florida Statutes, to read:
465     395.1055  Rules and enforcement.--
466     (1)  The agency shall adopt rules pursuant to ss.
467120.536(1) and 120.54 to implement the provisions of this part,
468which shall include reasonable and fair minimum standards for
469ensuring that:
470     (h)  Licensed facilities make available on their Internet
471websites, no later than October 1, 2004, and in a hard-copy
472format upon request, a description of and a link to the patient
473charge and performance outcome data collected from licensed
474facilities pursuant to s. 408.061.
475     Section 7.  Subsection (7) is added to section 395.1065,
476Florida Statutes, to read:
477     395.1065  Criminal and administrative penalties;
478injunctions; emergency orders; moratorium.--
479     (7)  The agency shall impose a fine of $500 for each
480instance of the facility's failure to provide the information
481required by rules adopted pursuant to s. 395.1055(1)(h).
482     Section 8.  Subsections (1), (2), and (3) of section
483395.301, Florida Statutes, are amended, and subsections (7),
484(8), (9), and (10) are added to said section, to read:
485     395.301  Itemized patient bill; form and content prescribed
486by the agency.--
487     (1)  A licensed facility not operated by the state shall
488notify each patient during admission and at discharge of his or
489her right to receive an itemized bill upon request. Within 7
490days following the patient's discharge or release from a
491licensed facility not operated by the state, or within 7 days
492after the earliest date at which the loss or expense from the
493service may be determined, the licensed facility providing the
494service shall, upon request, submit to the patient, or to the
495patient's survivor or legal guardian as may be appropriate, an
496itemized statement detailing in language comprehensible to an
497ordinary layperson the specific nature of charges or expenses
498incurred by the patient, which in the initial billing shall
499contain a statement of specific services received and expenses
500incurred for such items of service, enumerating in detail the
501constituent components of the services received within each
502department of the licensed facility and including unit price
503data on rates charged by the licensed facility, as prescribed by
504the agency.
505     (2)(a)  Each such statement submitted pursuant to this
506section:
507     1.(a)  May not include charges of hospital-based physicians
508if billed separately.
509     2.(b)  May not include any generalized category of expenses
510such as "other" or "miscellaneous" or similar categories.
511     3.(c)  Shall list drugs by brand or generic name and not
512refer to drug code numbers when referring to drugs of any sort.
513     4.(d)  Shall specifically identify therapy treatment as to
514the date, type, and length of treatment when therapy treatment
515is a part of the statement.
516     (b)  Any person receiving a statement pursuant to this
517section shall be fully and accurately informed as to each charge
518and service provided by the institution preparing the statement.
519     (3)  On each such itemized statement submitted pursuant to
520subsection (1) there shall appear the words "A FOR-PROFIT (or
521NOT-FOR-PROFIT or PUBLIC) HOSPITAL (or AMBULATORY SURGICAL
522CENTER) LICENSED BY THE STATE OF FLORIDA" or substantially
523similar words sufficient to identify clearly and plainly the
524ownership status of the licensed facility. Each itemized
525statement must prominently display the phone number of the
526medical facility's patient liaison who is responsible for
527expediting the resolution of any billing dispute between the
528patient, or his or her representative, and the billing
529department.
530     (7)  Each licensed facility not operated by the state shall
531provide, prior to provision of any nonemergency medical
532services, a written good-faith estimate of reasonably
533anticipated charges for the facility to treat the patient's
534condition upon written request of a prospective patient. The
535estimate shall be provided to the prospective patient within 7
536business days after the receipt of the request. The estimate may
537be the average charges for that diagnosis related group or the
538average charges for that procedure. Upon request, the facility
539shall notify the patient of any revision to the good-faith
540estimate. Such estimate shall not preclude the actual charges
541from exceeding the estimate. The facility shall place a notice
542in the reception area that such information is available.
543Failure to provide the estimate within the provisions
544established pursuant to this section shall result in a fine of
545$500 for each instance of the facility's failure to provide the
546requested information.
547     (8)  A licensed facility shall make available to a patient
548all records necessary for verification of the accuracy of the
549patient's bill within 30 business days after the request for
550such records. The verification information must be made
551available in the facility's offices. Such records shall be
552available to the patient prior to and after payment of the bill
553or claim. The facility may not charge the patient for making
554such verification records available; however, the facility may
555charge its usual fee for providing copies of records as
556specified in s. 395.3025.
557     (9)  Each facility shall establish a method for reviewing
558and responding to questions from patients concerning the
559patient's itemized bill. Such response shall be provided within
56030 days after the date a question is received. If the patient is
561not satisfied with the response, the facility must provide the
562patient with the address of the agency to which the issue may be
563sent for review.
564     (10)  Each licensed facility shall make available on its
565Internet website a link to the performance outcome and financial
566data that is published by the Agency for Health Care
567Administration pursuant to s. 408.05(3)(l). The facility shall
568place a notice in the reception area that the information is
569available electronically and the facility's Internet website
570address.
571     Section 9.  Subsection (1) of section 408.061, Florida
572Statutes, is amended to read:
573     408.061  Data collection; uniform systems of financial
574reporting; information relating to physician charges;
575confidential information; immunity.--
576     (1)  The agency shall may require the submission by health
577care facilities, health care providers, and health insurers of
578data necessary to carry out the agency's duties. Specifications
579for data to be collected under this section shall be developed
580by the agency with the assistance of technical advisory panels
581including representatives of affected entities, consumers,
582purchasers, and such other interested parties as may be
583determined by the agency.
584     (a)  Data to be submitted by health care facilities,
585including the facilities as defined in chapter 395, shall may
586include, but are not limited to: case-mix data, patient
587admission and or discharge data, hospital emergency department
588data which shall include the number of patients treated in the
589emergency department of a licensed hospital reported by patient
590acuity level, data on hospital-acquired infections as specified
591by rule, data on complications as specified by rule, data on
592readmissions as specified by rule, with patient and provider-
593specific identifiers included, actual charge data by diagnostic
594groups, financial data, accounting data, operating expenses,
595expenses incurred for rendering services to patients who cannot
596or do not pay, interest charges, depreciation expenses based on
597the expected useful life of the property and equipment involved,
598and demographic data. The agency shall adopt nationally
599recognized risk adjustment methodologies or software consistent
600with the standards of the Agency for Healthcare Research and
601Quality and as selected by the agency for all data submitted as
602required by this section. Data may be obtained from documents
603such as, but not limited to: leases, contracts, debt
604instruments, itemized patient bills, medical record abstracts,
605and related diagnostic information. Reported data elements shall
606be reported electronically in accordance with Rule 59E-7.012,
607Florida Administrative Code. Data submitted shall be certified
608by the chief executive officer or an appropriate and duly
609authorized representative or employee of the licensed facility
610that the information submitted is true and accurate.
611     (b)  Data to be submitted by health care providers may
612include, but are not limited to: Medicare and Medicaid
613participation, types of services offered to patients, amount of
614revenue and expenses of the health care provider, and such other
615data which are reasonably necessary to study utilization
616patterns. Data submitted shall be certified by the appropriate
617duly authorized representative or employee of the health care
618provider that the information submitted is true and accurate.
619     (c)  Data to be submitted by health insurers may include,
620but are not limited to: claims, premium, administration, and
621financial information. Data submitted shall be certified by the
622chief financial officer, an appropriate and duly authorized
623representative, or an employee of the insurer that the
624information submitted is true and accurate.
625     (d)  Data required to be submitted by health care
626facilities, health care providers, or health insurers shall not
627include specific provider contract reimbursement information.
628However, such specific provider reimbursement data shall be
629reasonably available for onsite inspection by the agency as is
630necessary to carry out the agency's regulatory duties. Any such
631data obtained by the agency as a result of onsite inspections
632may not be used by the state for purposes of direct provider
633contracting and are confidential and exempt from the provisions
634of s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
635     (e)  A requirement to submit data shall be adopted by rule
636if the submission of data is being required of all members of
637any type of health care facility, health care provider, or
638health insurer. Rules are not required, however, for the
639submission of data for a special study mandated by the
640Legislature or when information is being requested for a single
641health care facility, health care provider, or health insurer.
642     Section 10.  Subsections (1) and (4) of section 408.062,
643Florida Statutes, are amended, and subsection (5) is added to
644said section, to read:
645     408.062  Research, analyses, studies, and reports.--
646     (1)  The agency shall have the authority to conduct
647research, analyses, and studies relating to health care costs
648and access to and quality of health care services as access and
649quality are affected by changes in health care costs. Such
650research, analyses, and studies shall include, but not be
651limited to, research and analysis relating to:
652     (a)  The financial status of any health care facility or
653facilities subject to the provisions of this chapter.
654     (b)  The impact of uncompensated charity care on health
655care facilities and health care providers.
656     (c)  The state's role in assisting to fund indigent care.
657     (d)  In conjunction with the Office of Insurance
658Regulation, the availability and affordability of health
659insurance for small businesses.
660     (e)  Total health care expenditures in the state according
661to the sources of payment and the type of expenditure.
662     (f)  The quality of health services, using techniques such
663as small area analysis, severity adjustments, and risk-adjusted
664mortality rates.
665     (g)  The development of physician information payment
666systems which are capable of providing data for health care
667consumers taking into account the amount of resources consumed,
668including such information at licensed facilities as defined in
669chapter 395, and the outcomes produced in the delivery of care.
670     (h)  The collection of a statistically valid sample of data
671on the retail prices charged by pharmacies for the 50 most
672frequently prescribed medicines from any pharmacy licensed by
673this state as a special study authorized by the Legislature to
674be performed by the agency quarterly. If the drug is available
675generically, price data shall be reported for the generic drug
676and price data of a brand-named drug for which the generic drug
677is the equivalent shall be reported. The agency shall make
678available on its Internet website for each pharmacy, no later
679than October 1, 2005, drug prices for a 30-day supply at a
680standard dose. The data collected shall be reported for each
681drug by pharmacy and by metropolitan statistical area or region
682and updated quarterly The impact of subacute admissions on
683hospital revenues and expenses for purposes of calculating
684adjusted admissions as defined in s. 408.07.
685     (i)  The use of emergency department services by patient
686acuity level and the implication of increasing hospital cost by
687providing nonurgent care in emergency departments. The agency
688shall submit an annual report based on this monitoring and
689assessment to the Governor, the Speaker of the House of
690Representatives, the President of the Senate, and the
691substantive legislative committees with the first report due
692January 1, 2006.
693     (j)  The making available on its Internet website no later
694than October 1, 2004, and in a hard-copy format upon request, of
695patient charge, volumes, length of stay, and performance outcome
696indicators collected from health care facilities pursuant to s.
697408.061(1)(a) for specific medical conditions, surgeries, and
698procedures provided in inpatient and outpatient facilities as
699determined by the agency. In making the determination of
700specific medical conditions, surgeries, and procedures to
701include, the agency shall consider such factors as volume,
702severity of the illness, urgency of admission, individual and
703societal costs, and whether the condition is acute or chronic.
704Performance outcome indicators shall be risk adjusted or
705severity adjusted, as applicable, using nationally recognized
706risk adjustment methodologies or software consistent with the
707standards of the Agency for Healthcare Research and Quality and
708as selected by the agency. The website shall also provide an
709interactive search that allows consumers to view and compare the
710information for specific facilities, a map that allows consumers
711to select a county or region, definitions of all of the data,
712descriptions of each procedure, and an explanation about why the
713data may differ from facility to facility. Such public data
714shall be updated quarterly. The agency shall submit an annual
715status report on the collection of data and publication of
716performance outcome indicators to the Governor, the Speaker of
717the House of Representatives, the President of the Senate, and
718the substantive legislative committees with the first status
719report due January 1, 2005.
720     (4)(a)  The agency shall may conduct data-based studies and
721evaluations and make recommendations to the Legislature and the
722Governor concerning exemptions, the effectiveness of limitations
723of referrals, restrictions on investment interests and
724compensation arrangements, and the effectiveness of public
725disclosure. Such analysis shall may include, but need not be
726limited to, utilization of services, cost of care, quality of
727care, and access to care. The agency may require the submission
728of data necessary to carry out this duty, which may include, but
729need not be limited to, data concerning ownership, Medicare and
730Medicaid, charity care, types of services offered to patients,
731revenues and expenses, patient-encounter data, and other data
732reasonably necessary to study utilization patterns and the
733impact of health care provider ownership interests in health-
734care-related entities on the cost, quality, and accessibility of
735health care.
736     (b)  The agency may collect such data from any health
737facility or licensed health care provider as a special study.
738     (5)  The agency shall develop and implement a strategy for
739the adoption and use of electronic health records. The agency
740may develop rules to facilitate the functionality and protect
741the confidentiality of electronic health records. The agency
742shall report to the Governor, the Speaker of the House of
743Representatives, and the President of the Senate on legislative
744recommendations to protect the confidentiality of electronic
745health records.
746     Section 11.  Paragraph (l) is added to subsection (3) of
747section 408.05, Florida Statutes, to read:
748     408.05  State Center for Health Statistics.--
749     (3)  COMPREHENSIVE HEALTH INFORMATION SYSTEM.--In order to
750produce comparable and uniform health information and
751statistics, the agency shall perform the following functions:
752     (l)  Develop, in conjunction with the State Comprehensive
753Health Information System Advisory Council, and implement a
754long-range plan for making available performance outcome and
755financial data that will allow consumers to compare health care
756services. The performance outcomes and financial data the agency
757must make available shall include, but is not limited to,
758pharmaceuticals, physicians, health care facilities, and health
759plans and managed care entities. The agency shall submit the
760initial plan to the Governor, the President of the Senate, and
761the Speaker of the House of Representatives by March 1, 2005,
762and shall update the plan and report on the status of its
763implementation annually thereafter. The agency shall also make
764the plan and status report available to the public on its
765Internet website. As part of the plan, the agency shall identify
766the process and timeframes for implementation, any barriers to
767implementation, and recommendations of changes in the law that
768may be enacted by the Legislature to eliminate the barriers. As
769preliminary elements of the plan, the agency shall:
770     1.  Make available performance outcome and patient charge
771data collected from health care facilities pursuant to s.
772408.061(1)(a) and (2). The agency shall determine which
773conditions and procedures, performance outcomes, and patient
774charge data to disclose based upon input from the council. When
775determining which conditions and procedures are to be disclosed,
776the council and the agency shall consider variation in costs,
777variation in outcomes, and magnitude of variations and other
778relevant information. When determining which performance
779outcomes to disclose, the agency:
780     a.  Shall consider such factors as volume of cases; average
781patient charges; average length of stay; complication rates;
782mortality rates; and infection rates, among others, which shall
783be adjusted for case mix and severity, if applicable.
784     b.  May consider such additional measures that are adopted
785by the Centers for Medicare and Medicaid Studies, National
786Quality Forum, the Joint Commission on Accreditation of
787Healthcare Organizations, the Agency for Healthcare Research and
788Quality, or a similar national entity that establishes standards
789to measure the performance of health care providers, or by other
790states.
791
792When determining which patient charge data to disclose, the
793agency shall consider such measures as average charge, average
794net revenue per adjusted patient day, average cost per adjusted
795patient day, and average cost per admission, among others.
796     2.  Make available performance measures, benefit design,
797and premium cost data from health plans licensed pursuant to
798chapter 627 or chapter 641. The agency shall determine which
799performance outcome and member and subscriber cost data to
800disclose, based upon input from the council. When determining
801which data to disclose, the agency shall consider information
802that may be required by either individual or group purchasers to
803assess the value of the product, which may include membership
804satisfaction, quality of care, current enrollment or membership,
805coverage areas, accreditation status, premium costs, plan costs,
806premium increases, range of benefits, copayments and
807deductibles, accuracy and speed of claims payment, credentials
808of physicians, number of providers, names of network providers,
809and hospitals in the network. Health plans shall make available
810to the agency any such data or information that is not currently
811reported to the agency or the office.
812     3.  Determine the method and format for public disclosure
813of data reported pursuant to this paragraph. The agency shall
814make its determination based upon input from the Comprehensive
815Health Information System Advisory Council. At a minimum, the
816data shall be made available on the agency's Internet website in
817a manner that allows consumers to conduct an interactive search
818that allows them to view and compare the information for
819specific providers. The website must include such additional
820information as is determined necessary to ensure that the
821website enhances informed decision making among consumers and
822health care purchasers, which shall include, at a minimum,
823appropriate guidance on how to use the data and an explanation
824of why the data may vary from provider to provider. The data
825specified in subparagraph 1. shall be released no later than
826March 1, 2005. The data specified in subparagraph 2. shall be
827released no later than March 1, 2006.
828     Section 12.  Subsection (3) of section 409.9066, Florida
829Statutes, is amended to read:
830     409.9066  Medicare prescription discount program.--
831     (3)  The Agency for Health Care Administration shall
832publish, on a free website available to the public, the most
833recent average wholesale prices for the 200 drugs most
834frequently dispensed to the elderly and, to the extent possible,
835shall provide a mechanism that consumers may use to calculate
836the retail price and the price that should be paid after the
837discount required in subsection (1) is applied. The agency shall
838provide retail information by geographic area and retail
839information by provider within geographical areas.
840     Section 13.  Section 408.7056, Florida Statutes, is amended
841to read:
842     408.7056  Statewide Provider and Subscriber Assistance
843Program.--
844     (1)  As used in this section, the term:
845     (a)  "Agency" means the Agency for Health Care
846Administration.
847     (b)  "Department" means the Department of Financial
848Services.
849     (c)  "Grievance procedure" means an established set of
850rules that specify a process for appeal of an organizational
851decision.
852     (d)  "Health care provider" or "provider" means a state-
853licensed or state-authorized facility, a facility principally
854supported by a local government or by funds from a charitable
855organization that holds a current exemption from federal income
856tax under s. 501(c)(3) of the Internal Revenue Code, a licensed
857practitioner, a county health department established under part
858I of chapter 154, a prescribed pediatric extended care center
859defined in s. 400.902, a federally supported primary care
860program such as a migrant health center or a community health
861center authorized under s. 329 or s. 330 of the United States
862Public Health Services Act that delivers health care services to
863individuals, or a community facility that receives funds from
864the state under the Community Alcohol, Drug Abuse, and Mental
865Health Services Act and provides mental health services to
866individuals.
867     (e)  "Managed care entity" means a health maintenance
868organization or a prepaid health clinic certified under chapter
869641, a prepaid health plan authorized under s. 409.912, or an
870exclusive provider organization certified under s. 627.6472.
871     (f)  "Office" means the Office of Insurance Regulation of
872the Financial Services Commission.
873     (g)  "Panel" means a statewide provider and subscriber
874assistance panel selected as provided in subsection (11).
875     (2)  The agency shall adopt and implement a program to
876provide assistance to subscribers and providers, including those
877whose grievances are not resolved by the managed care entity to
878the satisfaction of the subscriber or provider. The program
879shall consist of one or more panels that meet as often as
880necessary to timely review, consider, and hear grievances and
881recommend to the agency or the office any actions that should be
882taken concerning individual cases heard by the panel. The panel
883shall hear every grievance filed by subscribers and providers on
884behalf of subscribers, unless the grievance:
885     (a)  Relates to a managed care entity's refusal to accept a
886provider into its network of providers;
887     (b)  Is part of an internal grievance in a Medicare managed
888care entity or a reconsideration appeal through the Medicare
889appeals process which does not involve a quality of care issue;
890     (c)  Is related to a health plan not regulated by the state
891such as an administrative services organization, third-party
892administrator, or federal employee health benefit program;
893     (d)  Is related to appeals by in-plan suppliers and
894providers, unless related to quality of care provided by the
895plan;
896     (e)  Is part of a Medicaid fair hearing pursued under 42
897C.F.R. ss. 431.220 et seq.;
898     (f)  Is the basis for an action pending in state or federal
899court;
900     (g)  Is related to an appeal by nonparticipating providers,
901unless related to the quality of care provided to a subscriber
902by the managed care entity and the provider is involved in the
903care provided to the subscriber;
904     (h)  Was filed before the subscriber or provider completed
905the entire internal grievance procedure of the managed care
906entity, the managed care entity has complied with its timeframes
907for completing the internal grievance procedure, and the
908circumstances described in subsection (6) do not apply;
909     (i)  Has been resolved to the satisfaction of the
910subscriber or provider who filed the grievance, unless the
911managed care entity's initial action is egregious or may be
912indicative of a pattern of inappropriate behavior;
913     (j)  Is limited to seeking damages for pain and suffering,
914lost wages, or other incidental expenses, including accrued
915interest on unpaid balances, court costs, and transportation
916costs associated with a grievance procedure;
917     (k)  Is limited to issues involving conduct of a health
918care provider or facility, staff member, or employee of a
919managed care entity which constitute grounds for disciplinary
920action by the appropriate professional licensing board and is
921not indicative of a pattern of inappropriate behavior, and the
922agency, office, or department has reported these grievances to
923the appropriate professional licensing board or to the health
924facility regulation section of the agency for possible
925investigation; or
926     (l)  Is withdrawn by the subscriber or provider. Failure of
927the subscriber or the provider to attend the hearing shall be
928considered a withdrawal of the grievance; or
929     (3)  The agency shall review all grievances within 60 days
930after receipt and make a determination whether the grievance
931shall be heard. Once the agency notifies the panel, the
932subscriber or provider, and the managed care entity that a
933grievance will be heard by the panel, the panel shall hear the
934grievance either in the network area or by teleconference no
935later than 120 days after the date the grievance was filed. The
936agency shall notify the parties, in writing, by facsimile
937transmission, or by phone, of the time and place of the hearing.
938The panel may take testimony under oath, request certified
939copies of documents, and take similar actions to collect
940information and documentation that will assist the panel in
941making findings of fact and a recommendation. The panel shall
942issue a written recommendation, supported by findings of fact,
943to the provider or subscriber, to the managed care entity, and
944to the agency or the office no later than 15 working days after
945hearing the grievance. If at the hearing the panel requests
946additional documentation or additional records, the time for
947issuing a recommendation is tolled until the information or
948documentation requested has been provided to the panel. The
949proceedings of the panel are not subject to chapter 120.
950     (4)  If, upon receiving a proper patient authorization
951along with a properly filed grievance, the agency requests
952medical records from a health care provider or managed care
953entity, the health care provider or managed care entity that has
954custody of the records has 10 days to provide the records to the
955agency. Records include medical records, communication logs
956associated with the grievance both to and from the subscriber,
957and contracts. Failure to provide requested medical records may
958result in the imposition of a fine of up to $500. Each day that
959records are not produced is considered a separate violation.
960     (5)  Grievances that the agency determines pose an
961immediate and serious threat to a subscriber's health must be
962given priority over other grievances. The panel may meet at the
963call of the chair to hear the grievances as quickly as possible
964but no later than 45 days after the date the grievance is filed,
965unless the panel receives a waiver of the time requirement from
966the subscriber. The panel shall issue a written recommendation,
967supported by findings of fact, to the office or the agency
968within 10 days after hearing the expedited grievance.
969     (6)  When the agency determines that the life of a
970subscriber is in imminent and emergent jeopardy, the chair of
971the panel may convene an emergency hearing, within 24 hours
972after notification to the managed care entity and to the
973subscriber, to hear the grievance. The grievance must be heard
974notwithstanding that the subscriber has not completed the
975internal grievance procedure of the managed care entity. The
976panel shall, upon hearing the grievance, issue a written
977emergency recommendation, supported by findings of fact, to the
978managed care entity, to the subscriber, and to the agency or the
979office for the purpose of deferring the imminent and emergent
980jeopardy to the subscriber's life. Within 24 hours after receipt
981of the panel's emergency recommendation, the agency or office
982may issue an emergency order to the managed care entity. An
983emergency order remains in force until:
984     (a)  The grievance has been resolved by the managed care
985entity;
986     (b)  Medical intervention is no longer necessary; or
987     (c)  The panel has conducted a full hearing under
988subsection (3) and issued a recommendation to the agency or the
989office, and the agency or office has issued a final order.
990     (7)  After hearing a grievance, the panel shall make a
991recommendation to the agency or the office which may include
992specific actions the managed care entity must take to comply
993with state laws or rules regulating managed care entities.
994     (8)  A managed care entity, subscriber, or provider that is
995affected by a panel recommendation may within 10 days after
996receipt of the panel's recommendation, or 72 hours after receipt
997of a recommendation in an expedited grievance, furnish to the
998agency or office written evidence in opposition to the
999recommendation or findings of fact of the panel.
1000     (9)  No later than 30 days after the issuance of the
1001panel's recommendation and, for an expedited grievance, no later
1002than 10 days after the issuance of the panel's recommendation,
1003the agency or the office may adopt the panel's recommendation or
1004findings of fact in a proposed order or an emergency order, as
1005provided in chapter 120, which it shall issue to the managed
1006care entity. The agency or office may issue a proposed order or
1007an emergency order, as provided in chapter 120, imposing fines
1008or sanctions, including those contained in ss. 641.25 and
1009641.52. The agency or the office may reject all or part of the
1010panel's recommendation. All fines collected under this
1011subsection must be deposited into the Health Care Trust Fund.
1012     (10)  In determining any fine or sanction to be imposed,
1013the agency and the office may consider the following factors:
1014     (a)  The severity of the noncompliance, including the
1015probability that death or serious harm to the health or safety
1016of the subscriber will result or has resulted, the severity of
1017the actual or potential harm, and the extent to which provisions
1018of chapter 641 were violated.
1019     (b)  Actions taken by the managed care entity to resolve or
1020remedy any quality-of-care grievance.
1021     (c)  Any previous incidents of noncompliance by the managed
1022care entity.
1023     (d)  Any other relevant factors the agency or office
1024considers appropriate in a particular grievance.
1025     (11)(a)  The panel shall consist of the Insurance Consumer
1026Advocate, or designee thereof, established by s. 627.0613; at
1027least two members employed by the agency and at least two
1028members employed by the department, chosen by their respective
1029agencies; a consumer appointed by the Governor; a physician
1030appointed by the Governor, as a standing member; and, if
1031necessary, physicians who have expertise relevant to the case to
1032be heard, on a rotating basis. The agency may contract with a
1033medical director, and a primary care physician, or both, who
1034shall provide additional technical expertise to the panel but
1035shall not be voting members of the panel. The medical director
1036shall be selected from a health maintenance organization with a
1037current certificate of authority to operate in Florida.
1038     (b)  A majority of those panel members required under
1039paragraph (a) shall constitute a quorum for any meeting or
1040hearing of the panel. A grievance may not be heard or voted upon
1041at any panel meeting or hearing unless a quorum is present,
1042except that a minority of the panel may adjourn a meeting or
1043hearing until a quorum is present. A panel convened for the
1044purpose of hearing a subscriber's grievance in accordance with
1045subsections (2) and (3) shall not consist of more than 11
1046members.
1047     (12)  Every managed care entity shall submit a quarterly
1048report to the agency, the office, and the department listing the
1049number and the nature of all subscribers' and providers'
1050grievances which have not been resolved to the satisfaction of
1051the subscriber or provider after the subscriber or provider
1052follows the entire internal grievance procedure of the managed
1053care entity. The agency shall notify all subscribers and
1054providers included in the quarterly reports of their right to
1055file an unresolved grievance with the panel.
1056     (13)  A proposed order issued by the agency or office which
1057only requires the managed care entity to take a specific action
1058under subsection (7) is subject to a summary hearing in
1059accordance with s. 120.574, unless all of the parties agree
1060otherwise. If the managed care entity does not prevail at the
1061hearing, the managed care entity must pay reasonable costs and
1062attorney's fees of the agency or the office incurred in that
1063proceeding.
1064     (14)(a)  Any information that identifies a subscriber which
1065is held by the panel, agency, or department pursuant to this
1066section is confidential and exempt from the provisions of s.
1067119.07(1) and s. 24(a), Art. I of the State Constitution.
1068However, at the request of a subscriber or managed care entity
1069involved in a grievance procedure, the panel, agency, or
1070department shall release information identifying the subscriber
1071involved in the grievance procedure to the requesting subscriber
1072or managed care entity.
1073     (b)  Meetings of the panel shall be open to the public
1074unless the provider or subscriber whose grievance will be heard
1075requests a closed meeting or the agency or the department
1076determines that information which discloses the subscriber's
1077medical treatment or history or information relating to internal
1078risk management programs as defined in s. 641.55(5)(c), (6), and
1079(8) may be revealed at the panel meeting, in which case that
1080portion of the meeting during which a subscriber's medical
1081treatment or history or internal risk management program
1082information is discussed shall be exempt from the provisions of
1083s. 286.011 and s. 24(b), Art. I of the State Constitution. All
1084closed meetings shall be recorded by a certified court reporter.
1085     Section 14.  Paragraph (c) of subsection (4) of section
1086641.3154, Florida Statutes, is amended to read:
1087     641.3154  Organization liability; provider billing
1088prohibited.--
1089     (4)  A provider or any representative of a provider,
1090regardless of whether the provider is under contract with the
1091health maintenance organization, may not collect or attempt to
1092collect money from, maintain any action at law against, or
1093report to a credit agency a subscriber of an organization for
1094payment of services for which the organization is liable, if the
1095provider in good faith knows or should know that the
1096organization is liable. This prohibition applies during the
1097pendency of any claim for payment made by the provider to the
1098organization for payment of the services and any legal
1099proceedings or dispute resolution process to determine whether
1100the organization is liable for the services if the provider is
1101informed that such proceedings are taking place. It is presumed
1102that a provider does not know and should not know that an
1103organization is liable unless:
1104     (c)  The office or agency makes a final determination that
1105the organization is required to pay for such services subsequent
1106to a recommendation made by the Statewide Provider and
1107Subscriber Assistance Panel pursuant to s. 408.7056; or
1108     Section 15.  Subsection (1), paragraphs (b) and (e) of
1109subsection (3), paragraph (d) of subsection (4), subsection (5),
1110paragraph (g) of subsection (6), and subsections (9), (10), and
1111(11) of section 641.511, Florida Statutes, are amended to read:
1112     641.511  Subscriber grievance reporting and resolution
1113requirements.--
1114     (1)  Every organization must have a grievance procedure
1115available to its subscribers for the purpose of addressing
1116complaints and grievances. Every organization must notify its
1117subscribers that a subscriber must submit a grievance within 1
1118year after the date of occurrence of the action that initiated
1119the grievance, and may submit the grievance for review to the
1120Statewide Provider and Subscriber Assistance Program panel as
1121provided in s. 408.7056 after receiving a final disposition of
1122the grievance through the organization's grievance process. An
1123organization shall maintain records of all grievances and shall
1124report annually to the agency the total number of grievances
1125handled, a categorization of the cases underlying the
1126grievances, and the final disposition of the grievances.
1127     (3)  Each organization's grievance procedure, as required
1128under subsection (1), must include, at a minimum:
1129     (b)  The names of the appropriate employees or a list of
1130grievance departments that are responsible for implementing the
1131organization's grievance procedure. The list must include the
1132address and the toll-free telephone number of each grievance
1133department, the address of the agency and its toll-free
1134telephone hotline number, and the address of the Statewide
1135Provider and Subscriber Assistance Program and its toll-free
1136telephone number.
1137     (e)  A notice that a subscriber may voluntarily pursue
1138binding arbitration in accordance with the terms of the contract
1139if offered by the organization, after completing the
1140organization's grievance procedure and as an alternative to the
1141Statewide Provider and Subscriber Assistance Program. Such
1142notice shall include an explanation that the subscriber may
1143incur some costs if the subscriber pursues binding arbitration,
1144depending upon the terms of the subscriber's contract.
1145     (4)
1146     (d)  In any case when the review process does not resolve a
1147difference of opinion between the organization and the
1148subscriber or the provider acting on behalf of the subscriber,
1149the subscriber or the provider acting on behalf of the
1150subscriber may submit a written grievance to the Statewide
1151Provider and Subscriber Assistance Program.
1152     (5)  Except as provided in subsection (6), the organization
1153shall resolve a grievance within 60 days after receipt of the
1154grievance, or within a maximum of 90 days if the grievance
1155involves the collection of information outside the service area.
1156These time limitations are tolled if the organization has
1157notified the subscriber, in writing, that additional information
1158is required for proper review of the grievance and that such
1159time limitations are tolled until such information is provided.
1160After the organization receives the requested information, the
1161time allowed for completion of the grievance process resumes.
1162The Employee Retirement Income Security Act of 1974, as
1163implemented by 29 C.F.R. 2560.503-1, is adopted and incorporated
1164by reference as applicable to all organizations that administer
1165small and large group health plans that are subject to 29 C.F.R.
11662560.503-1. The claims procedures of the regulations of the
1167Employee Retirement Income Security Act of 1974 as implemented
1168by 29 C.F.R. 2560.503-1 shall be the minimum standards for
1169grievance processes for claims for benefits for small and large
1170group health plans that are subject to 29 C.F.R. 2560.503-1.
1171     (6)
1172     (g)  In any case when the expedited review process does not
1173resolve a difference of opinion between the organization and the
1174subscriber or the provider acting on behalf of the subscriber,
1175the subscriber or the provider acting on behalf of the
1176subscriber may submit a written grievance to the Statewide
1177Provider and Subscriber Assistance Program.
1178     (9)(a)  The agency shall advise subscribers with grievances
1179to follow their organization's formal grievance process for
1180resolution prior to review by the Statewide Provider and
1181Subscriber Assistance Program. The subscriber may, however,
1182submit a copy of the grievance to the agency at any time during
1183the process.
1184     (b)  Requiring completion of the organization's grievance
1185process before the Statewide Provider and Subscriber Assistance
1186Program panel's review does not preclude the agency from
1187investigating any complaint or grievance before the organization
1188makes its final determination.
1189     (10)  Each organization must notify the subscriber in a
1190final decision letter that the subscriber may request review of
1191the organization's decision concerning the grievance by the
1192Statewide Provider and Subscriber Assistance Program, as
1193provided in s. 408.7056, if the grievance is not resolved to the
1194satisfaction of the subscriber. The final decision letter must
1195inform the subscriber that the request for review must be made
1196within 365 days after receipt of the final decision letter, must
1197explain how to initiate such a review, and must include the
1198addresses and toll-free telephone numbers of the agency and the
1199Statewide Provider and Subscriber Assistance Program.
1200     (11)  Each organization, as part of its contract with any
1201provider, must require the provider to post a consumer
1202assistance notice prominently displayed in the reception area of
1203the provider and clearly noticeable by all patients. The
1204consumer assistance notice must state the addresses and toll-
1205free telephone numbers of the Agency for Health Care
1206Administration, the Statewide Provider and Subscriber Assistance
1207Program, and the Department of Financial Services. The consumer
1208assistance notice must also clearly state that the address and
1209toll-free telephone number of the organization's grievance
1210department shall be provided upon request. The agency may adopt
1211rules to implement this section.
1212     Section 16.  Subsection (4) of section 641.58, Florida
1213Statutes, is amended to read:
1214     641.58  Regulatory assessment; levy and amount; use of
1215funds; tax returns; penalty for failure to pay.--
1216     (4)  The moneys received and deposited into the Health Care
1217Trust Fund shall be used to defray the expenses of the agency in
1218the discharge of its administrative and regulatory powers and
1219duties under this part, including conducting an annual survey of
1220the satisfaction of members of health maintenance organizations;
1221contracting with physician consultants for the Statewide
1222Provider and Subscriber Assistance Panel; maintaining offices
1223and necessary supplies, essential equipment, and other
1224materials, salaries and expenses of required personnel; and
1225discharging the administrative and regulatory powers and duties
1226imposed under this part.
1227     Section 17.  Paragraph (f) of subsection (2) and
1228subsections (3) and (9) of section 408.909, Florida Statutes,
1229are amended to read:
1230     408.909  Health flex plans.--
1231     (2)  DEFINITIONS.--As used in this section, the term:
1232     (f)  "Health flex plan entity" means a health insurer,
1233health maintenance organization, health-care-provider-sponsored
1234organization, local government, health care district, or other
1235public or private community-based organization, or public-
1236private partnership that develops and implements an approved
1237health flex plan and is responsible for administering the health
1238flex plan and paying all claims for health flex plan coverage by
1239enrollees of the health flex plan.
1240     (3)  PILOT PROGRAM.--The agency and the office shall each
1241approve or disapprove health flex plans that provide health care
1242coverage for eligible participants who reside in the three areas
1243of the state that have the highest number of uninsured persons,
1244as identified in the Florida Health Insurance Study conducted by
1245the agency and in Indian River County. A health flex plan may
1246limit or exclude benefits otherwise required by law for insurers
1247offering coverage in this state, may cap the total amount of
1248claims paid per year per enrollee, may limit the number of
1249enrollees, or may take any combination of those actions. A
1250health flex plan offering may include the option of a
1251catastrophic plan supplementing the health flex plan.
1252     (a)  The agency shall develop guidelines for the review of
1253applications for health flex plans and shall disapprove or
1254withdraw approval of plans that do not meet or no longer meet
1255minimum standards for quality of care and access to care. The
1256agency shall ensure that the health flex plans follow
1257standardized grievance procedures similar to those required of
1258health maintenance organizations.
1259     (b)  The office shall develop guidelines for the review of
1260health flex plan applications and provide regulatory oversight
1261of health flex plan advertisement and marketing procedures. The
1262office shall disapprove or shall withdraw approval of plans
1263that:
1264     1.  Contain any ambiguous, inconsistent, or misleading
1265provisions or any exceptions or conditions that deceptively
1266affect or limit the benefits purported to be assumed in the
1267general coverage provided by the health flex plan;
1268     2.  Provide benefits that are unreasonable in relation to
1269the premium charged or contain provisions that are unfair or
1270inequitable or contrary to the public policy of this state, that
1271encourage misrepresentation, or that result in unfair
1272discrimination in sales practices; or
1273     3.  Cannot demonstrate that the health flex plan is
1274financially sound and that the applicant is able to underwrite
1275or finance the health care coverage provided.
1276     (c)  The agency and the Financial Services Commission may
1277adopt rules as needed to administer this section.
1278     (9)  PROGRAM EVALUATION.--The agency and the office shall
1279evaluate the pilot program and its effect on the entities that
1280seek approval as health flex plans, on the number of enrollees,
1281and on the scope of the health care coverage offered under a
1282health flex plan; shall provide an assessment of the health flex
1283plans and their potential applicability in other settings; shall
1284use health flex plans to gather more information to evaluate
1285low-income consumer driven benefit packages; and shall, by
1286January 1, 2005, and annually thereafter 2004, jointly submit a
1287report to the Governor, the President of the Senate, and the
1288Speaker of the House of Representatives.
1289     Section 18.  Section 381.0271, Florida Statutes, is created
1290to read:
1291     381.0271  Florida Patient Safety Corporation.--
1292     (1)  DEFINITIONS.--As used in this section, the term:
1293     (a)  "Adverse incident" has the same meanings provided in
1294ss. 395.0197, 458.351, and 459.026.
1295     (b)  "Corporation" means the Florida Patient Safety
1296Corporation.
1297     (c)  "Patient safety data" has the same meaning provided in
1298s. 766.1016.
1299     (2)  CREATION.--
1300     (a)  The Florida Patient Safety Corporation is created as a
1301not-for-profit corporation and shall be registered,
1302incorporated, organized, and operated in compliance with chapter
1303617. The corporation may create not-for-profit corporate
1304subsidiaries that are organized under the provisions of chapter
1305617, upon the prior approval of the board of directors, as
1306necessary, to fulfill its mission.
1307     (b)  The corporation and any authorized and approved
1308subsidiary are not an agency as defined in s. 20.03(11).
1309     (c)  The corporation and any authorized and approved
1310subsidiary are subject to the public meetings and records
1311requirements of s. 24, Art. I of the State Constitution, chapter
1312119, and s. 286.011.
1313     (d)  The corporation and any authorized and approved
1314subsidiary are not subject to the provisions of chapter 287.
1315     (e)  The corporation is a patient safety organization as
1316defined in s. 766.1016.
1317     (3)  PURPOSE.--
1318     (a)  The purpose of the corporation is to serve as a
1319learning organization dedicated to assisting health care
1320providers in this state to improve the quality and safety of
1321health care rendered and to reduce harm to patients. The
1322corporation shall promote the development of a culture of
1323patient safety in the health care system in this state. The
1324corporation shall not regulate health care providers in this
1325state.
1326     (b)  In fulfilling its purpose, the corporation shall work
1327with a consortium of patient safety centers and other patient
1328safety programs.
1329     (4)  BOARD OF DIRECTORS; MEMBERSHIP.--The corporation shall
1330be governed by a board of directors. The board of directors
1331shall consist of:
1332     (a)  The chair of the Florida Council of Medical School
1333Deans.
1334     (b)  Two representatives with expertise in patient safety
1335issues for the authorized health insurer and authorized health
1336maintenance organization with the largest market shares,
1337respectively, as measured by premiums written in the state for
1338the most recent calendar year, appointed by such insurer.
1339     (c)  A representative of an authorized medical malpractice
1340insurer appointed by the Florida Insurance Council.
1341     (d)  The president of the Central Florida Health Care
1342Coalition.
1343     (e)  Two representatives of a hospital in this state that
1344is implementing innovative patient safety initiatives, appointed
1345by the Florida Hospital Association.
1346     (f)  A physician with expertise in patient safety,
1347appointed by the Florida Medical Association.
1348     (g)  A physician with expertise in patient safety,
1349appointed by the Florida Osteopathic Medical Association.
1350     (h)  A physician with expertise in patient safety,
1351appointed by the Florida Podiatric Medical Association.
1352     (i)  A physician with expertise in patient safety,
1353appointed by the Florida Chiropractic Association.
1354     (j)  A dentist with expertise in patient safety, appointed
1355by the Florida Dental Association.
1356     (k)  A nurse with expertise in patient safety, appointed by
1357the Florida Nurses Association.
1358     (l)  An institutional pharmacist, appointed by the Florida
1359Society of Health-System Pharmacists.
1360     (m)  A representative of Florida AARP, appointed by the
1361state director of Florida AARP.
1362     (5)  ADVISORY COMMITTEES.--In addition to any committees
1363that the corporation may establish, the corporation shall
1364establish the following advisory committees:
1365     (a)  A scientific research advisory committee that
1366includes, at a minimum, a representative from each patient
1367safety center or other patient safety program in the
1368universities of the state who are physicians licensed pursuant
1369to chapter 458 or chapter 459, with experience in patient safety
1370and evidenced-based medicine. The duties of the advisory
1371committee shall include, but not be limited to, the analysis of
1372existing data and research to improve patient safety and
1373encourage evidence-based medicine.
1374     (b)  A technology advisory committee that includes, at a
1375minimum, a representative of a hospital that has implemented a
1376computerized physician order entry system and a health care
1377provider that has implemented an electronic medical records
1378system. The duties of the advisory committee shall include, but
1379not be limited to, implementation of new technologies, including
1380electronic medical records.
1381     (c)  A health care provider advisory committee that
1382includes, at a minimum, representatives of hospitals, ambulatory
1383surgical centers, physicians, nurses, and pharmacists licensed
1384in this state and a representative of the Veterans Integrated
1385Service Network 8, Virginia Patient Safety Center. The duties of
1386the advisory committee shall include, but not be limited to,
1387promotion of a culture of patient safety that reduces errors.
1388     (d)  A health care consumer advisory committee that
1389includes, at a minimum, representatives of businesses that
1390provide health insurance coverage to their employees, consumer
1391advocacy groups, and representatives of patient safety
1392organizations. The duties of the advisory committee shall
1393include, but not be limited to, incentives to encourage patient
1394safety and the efficiency and quality of care.
1395     (e)  A state agency advisory committee that includes, at a
1396minimum, a representative from each state agency that has
1397regulatory responsibilities related to patient safety. The
1398duties of the advisory committee shall include, but not be
1399limited to, interagency coordination of patient safety efforts.
1400     (f)  A litigation alternatives advisory committee that
1401includes, at a minimum, representatives of medical malpractice
1402attorneys for plaintiffs and defendants and a representative of
1403each law school in the state. The duties of the advisory
1404committee shall include, but not be limited to, alternatives
1405systems to compensate for injuries.
1406     (g)  An education advisory committee that includes, at a
1407minimum, the associate dean for education, or the equivalent
1408position, as a representative from each medicine, nursing,
1409public health, or allied health service to provide advice on the
1410development, implementation, and measurement of core
1411competencies for patient safety to be considered for
1412incorporation in the educational programs of the universities
1413and colleges of this state.
1414     (6)  ORGANIZATION; MEETINGS.--
1415     (a)  The Agency for Health Care Administration shall assist
1416the corporation in its organizational activities required under
1417chapter 617, including, but not limited to:
1418     1.  Eliciting appointments for the initial board of
1419directors.
1420     2.  Convening the first meeting of the board of directors
1421and assisting with other meetings of the board of directors,
1422upon request of the board of directors, during the first year of
1423operation of the corporation.
1424     3.  Drafting articles of incorporation for the board of
1425directors and, upon request of the board of directors,
1426delivering articles of incorporation to the Department of State
1427for filing.
1428     4.  Drafting proposed bylaws for the corporation.
1429     5.  Paying fees related to incorporation.
1430     6.  Providing office space and administrative support, at
1431the request of the board of directors, but not beyond July 1,
14322005.
1433     (b)  The board of directors must conduct its first meeting
1434no later than August 1, 2004, and shall meet thereafter as
1435frequently as necessary to carry out the duties of the
1436corporation.
1437     (7)  POWERS AND DUTIES.--
1438     (a)  In addition to the powers and duties prescribed in
1439chapter 617, and the articles and bylaws adopted under that
1440chapter, the corporation shall, directly or through contract:
1441     1.  Secure staff necessary to properly administer the
1442corporation.
1443     2.  Collect, analyze, and evaluate patient safety data and
1444quality and patient safety indicators, medical malpractice
1445closed claims, and adverse incidents reported to the Agency for
1446Health Care Administration and the Department of Health for the
1447purpose of recommending changes in practices and procedures that
1448may be implemented by health care practitioners and health care
1449facilities to improve health care quality and to prevent future
1450adverse incidents. Notwithstanding any other provision of law,
1451the Agency for Health Care Administration and the Department of
1452Health shall make available to the corporation any adverse
1453incident report submitted under ss. 395.0197, 458.351, and
1454459.026. To the extent that adverse incident reports submitted
1455under s. 395.0197 are confidential and exempt, the confidential
1456and exempt status of such reports shall be maintained by the
1457corporation.
1458     3.  Establish a "near-miss" patient safety reporting
1459system. The purpose of the near-miss reporting system is to:
1460identify potential systemic problems that could lead to adverse
1461incidents; enable publication of systemwide alerts of potential
1462harm; and facilitate development of both facility-specific and
1463statewide options to avoid adverse incidents and improve patient
1464safety. The reporting system shall record "near misses"
1465submitted by hospitals, birthing centers, and ambulatory
1466surgical centers and other providers. For the purpose of the
1467reporting system:
1468     a.  The term "near miss" means any potentially harmful
1469event that could have had an adverse result but, through chance
1470or intervention in which, harm was prevented.
1471     b.  The near-miss reporting system shall be voluntary and
1472anonymous and independent of mandatory reporting systems used
1473for regulatory purposes.
1474     c.  Near-miss data submitted to the corporation is patient
1475safety data as defined in s. 766.1016.
1476     d.  Reports of near-miss data shall be published on a
1477regular basis and special alerts shall be published as needed
1478regarding newly identified, significant risks.
1479     e.  Aggregated data shall be made available publicly.
1480     f.  The corporation shall report the performance and
1481results of the near-miss project in its annual report.
1482     4.  Work collaboratively with the appropriate state
1483agencies in the development of electronic health records.
1484     5.  Provide for access to an active library of evidence-
1485based medicine and patient safety practices, together with the
1486emerging evidence supporting their retention or modification,
1487and make this information available to health care
1488practitioners, health care facilities, and the public. Support
1489for implementation of evidence-based medicine shall include:
1490     a.  A report to the Governor, the President of the Senate,
1491the Speaker of the House of Representatives, and the Agency for
1492Health Care Administration by January 1, 2005, on:
1493     (I)  The ability to join or support efforts for the use of
1494evidence-based medicine already underway, such as those of the
1495Leapfrog Group, the international group Bandolier, and the
1496Healthy Florida Foundation.
1497     (II)  The means by which to promote research using Medicaid
1498and other data collected by the Agency for Health Care
1499Administration to identify and quantify the most cost-effective
1500treatment and interventions, including disease management and
1501prevention programs.
1502     (III)  The means by which to encourage development of
1503systems to measure and reward providers who implement evidence-
1504based medical practices.
1505     (IV)  The review of other state and private initiatives and
1506published literature for promising approaches and the
1507dissemination of information about them to providers.
1508     (V)  The encouragement of the Florida health care boards
1509under the Department of Health to regularly publish findings
1510related to the cost-effectiveness of disease-specific, evidence-
1511based standards.
1512     (VI)  Public and private sector initiatives related to
1513evidence-based medicine and communication systems for the
1514sharing of clinical information among caregivers.
1515     (VII)  Regulatory barriers that interfere with the sharing
1516of clinical information among caregivers.
1517     b.  An implementation plan reported to the Governor, the
1518President of the Senate, the Speaker of the House of
1519Representatives, and the Agency for Health Care Administration
1520by September 1, 2005, that must include, but need not be limited
1521to: estimated costs and savings, capital investment
1522requirements, recommended investment incentives, initial
1523committed provider participation by region, standards of
1524functionality and features, a marketing plan, and implementation
1525schedules for key components.
1526     6.  Develop and recommend core competencies in patient
1527safety that can be incorporated into the undergraduate and
1528graduate curricula in schools of medicine, nursing, and allied
1529health in the state.
1530     7.  Develop and recommend programs to educate the public
1531about the role of health care consumers in promoting patient
1532safety.
1533     8.  Provide recommendations for interagency coordination of
1534patient safety efforts in the state.
1535     (b)  In carrying out its powers and duties, the corporation
1536may also:
1537     1.  Assess the patient safety culture at volunteering
1538hospitals and recommend methods to improve the working
1539environment related to patient safety at these hospitals.
1540     2.  Inventory the information technology capabilities
1541related to patient safety of health care facilities and health
1542care practitioners and recommend a plan for expediting the
1543implementation of patient safety technologies statewide.
1544     3.  Recommend continuing medical education regarding
1545patient safety to practicing health care practitioners.
1546     4.  Study and facilitate the testing of alternative systems
1547of compensating injured patients as a means of reducing and
1548preventing medical errors and promoting patient safety.
1549     5.  Conduct other activities identified by the board of
1550directors to promote patient safety in this state.
1551     (8)  ANNUAL REPORT.--By December 1, 2004, the corporation
1552shall prepare a report on the startup activities of the
1553corporation and any proposals for legislative action that are
1554needed for the corporation to fulfill its purposes under this
1555section. By December 1 of each year thereafter, the corporation
1556shall prepare a report for the preceding fiscal year. The
1557report, at a minimum, must include:
1558     (a)  A description of the activities of the corporation
1559under this section.
1560     (b)  Progress made in improving patient safety and reducing
1561medical errors.
1562     (c)  Policies and programs that have been implemented and
1563their outcomes.
1564     (d)  A compliance and financial audit of the accounts and
1565records of the corporation at the end of the preceding fiscal
1566year conducted by an independent certified public accountant.
1567     (e)  Recommendations for legislative action needed to
1568improve patient safety in the state.
1569     (f)  An assessment of the ability of the corporation to
1570fulfill the duties specified in this section and the
1571appropriateness of those duties for the corporation.
1572
1573The corporation shall submit the report to the Governor, the
1574President of the Senate, and the Speaker of the House of
1575Representatives.
1576     (9)  FUNDING.--The corporation is required to seek private
1577sector funding and apply for grants to accomplish its goals and
1578duties.
1579     (10)  PERFORMANCE EXPECTATIONS.--The Office of Program
1580Policy Analysis and Government Accountability, the Agency for
1581Health Care Administration, and the Department of Health shall
1582develop performance standards by which to measure the success of
1583the corporation in fulfilling the purposes established in this
1584section. Using the performance standards, the Office of Program
1585Policy Analysis and Government Accountability shall conduct a
1586performance audit of the corporation during 2006 and shall
1587submit a report to the Governor, the President of the Senate,
1588and the Speaker of the House of Representatives by January 1,
15892007.
1590     Section 19.  Subsection (3) of section 409.91255, Florida
1591Statutes, is amended to read:
1592     409.91255  Federally qualified health center access
1593program.--
1594     (3)  ASSISTANCE TO FEDERALLY QUALIFIED HEALTH CENTERS.--The
1595Department of Health shall develop a program for the expansion
1596of federally qualified health centers for the purpose of
1597providing comprehensive primary and preventive health care and
1598urgent care services, including services that may reduce the
1599morbidity, mortality, and cost of care among the uninsured
1600population of the state. The program shall provide for
1601distribution of financial assistance to federally qualified
1602health centers that apply and demonstrate a need for such
1603assistance in order to sustain or expand the delivery of primary
1604and preventive health care services. In selecting centers to
1605receive this financial assistance, the program:
1606     (a)  Shall give preference to communities that have few or
1607no community-based primary care services or in which the current
1608services are unable to meet the community's needs.
1609     (b)  Shall require that primary care services be provided
1610to the medically indigent using a sliding fee schedule based on
1611income.
1612     (c)  Shall allow innovative and creative uses of federal,
1613state, and local health care resources.
1614     (d)  Shall require that the funds provided be used to pay
1615for operating costs of a projected expansion in patient
1616caseloads or services or for capital improvement projects.
1617Capital improvement projects may include renovations to existing
1618facilities or construction of new facilities, provided that an
1619expansion in patient caseloads or services to a new patient
1620population will occur as a result of the capital expenditures.
1621The department shall include in its standard contract document a
1622requirement that any state funds provided for the purchase of or
1623improvements to real property are contingent upon the contractor
1624granting to the state a security interest in the property at
1625least to the amount of the state funds provided for at least 5
1626years from the date of purchase or the completion of the
1627improvements or as further required by law. The contract must
1628include a provision that, as a condition of receipt of state
1629funding for this purpose, the contractor agrees that, if it
1630disposes of the property before the department's interest is
1631vacated, the contractor will refund the proportionate share of
1632the state's initial investment, as adjusted by depreciation.
1633     (e)  May require in-kind support from other sources.
1634     (f)  May encourage coordination among federally qualified
1635health centers, other private-sector providers, and publicly
1636supported programs.
1637     (g)  Shall allow the development of community emergency
1638room diversion programs in conjunction with local resources,
1639providing extended hours of operation to urgent care patients.
1640Diversion programs shall include case management for emergency
1641room followup care.
1642     Section 20.  Paragraph (a) of subsection (6) of section
1643627.410, Florida Statutes, is amended to read:
1644     627.410  Filing, approval of forms.--
1645     (6)(a)  An insurer shall not deliver or issue for delivery
1646or renew in this state any health insurance policy form until it
1647has filed with the office a copy of every applicable rating
1648manual, rating schedule, change in rating manual, and change in
1649rating schedule; if rating manuals and rating schedules are not
1650applicable, the insurer must file with the office order
1651applicable premium rates and any change in applicable premium
1652rates. This paragraph does not apply to group health insurance
1653policies, effectuated and delivered in this state, insuring
1654groups of 51 or more persons, except for Medicare supplement
1655insurance, long-term care insurance, and any coverage under
1656which the increase in claim costs over the lifetime of the
1657contract due to advancing age or duration is prefunded in the
1658premium.
1659     Section 21.  Section 627.64872, Florida Statutes, is
1660created to read:
1661     627.64872  Florida Health Insurance Plan.--
1662     (1)  LEGISLATIVE INTENT.--
1663     (a)  The Legislature recognizes that to secure a more
1664stable and orderly health insurance market, the establishment of
1665a plan to assume risks deemed uninsurable by the private
1666marketplace is required.
1667     (b)  The Florida Health Insurance Plan is to make coverage
1668available to individuals who have no other option for similar
1669coverage, at a premium that is commensurate with the risk and
1670benefits provided, and with benefit designs that are reasonable
1671in relation to the general market. While plan operations may
1672include supplementary funding, the plan shall fundamentally
1673operate on sound actuarial principles, using basic insurance
1674management techniques to ensure that the plan is run in an
1675economical, cost-efficient, and sound manner, conserving plan
1676resources to serve the maximum number of people possible in a
1677sustainable fashion.
1678     (2)  DEFINITIONS.--As used in this section:
1679     (a)  "Board" means the board of directors of the plan.
1680     (b)  "Dependent" means a resident spouse or resident
1681unmarried child under the age of 19 years, a child who is a
1682student under the age of 25 years and who is financially
1683dependent upon the parent, or a child of any age who is disabled
1684and dependent upon the parent.
1685     (c)  "Director" means the director of the Office of
1686Insurance Regulation.
1687     (d)  "Health insurance" means any hospital or medical
1688expense incurred policy or health maintenance organization
1689subscriber contract pursuant to chapter 641. The term does not
1690include short-term, accident, dental-only, vision-only, fixed-
1691indemnity, limited-benefit, or credit insurance; disability
1692income insurance; coverage for onsite medical clinics; insurance
1693coverage specified in federal regulations issued pursuant to
1694Pub. L. No. 104-191, under which benefits for medical care are
1695secondary or incidental to other insurance benefits; benefits
1696for long-term care, nursing home care, home health care,
1697community-based care, or any combination thereof, or other
1698similar, limited benefits specified in federal regulations
1699issued pursuant to Pub. L. No. 104-191; benefits provided under
1700a separate policy, certificate, or contract of insurance, under
1701which there is no coordination between the provision of the
1702benefits and any exclusion of benefits under any group health
1703plan maintained by the same plan sponsor and the benefits are
1704paid with respect to an event without regard to whether benefits
1705are provided with respect to such an event under any group
1706health plan maintained by the same plan sponsor, such as for
1707coverage only for a specified disease or illness; hospital
1708indemnity or other fixed indemnity insurance; coverage offered
1709as a separate policy, certificate, or contract of insurance,
1710such as Medicare supplemental health insurance as defined under
1711s. 1882(g)(1) of the Social Security Act; coverage supplemental
1712to the coverage provided under chapter 55 of Title 10, United
1713States Code, the Civilian Health and Medical Program of the
1714Uniformed Services (CHAMPUS); similar supplemental coverage
1715provided to coverage under a group health plan; coverage issued
1716as a supplement to liability insurance; insurance arising out of
1717a workers' compensation or similar law; automobile medical
1718payment insurance; or insurance under which benefits are payable
1719with or without regard to fault and which is statutorily
1720required to be contained in any liability insurance policy or
1721equivalent selfinsurance.
1722     (e)  "Implementation" means the effective date after the
1723first meeting of the board when legal authority and
1724administrative ability exists for the board to subsume the
1725transfer of all statutory powers, duties, functions, assets,
1726records, personnel, and property of the Florida Comprehensive
1727Health Association as specified in s. 627.6488.
1728     (f)  "Insurer" means any entity that provides health
1729insurance in this state. For purposes of this section, insurer
1730includes an insurance company with a valid certificate in
1731accordance with chapter 624, a health maintenance organization
1732with a valid certificate of authority in accordance with part I
1733or part III of chapter 641, a prepaid health clinic authorized
1734to transact business in this state pursuant to part II of
1735chapter 641, multiple employer welfare arrangements authorized
1736to transact business in this state pursuant to ss. 624.436-
1737624.45, or a fraternal benefit society providing health benefits
1738to its members as authorized pursuant to chapter 632.
1739     (g)  "Medicare" means coverage under both Parts A and B of
1740Title XVIII of the Social Security Act, 42 USC 1395 et seq., as
1741amended.
1742     (h)  "Medicaid" means coverage under Title XIX of the
1743Social Security Act.
1744     (i)  "Office" means the Office of Insurance Regulation of
1745the Financial Services Commission.
1746     (j)  "Participating insurer" means any insurer providing
1747health insurance to citizens of this state.
1748     (k)  "Provider" means any physician, hospital, or other
1749institution, organization, or person that furnishes health care
1750services and is licensed or otherwise authorized to practice in
1751the state.
1752     (l)  "Plan" means the Florida Health Insurance Plan created
1753in subsection (1).
1754     (m)  "Plan of operation" means the articles, bylaws, and
1755operating rules and procedures adopted by the board pursuant to
1756this section.
1757     (n)  "Resident" means an individual who has been legally
1758domiciled in this state for a period of at least 6 months.
1759     (3)  BOARD OF DIRECTORS.--
1760     (a)  The plan shall operate subject to the supervision and
1761control of the board. The board shall consist of the director or
1762his or her designated representative, who shall serve as a
1763member of the board and shall be its chair, and an additional
1764eight members, five of whom shall be appointed by the Governor,
1765at least two of whom shall be individuals not representative of
1766insurers or health care providers, one of whom shall be
1767appointed by the President of the Senate, one of whom shall be
1768appointed by the Speaker of the House of Representatives, and
1769one of whom shall be appointed by the Chief Financial Officer.
1770     (b)  The term to be served on the board by the director of
1771the Office of Insurance Regulation shall be determined by
1772continued employment in such position. The remaining initial
1773board members shall serve for a period of time as follows: two
1774members appointed by the Governor and the members appointed by
1775the President of the Senate and the Speaker of the House of
1776Representatives shall serve a term of 2 years; and three members
1777appointed by the Governor and the Chief Financial Officer shall
1778serve a term of 4 years. Subsequent board members shall serve
1779for a term of 3 years. A board member's term shall continue
1780until his or her successor is appointed.
1781     (c)  Vacancies on the board shall be filled by the
1782appointing authority, such authority being the Governor, the
1783President of the Senate, the Speaker of the House of
1784Representatives, or the Chief Financial Officer. The appointing
1785authority may remove board members for cause.
1786     (d)  The director, or his or her recognized representative,
1787shall be responsible for any organizational requirements
1788necessary for the initial meeting of the board which shall take
1789place no later than September 1, 2004.
1790     (e)  Members shall not be compensated in their capacity as
1791board members but shall be reimbursed for reasonable expenses
1792incurred in the necessary performance of their duties in
1793accordance with s. 112.061.
1794     (f)  The board shall submit to the Financial Services
1795Commission a plan of operation for the plan and any amendments
1796thereto necessary or suitable to ensure the fair, reasonable,
1797and equitable administration of the plan. The plan of operation
1798shall ensure that the plan qualifies to apply for any available
1799funding from the Federal Government that adds to the financial
1800viability of the plan. The plan of operation shall become
1801effective upon approval in writing by the Financial Services
1802Commission consistent with the date on which the coverage under
1803this section must be made available. If the board fails to
1804submit a suitable plan of operation within 1 year after the
1805appointment of the board of directors, or at any time thereafter
1806fails to submit suitable amendments to the plan of operation,
1807the Financial Services Commission shall adopt such rules as are
1808necessary or advisable to effectuate the provisions of this
1809section. Such rules shall continue in force until modified by
1810the office or superseded by a plan of operation submitted by the
1811board and approved by the Financial Services Commission.
1812     (4)  PLAN OF OPERATION.--The plan of operation shall:
1813     (a)  Establish procedures for operation of the plan.
1814     (b)  Establish procedures for selecting an administrator in
1815accordance with subsection (11).
1816     (c)  Establish procedures to create a fund, under
1817management of the board, for administrative expenses.
1818     (d)  Establish procedures for the handling, accounting, and
1819auditing of assets, moneys, and claims of the plan and the plan
1820administrator.
1821     (e)  Develop and implement a program to publicize the
1822existence of the plan, plan eligibility requirements, and
1823procedures for enrollment and maintain public awareness of the
1824plan.
1825     (f)  Establish procedures under which applicants and
1826participants may have grievances reviewed by a grievance
1827committee appointed by the board. The grievances shall be
1828reported to the board after completion of the review, with the
1829committee's recommendation for grievance resolution. The board
1830shall retain all written grievances regarding the plan for at
1831least 3 years.
1832     (g)  Provide for other matters as may be necessary and
1833proper for the execution of the board's powers, duties, and
1834obligations under this section.
1835     (5)  POWERS OF THE PLAN.--The plan shall have the general
1836powers and authority granted under the laws of this state to
1837health insurers and, in addition thereto, the specific authority
1838to:
1839     (a)  Enter into such contracts as are necessary or proper
1840to carry out the provisions and purposes of this section,
1841including the authority, with the approval of the Chief
1842Financial Officer, to enter into contracts with similar plans of
1843other states for the joint performance of common administrative
1844functions, or with persons or other organizations for the
1845performance of administrative functions.
1846     (b)  Take any legal actions necessary or proper to recover
1847or collect assessments due the plan.
1848     (c)  Take such legal action as is necessary to:
1849     1.  Avoid payment of improper claims against the plan or
1850the coverage provided by or through the plan;
1851     2.  Recover any amounts erroneously or improperly paid by
1852the plan;
1853     3.  Recover any amounts paid by the plan as a result of
1854mistake of fact or law; or
1855     4.  Recover other amounts due the plan.
1856     (d)  Establish, and modify as appropriate, rates, rate
1857schedules, rate adjustments, expense allowances, agents'
1858commissions, claims reserve formulas, and any other actuarial
1859functions appropriate to the operation of the plan. Rates and
1860rate schedules may be adjusted for appropriate factors such as
1861age, sex, and geographic variation in claim cost and shall take
1862into consideration appropriate factors in accordance with
1863established actuarial and underwriting practices. For purposes
1864of this paragraph, usual and customary agent's commissions shall
1865be paid for the initial placement of coverage with the plan and
1866for one renewal only.
1867     (e)  Issue policies of insurance in accordance with the
1868requirements of this section.
1869     (f)  Appoint appropriate legal, actuarial, investment, and
1870other committees as necessary to provide technical assistance in
1871the operation of the plan and develop and educate its
1872policyholders regarding health savings accounts, policy and
1873contract design, and any other function within the authority of
1874the plan.
1875     (g)  Borrow money to effectuate the purposes of the plan.
1876Any notes or other evidence of indebtedness of the plan not in
1877default shall be legal investments for insurers and may be
1878carried as admitted assets.
1879     (h)  Employ and fix the compensation of employees.
1880     (i)  Prepare and distribute certificate of eligibility
1881forms and enrollment instruction forms to insurance producers
1882and to the general public.
1883     (j)  Provide for reinsurance of risks incurred by the plan.
1884     (k)  Provide for and employ cost-containment measures and
1885requirements, including, but not limited to, preadmission
1886screening, second surgical opinion, concurrent utilization
1887review, and individual case management for the purpose of making
1888the plan more cost-effective.
1889     (l)  Design, use, contract, or otherwise arrange for the
1890delivery of cost-effective health care services, including, but
1891not limited to, establishing or contracting with preferred
1892provider organizations, health maintenance organizations, and
1893other limited network provider arrangements.
1894     (m)  Adopt such bylaws, policies, and procedures as may be
1895necessary or convenient for the implementation of this section
1896and the operation of the plan.
1897     (n)  Subsume the transfer of statutory powers, duties,
1898functions, assets, records, personnel, and property of the
1899Florida Comprehensive Health Association as specified in ss.
1900627.6488, 627.6489, 627.649, 627.6492, 627.6496, 627.6498, and
1901627.6499, unless otherwise specified by law.
1902     (6)  INTERIM REPORT; ANNUAL REPORT.--
1903     (a)  By no later than December 1, 2004, the board shall
1904report to the Governor, the President of the Senate, and the
1905Speaker of the House of Representatives the results of an
1906actuarial study conducted by the board to determine, including,
1907but not limited to:
1908     1.  The impact the creation of the plan will have on the
1909small group insurance market and the individual market on
1910premiums paid by insureds. This shall include an estimate of the
1911total anticipated aggregate savings for all small employers in
1912the state.
1913     2.  The number of individuals the pool could reasonably
1914cover at various funding levels, specifically, the number of
1915people the pool may cover at each of those funding levels.
1916     3.  A recommendation as to the best source of funding for
1917the anticipated deficits of the pool.
1918     4.  The effect on the individual and small group market by
1919including in the Florida Health Insurance Plan persons eligible
1920for coverage under s. 627.6487, as well as the cost of including
1921these individuals.
1922
1923The board shall take no action to implement the Florida Health
1924Insurance Plan, other than the completion of the actuarial study
1925authorized in this paragraph, until funds are appropriated for
1926startup cost and any projected deficits.
1927     (b)  No later than December 1, 2005, and annually
1928thereafter, the board shall submit to the Governor, the
1929President of the Senate, the Speaker of the House of
1930Representatives, and the substantive legislative committees of
1931the Legislature a report which includes an independent actuarial
1932study to determine, including, but not be limited to:
1933     1.  The impact the creation of the plan has on the small
1934group and individual insurance market, specifically on the
1935premiums paid by insureds. This shall include an estimate of the
1936total anticipated aggregate savings for all small employers in
1937the state.
1938     2.  The actual number of individuals covered at the current
1939funding and benefit level, the projected number of individuals
1940that may seek coverage in the forthcoming fiscal year, and the
1941projected funding needed to cover anticipated increase or
1942decrease in plan participation.
1943     3.  A recommendation as to the best source of funding for
1944the anticipated deficits of the pool.
1945     4.  A summarization of the activities of the plan in the
1946preceding calendar year, including the net written and earned
1947premiums, plan enrollment, the expense of administration, and
1948the paid and incurred losses.
1949     5.  A review of the operation of the plan as to whether the
1950plan has met the intent of this section.
1951     (7)  LIABILITY OF THE PLAN.--Neither the board nor its
1952employees shall be liable for any obligations of the plan. No
1953member or employee of the board shall be liable, and no cause of
1954action of any nature may arise against a member or employee of
1955the board, for any act or omission related to the performance of
1956any powers and duties under this section, unless such act or
1957omission constitutes willful or wanton misconduct. The board may
1958provide in its bylaws or rules for indemnification of, and legal
1959representation for, its members and employees.
1960     (8)  AUDITED FINANCIAL STATEMENT.--No later than June 1
1961following the close of each calendar year, the plan shall submit
1962to the Financial Services Commission an audited financial
1963statement prepared in accordance with statutory accounting
1964principles as adopted by the National Association of Insurance
1965Commissioners.
1966     (9)  ELIGIBILITY.--
1967     (a)  Any individual person who is and continues to be a
1968resident of this state shall be eligible for coverage under the
1969plan if:
1970     1.  Evidence is provided that the person received notices
1971of rejection or refusal to issue substantially similar coverage
1972for health reasons from at least two health insurers or health
1973maintenance organizations. A rejection or refusal by an insurer
1974offering only stoploss, excess of loss, or reinsurance coverage
1975with respect to the applicant shall not be sufficient evidence
1976under this paragraph.
1977     2.  The person is enrolled in the Florida Comprehensive
1978Health Association as of the date the plan is implemented.
1979     (b)  Each resident dependent of a person who is eligible
1980for coverage under the plan shall also be eligible for such
1981coverage.
1982     (c)  A person shall not be eligible for coverage under the
1983plan if:
1984     1.  The person has or obtains health insurance coverage
1985substantially similar to or more comprehensive than a plan
1986policy, or would be eligible to obtain such coverage, unless a
1987person may maintain other coverage for the period of time the
1988person is satisfying any preexisting condition waiting period
1989under a plan policy or may maintain plan coverage for the period
1990of time the person is satisfying a preexisting condition waiting
1991period under another health insurance policy intended to replace
1992the plan policy.
1993     2.  The person is determined to be eligible for health care
1994benefits under Medicaid, Medicare, the state's children's health
1995insurance program, or any other federal, state, or local
1996government program that provides health benefits;
1997     3.  The person voluntarily terminated plan coverage unless
199812 months have elapsed since such termination;
1999     4.  The person is an inmate or resident of a public
2000institution; or
2001     5.  The person's premiums are paid for or reimbursed under
2002any government-sponsored program or by any government agency or
2003health care provider.
2004     (d)  Coverage shall cease:
2005     1.  On the date a person is no longer a resident of this
2006state;
2007     2.  On the date a person requests coverage to end;
2008     3.  Upon the death of the covered person;
2009     4.  On the date state law requires cancellation or
2010nonrenewal of the policy; or
2011     5.  At the option of the plan, 30 days after the plan makes
2012any inquiry concerning the person's eligibility or place of
2013residence to which the person does not reply.
2014     6.  Upon failure of the insured to pay for continued
2015coverage.
2016     (e)  Except under the circumstances described in this
2017subsection, coverage of a person who ceases to meet the
2018eligibility requirements of this subsection shall be terminated
2019at the end of the policy period for which the necessary premiums
2020have been paid.
2021     (10)  UNFAIR REFERRAL TO PLAN.--It is an unfair trade
2022practice for the purposes of part IX of chapter 626 or s.
2023641.3901 for an insurer, health maintenance organization
2024insurance agent, insurance broker, or third-party administrator
2025to refer an individual employee to the plan, or arrange for an
2026individual employee to apply to the plan, for the purpose of
2027separating that employee from group health insurance coverage
2028provided in connection with the employee's employment.
2029     (11)  PLAN ADMINISTRATOR.--The board shall select through a
2030competitive bidding process a plan administrator to administer
2031the plan. The board shall evaluate bids submitted based on
2032criteria established by the board, which shall include:
2033     (a)  The plan administrator's proven ability to handle
2034health insurance coverage to individuals.
2035     (b)  The efficiency and timeliness of the plan
2036administrator's claim processing procedures.
2037     (c)  An estimate of total charges for administering the
2038plan.
2039     (d)  The plan administrator's ability to apply effective
2040cost-containment programs and procedures and to administer the
2041plan in a cost-efficient manner.
2042     (e)  The financial condition and stability of the plan
2043administrator.
2044
2045The administrator shall be an insurer, a health maintenance
2046organization, or a third-party administrator, or another
2047organization duly authorized to provide insurance pursuant to
2048the Florida Insurance Code.
2049     (12)  ADMINISTRATOR TERM LIMITS.--The plan administrator
2050shall serve for a period specified in the contract between the
2051plan and the plan administrator subject to removal for cause and
2052subject to any terms, conditions, and limitations of the
2053contract between the plan and the plan administrator. At least 1
2054year prior to the expiration of each period of service by a plan
2055administrator, the board shall invite eligible entities,
2056including the current plan administrator, to submit bids to
2057serve as the plan administrator. Selection of the plan
2058administrator for each succeeding period shall be made at least
20596 months prior to the end of the current period.
2060     (13)  DUTIES OF THE PLAN ADMINISTRATOR.--
2061     (a)  The plan administrator shall perform such functions
2062relating to the plan as may be assigned to it, including, but
2063not limited to:
2064     1.  Determination of eligibility.
2065     2.  Payment of claims.
2066     3.  Establishment of a premium billing procedure for
2067collection of premiums from persons covered under the plan.
2068     4.  Other necessary functions to ensure timely payment of
2069benefits to covered persons under the plan.
2070     (b)  The plan administrator shall submit regular reports to
2071the board regarding the operation of the plan. The frequency,
2072content, and form of the reports shall be specified in the
2073contract between the board and the plan administrator.
2074     (c)  On March 1 following the close of each calendar year,
2075the plan administrator shall determine net written and earned
2076premiums, the expense of administration, and the paid and
2077incurred losses for the year and report this information to the
2078board and the Governor on a form prescribed by the Governor.
2079     (14)  PAYMENT OF THE PLAN ADMINISTRATOR.--The plan
2080administrator shall be paid as provided in the contract between
2081the plan and the plan administrator.
2082     (15)  FUNDING OF THE PLAN.--
2083     (a)  Premiums.--
2084     1.  The plan shall establish premium rates for plan
2085coverage as provided in this section. Separate schedules of
2086premium rates based on age, sex, and geographical location may
2087apply for individual risks. Premium rates and schedules shall be
2088submitted to the office for approval prior to use.
2089     2.  Initial rates for plan coverage shall be limited to no
2090more than 300 percent of rates established for individual
2091standard risks as specified in s. 627.6675(3)(c). Subject to the
2092limits provided in this paragraph, subsequent rates shall be
2093established to provide fully for the expected costs of claims,
2094including recovery of prior losses, expenses of operation,
2095investment income of claim reserves, and any other cost factors
2096subject to the limitations described herein, but in no event
2097shall premiums exceed the 300-percent rate limitation provided
2098in this section. Notwithstanding the 300-percent rate
2099limitation, sliding scale premium surcharges based upon the
2100insured's income may apply to all enrollees.
2101     (b)  Sources of additional revenue.--Any deficit incurred
2102by the plan shall be primarily funded through amounts
2103appropriated by the Legislature from general revenue sources,
2104including, but not limited to, a portion of the annual growth in
2105existing net insurance premium taxes. The board shall operate
2106the plan in such a manner that the estimated cost of providing
2107health insurance during any fiscal year will not exceed total
2108income the plan expects to receive from policy premiums and
2109funds appropriated by the Legislature, including any interest on
2110investments. After determining the amount of funds appropriated
2111to the board for a fiscal year, the board shall estimate the
2112number of new policies it believes the plan has the financial
2113capacity to insure during that year so that costs do not exceed
2114income. The board shall take steps necessary to ensure that plan
2115enrollment does not exceed the number of residents it has
2116estimated it has the financial capacity to insure.
2117     (16)  BENEFITS.--
2118     (a)  The benefits provided shall be the same as the
2119standard and basic plans for small employers as outlined in s.
2120627.6699. The board shall also establish an option of
2121alternative coverage such as catastrophic coverage that includes
2122a minimum level of primary care coverage and a high deductible
2123plan that meets the federal requirements of a health savings
2124account.
2125     (b)  In establishing the plan coverage, the board shall
2126take into consideration the levels of health insurance provided
2127in the state and such medical economic factors as may be deemed
2128appropriate and adopt benefit levels, deductibles, copayments,
2129coinsurance factors, exclusions, and limitations determined to
2130be generally reflective of and commensurate with health
2131insurance provided through a representative number of large
2132employers in the state.
2133     (c)  The board may adjust any deductibles and coinsurance
2134factors annually according to the medical component of the
2135Consumer Price Index.
2136     (d)1.  Plan coverage shall exclude charges or expenses
2137incurred during the first 6 months following the effective date
2138of coverage for any condition for which medical advice, care, or
2139treatment was recommended or received for such condition during
2140the 6-month period immediately preceding the effective date of
2141coverage.
2142     2.  Such preexisting condition exclusions shall be waived
2143to the extent that similar exclusions, if any, have been
2144satisfied under any prior health insurance coverage which was
2145involuntarily terminated, provided application for pool coverage
2146is made not later than 63 days following such involuntary
2147termination. In such case, coverage under the plan shall be
2148effective from the date on which such prior coverage was
2149terminated and the applicant is not eligible for continuation or
2150conversion rights that would provide coverage substantially
2151similar to plan coverage.
2152     (17)  NONDUPLICATION OF BENEFITS.--
2153     (a)  The plan shall be payor of last resort of benefits
2154whenever any other benefit or source of third-party payment is
2155available. Benefits otherwise payable under plan coverage shall
2156be reduced by all amounts paid or payable through any other
2157health insurance, by all hospital and medical expense benefits
2158paid or payable under any workers' compensation coverage,
2159automobile medical payment, or liability insurance, whether
2160provided on the basis of fault or nonfault, and by any hospital
2161or medical benefits paid or payable under or provided pursuant
2162to any state or federal law or program.
2163     (b)  The plan shall have a cause of action against an
2164eligible person for the recovery of the amount of benefits paid
2165that are not for covered expenses. Benefits due from the plan
2166may be reduced or refused as a setoff against any amount
2167recoverable under this paragraph.
2168     (18)  ANNUAL AND MAXIMUM BENEFITS.--Maximum benefits under
2169the plan shall be determined by the board.
2170     (19)  TAXATION.--The plan is exempt from any tax imposed by
2171this state. The plan shall apply for federal tax exemption
2172status.
2173     (20)  COMBINING MEMBERSHIP OF THE FLORIDA COMPREHENSIVE
2174HEALTH ASSOCIATION; ASSESSMENT.--
2175     (a)1. Upon implementation of the Florida Health Insurance
2176Plan, the Florida Comprehensive Health Association, as specified
2177in s. 627.6488, is abolished as a separate nonprofit entity and
2178shall be subsumed under the board of directors of the Florida
2179Health Insurance Plan. All individuals actively enrolled in the
2180Florida Comprehensive Health Association shall be enrolled in
2181the plan subject to its rules and requirements, except as
2182otherwise specified in this section. Maximum lifetime benefits
2183paid to an individual in the plan shall not exceed the amount
2184established under subsection (16), and benefits previously paid
2185for any individual by the Florida Comprehensive Health
2186Association shall be used in the determination of total lifetime
2187benefits paid under the plan.
2188     2.  All persons enrolled in the Florida Comprehensive
2189Health Association upon implementation of the Florida Health
2190Insurance Plan are only eligible for the benefits authorized
2191under subsection (16). Persons identified by this section shall
2192convert to the benefits authorized under subsection (16) no
2193later than January 1, 2005.
2194     3.  Except as otherwise provided in this section, the
2195administration of the coverage of persons actively enrolled in
2196the Florida Comprehensive Health Association shall operate under
2197the existing plan of operation without modification until the
2198adoption of the new plan of operation for the Florida Health
2199Insurance Plan.
2200     (b)1.  As a condition of doing business in this state, an
2201insurer shall pay an assessment to the board in the amount
2202prescribed by this section. For operating losses incurred on or
2203after July 1, 2004, by persons enrolled in the Florida
2204Comprehensive Health Association, each insurer shall annually be
2205assessed by the board in the following calendar year a portion
2206of such incurred operating losses of the plan. Such portion
2207shall be determined by multiplying such operating losses by a
2208fraction, the numerator of which equals the insurer's earned
2209premium pertaining to direct writings of health insurance in the
2210state during the calendar year preceding that for which the
2211assessment is levied, and the denominator of which equals the
2212total of all such premiums earned by insurers in the state
2213during such calendar year.
2214     2.  The total of all assessments under this paragraph upon
2215an insurer shall not exceed 1 percent of such insurer's health
2216insurance premium earned in this state during the calendar year
2217preceding the year for which the assessments were levied.
2218     3.  All rights, title, and interest in the assessment funds
2219collected under this paragraph shall vest in this state.
2220However, all of such funds and interest earned shall be used by
2221the plan to pay claims and administrative expenses.
2222     (c)  If assessments and other receipts by the plan, board,
2223or plan administrator exceed the actual losses and
2224administrative expenses of the plan, the excess shall be held in
2225interest and used by the board to offset future losses. As used
2226in this subsection, the term "future losses" includes reserves
2227for claims incurred but not reported.
2228     (d)  Each insurer's assessment shall be determined annually
2229by the board or plan administrator based on annual statements
2230and other reports deemed necessary by the board or plan
2231administrator and filed with the board or plan administrator by
2232the insurer. Any deficit incurred under the plan by persons
2233previously enrolled in the Florida Comprehensive Health
2234Association shall be recouped by the assessments against
2235insurers by the board or plan administrator in the manner
2236provided in paragraph (b), and the insurers may recover the
2237assessment in the normal course of their respective businesses
2238without time limitation.
2239     (e)  If a person actively enrolled in the Florida
2240Comprehensive Health Association after implementation of the
2241plan loses eligibility for participation in the Florida
2242Comprehensive Health Association, such person shall not be
2243included in the calculation of the assessment if the person
2244later regains eligibility for participation in the plan.
2245     (f)  When all persons actively enrolled in the Florida
2246Comprehensive Health Association as of the date of
2247implementation of the plan are no longer eligible for
2248participation in the Florida Comprehensive Health Association,
2249the board of directors and plan administrator shall no longer be
2250allowed to assess insurers in this state for incurred losses in
2251the Florida Comprehensive Health Association.
2252     Section 22.  Upon implementation, as defined in s.
2253627.64872(2), Florida Statutes, and as provided in s.
2254627.64872(20), Florida Statutes, of the Florida Health Insurance
2255Plan created under s. 627.64872, Florida Statutes, sections
2256627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and
2257627.6498, Florida Statutes, are repealed.
2258     Section 23.  Subsections (12) and (13) are added to section
2259627.662, Florida Statutes, to read:
2260     627.662  Other provisions applicable.--The following
2261provisions apply to group health insurance, blanket health
2262insurance, and franchise health insurance:
2263     (12)  Section 627.6044, relating to the use of specific
2264methodology for payment of claims.
2265     (13)  Section 627.6405, relating to the inappropriate
2266utilization of emergency care.
2267     Section 24.  Paragraphs (c) and (d) of subsection (5),
2268paragraph (b) of subsection (6), and subsection (12) of section
2269627.6699, Florida Statutes, are amended, subsections (15) and
2270(16) of said section are renumbered as subsections (16) and
2271(17), respectively, present subsection (15) of said section is
2272amended, and new subsections (15) and (18) are added to said
2273section, to read:
2274     627.6699  Employee Health Care Access Act.--
2275     (5)  AVAILABILITY OF COVERAGE.--
2276     (c)  Every small employer carrier must, as a condition of
2277transacting business in this state:
2278     1.  Offer and issue all small employer health benefit plans
2279on a guaranteed-issue basis to every eligible small employer,
2280with 2 to 50 eligible employees, that elects to be covered under
2281such plan, agrees to make the required premium payments, and
2282satisfies the other provisions of the plan. A rider for
2283additional or increased benefits may be medically underwritten
2284and may only be added to the standard health benefit plan. The
2285increased rate charged for the additional or increased benefit
2286must be rated in accordance with this section.
2287     2.  In the absence of enrollment availability in the
2288Florida Health Insurance Plan, offer and issue basic and
2289standard small employer health benefit plans on a guaranteed-
2290issue basis, during a 31-day open enrollment period of August 1
2291through August 31 of each year, to every eligible small
2292employer, with fewer than two eligible employees, which small
2293employer is not formed primarily for the purpose of buying
2294health insurance and which elects to be covered under such plan,
2295agrees to make the required premium payments, and satisfies the
2296other provisions of the plan. Coverage provided under this
2297subparagraph shall begin on October 1 of the same year as the
2298date of enrollment, unless the small employer carrier and the
2299small employer agree to a different date. A rider for additional
2300or increased benefits may be medically underwritten and may only
2301be added to the standard health benefit plan. The increased rate
2302charged for the additional or increased benefit must be rated in
2303accordance with this section. For purposes of this subparagraph,
2304a person, his or her spouse, and his or her dependent children
2305constitute a single eligible employee if that person and spouse
2306are employed by the same small employer and either that person
2307or his or her spouse has a normal work week of less than 25
2308hours. Any right to an open enrollment of health benefit
2309coverage for groups of fewer than two employees, pursuant to
2310this section, shall remain in full force and effect in the
2311absence of the availability of new enrollment into the Florida
2312Health Insurance Plan.
2313     3.  This paragraph does not limit a carrier's ability to
2314offer other health benefit plans to small employers if the
2315standard and basic health benefit plans are offered and
2316rejected.
2317     (d)  A small employer carrier must file with the office, in
2318a format and manner prescribed by the committee, a standard
2319health care plan, a high deductible plan that meets the federal
2320requirements of a health savings account plan or a health
2321reimbursement arrangement, and a basic health care plan to be
2322used by the carrier. The provisions of this section requiring
2323the filing of a high deductible plan are effective September 1,
23242004.
2325     (6)  RESTRICTIONS RELATING TO PREMIUM RATES.--
2326     (b)  For all small employer health benefit plans that are
2327subject to this section and are issued by small employer
2328carriers on or after January 1, 1994, premium rates for health
2329benefit plans subject to this section are subject to the
2330following:
2331     1.  Small employer carriers must use a modified community
2332rating methodology in which the premium for each small employer
2333must be determined solely on the basis of the eligible
2334employee's and eligible dependent's gender, age, family
2335composition, tobacco use, or geographic area as determined under
2336paragraph (5)(j) and in which the premium may be adjusted as
2337permitted by this paragraph.
2338     2.  Rating factors related to age, gender, family
2339composition, tobacco use, or geographic location may be
2340developed by each carrier to reflect the carrier's experience.
2341The factors used by carriers are subject to office review and
2342approval.
2343     3.  Small employer carriers may not modify the rate for a
2344small employer for 12 months from the initial issue date or
2345renewal date, unless the composition of the group changes or
2346benefits are changed. However, a small employer carrier may
2347modify the rate one time prior to 12 months after the initial
2348issue date for a small employer who enrolls under a previously
2349issued group policy that has a common anniversary date for all
2350employers covered under the policy if:
2351     a.  The carrier discloses to the employer in a clear and
2352conspicuous manner the date of the first renewal and the fact
2353that the premium may increase on or after that date.
2354     b.  The insurer demonstrates to the office that
2355efficiencies in administration are achieved and reflected in the
2356rates charged to small employers covered under the policy.
2357     4.  A carrier may issue a group health insurance policy to
2358a small employer health alliance or other group association with
2359rates that reflect a premium credit for expense savings
2360attributable to administrative activities being performed by the
2361alliance or group association if such expense savings are
2362specifically documented in the insurer's rate filing and are
2363approved by the office. Any such credit may not be based on
2364different morbidity assumptions or on any other factor related
2365to the health status or claims experience of any person covered
2366under the policy. Nothing in this subparagraph exempts an
2367alliance or group association from licensure for any activities
2368that require licensure under the insurance code. A carrier
2369issuing a group health insurance policy to a small employer
2370health alliance or other group association shall allow any
2371properly licensed and appointed agent of that carrier to market
2372and sell the small employer health alliance or other group
2373association policy. Such agent shall be paid the usual and
2374customary commission paid to any agent selling the policy.
2375     5.  Any adjustments in rates for claims experience, health
2376status, or duration of coverage may not be charged to individual
2377employees or dependents. For a small employer's policy, such
2378adjustments may not result in a rate for the small employer
2379which deviates more than 15 percent from the carrier's approved
2380rate. Any such adjustment must be applied uniformly to the rates
2381charged for all employees and dependents of the small employer.
2382A small employer carrier may make an adjustment to a small
2383employer's renewal premium, not to exceed 10 percent annually,
2384due to the claims experience, health status, or duration of
2385coverage of the employees or dependents of the small employer.
2386Semiannually, small group carriers shall report information on
2387forms adopted by rule by the commission, to enable the office to
2388monitor the relationship of aggregate adjusted premiums actually
2389charged policyholders by each carrier to the premiums that would
2390have been charged by application of the carrier's approved
2391modified community rates. If the aggregate resulting from the
2392application of such adjustment exceeds the premium that would
2393have been charged by application of the approved modified
2394community rate by 4 5 percent for the current reporting period,
2395the carrier shall limit the application of such adjustments only
2396to minus adjustments beginning not more than 60 days after the
2397report is sent to the office. For any subsequent reporting
2398period, if the total aggregate adjusted premium actually charged
2399does not exceed the premium that would have been charged by
2400application of the approved modified community rate by 4 5
2401percent, the carrier may apply both plus and minus adjustments.
2402A small employer carrier may provide a credit to a small
2403employer's premium based on administrative and acquisition
2404expense differences resulting from the size of the group. Group
2405size administrative and acquisition expense factors may be
2406developed by each carrier to reflect the carrier's experience
2407and are subject to office review and approval.
2408     6.  A small employer carrier rating methodology may include
2409separate rating categories for one dependent child, for two
2410dependent children, and for three or more dependent children for
2411family coverage of employees having a spouse and dependent
2412children or employees having dependent children only. A small
2413employer carrier may have fewer, but not greater, numbers of
2414categories for dependent children than those specified in this
2415subparagraph.
2416     7.  Small employer carriers may not use a composite rating
2417methodology to rate a small employer with fewer than 10
2418employees. For the purposes of this subparagraph, a "composite
2419rating methodology" means a rating methodology that averages the
2420impact of the rating factors for age and gender in the premiums
2421charged to all of the employees of a small employer.
2422     8.a.  A carrier may separate the experience of small
2423employer groups with less than 2 eligible employees from the
2424experience of small employer groups with 2-50 eligible employees
2425for purposes of determining an alternative modified community
2426rating.
2427     b.  If a carrier separates the experience of small employer
2428groups as provided in sub-subparagraph a., the rate to be
2429charged to small employer groups of less than 2 eligible
2430employees may not exceed 150 percent of the rate determined for
2431small employer groups of 2-50 eligible employees. However, the
2432carrier may charge excess losses of the experience pool
2433consisting of small employer groups with less than 2 eligible
2434employees to the experience pool consisting of small employer
2435groups with 2-50 eligible employees so that all losses are
2436allocated and the 150-percent rate limit on the experience pool
2437consisting of small employer groups with less than 2 eligible
2438employees is maintained. Notwithstanding s. 627.411(1), the rate
2439to be charged to a small employer group of fewer than 2 eligible
2440employees, insured as of July 1, 2002, may be up to 125 percent
2441of the rate determined for small employer groups of 2-50
2442eligible employees for the first annual renewal and 150 percent
2443for subsequent annual renewals.
2444     (12)  STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED HEALTH
2445BENEFIT PLANS.--
2446     (a)1.  The Chief Financial Officer shall appoint a health
2447benefit plan committee composed of four representatives of
2448carriers which shall include at least two representatives of
2449HMOs, at least one of which is a staff model HMO, two
2450representatives of agents, four representatives of small
2451employers, and one employee of a small employer. The carrier
2452members shall be selected from a list of individuals recommended
2453by the board. The Chief Financial Officer may require the board
2454to submit additional recommendations of individuals for
2455appointment.
2456     2.  The plans shall comply with all of the requirements of
2457this subsection.
2458     3.  The plans must be filed with and approved by the office
2459prior to issuance or delivery by any small employer carrier.
2460     4.  After approval of the revised health benefit plans, if
2461the office determines that modifications to a plan might be
2462appropriate, the Chief Financial Officer shall appoint a new
2463health benefit plan committee in the manner provided in
2464subparagraph 1. to submit recommended modifications to the
2465office for approval.
2466     (b)1.  Each small employer carrier issuing new health
2467benefit plans shall offer to any small employer, upon request, a
2468standard health benefit plan, and a basic health benefit plan,
2469and a high deductible plan that meets the requirements of a
2470health savings account plan as defined by federal law or a
2471health reimbursement arrangement as authorized by the Internal
2472Revenue Service, that meet meets the criteria set forth in this
2473section.
2474     2.  For purposes of this subsection, the terms "standard
2475health benefit plan," and "basic health benefit plan," and "high
2476deductible plan" mean policies or contracts that a small
2477employer carrier offers to eligible small employers that
2478contain:
2479     a.  An exclusion for services that are not medically
2480necessary or that are not covered preventive health services;
2481and
2482     b.  A procedure for preauthorization by the small employer
2483carrier, or its designees.
2484     3.  A small employer carrier may include the following
2485managed care provisions in the policy or contract to control
2486costs:
2487     a.  A preferred provider arrangement or exclusive provider
2488organization or any combination thereof, in which a small
2489employer carrier enters into a written agreement with the
2490provider to provide services at specified levels of
2491reimbursement or to provide reimbursement to specified
2492providers. Any such written agreement between a provider and a
2493small employer carrier must contain a provision under which the
2494parties agree that the insured individual or covered member has
2495no obligation to make payment for any medical service rendered
2496by the provider which is determined not to be medically
2497necessary. A carrier may use preferred provider arrangements or
2498exclusive provider arrangements to the same extent as allowed in
2499group products that are not issued to small employers.
2500     b.  A procedure for utilization review by the small
2501employer carrier or its designees.
2502
2503This subparagraph does not prohibit a small employer carrier
2504from including in its policy or contract additional managed care
2505and cost containment provisions, subject to the approval of the
2506office, which have potential for controlling costs in a manner
2507that does not result in inequitable treatment of insureds or
2508subscribers. The carrier may use such provisions to the same
2509extent as authorized for group products that are not issued to
2510small employers.
2511     4.  The standard health benefit plan shall include:
2512     a.  Coverage for inpatient hospitalization;
2513     b.  Coverage for outpatient services;
2514     c.  Coverage for newborn children pursuant to s. 627.6575;
2515     d.  Coverage for child care supervision services pursuant
2516to s. 627.6579;
2517     e.  Coverage for adopted children upon placement in the
2518residence pursuant to s. 627.6578;
2519     f.  Coverage for mammograms pursuant to s. 627.6613;
2520     g.  Coverage for handicapped children pursuant to s.
2521627.6615;
2522     h.  Emergency or urgent care out of the geographic service
2523area; and
2524     i.  Coverage for services provided by a hospice licensed
2525under s. 400.602 in cases where such coverage would be the most
2526appropriate and the most cost-effective method for treating a
2527covered illness.
2528     5.  The standard health benefit plan and the basic health
2529benefit plan may include a schedule of benefit limitations for
2530specified services and procedures. If the committee develops
2531such a schedule of benefits limitation for the standard health
2532benefit plan or the basic health benefit plan, a small employer
2533carrier offering the plan must offer the employer an option for
2534increasing the benefit schedule amounts by 4 percent annually.
2535     6.  The basic health benefit plan shall include all of the
2536benefits specified in subparagraph 4.; however, the basic health
2537benefit plan shall place additional restrictions on the benefits
2538and utilization and may also impose additional cost containment
2539measures.
2540     7.  Sections 627.419(2), (3), and (4), 627.6574, 627.6612,
2541627.66121, 627.66122, 627.6616, 627.6618, 627.668, and 627.66911
2542apply to the standard health benefit plan and to the basic
2543health benefit plan. However, notwithstanding said provisions,
2544the plans may specify limits on the number of authorized
2545treatments, if such limits are reasonable and do not
2546discriminate against any type of provider.
2547     8.  The high deductible plan associated with a health
2548savings account or a health reimbursement arrangement shall
2549include all the benefits specified in subparagraph 4.
2550     9.8.  Each small employer carrier that provides for
2551inpatient and outpatient services by allopathic hospitals may
2552provide as an option of the insured similar inpatient and
2553outpatient services by hospitals accredited by the American
2554Osteopathic Association when such services are available and the
2555osteopathic hospital agrees to provide the service.
2556     (c)  If a small employer rejects, in writing, the standard
2557health benefit plan, and the basic health benefit plan, and the
2558high deductible health savings account plan or a health
2559reimbursement arrangement, the small employer carrier may offer
2560the small employer a limited benefit policy or contract.
2561     (d)1.  Upon offering coverage under a standard health
2562benefit plan, a basic health benefit plan, or a limited benefit
2563policy or contract for any small employer, the small employer
2564carrier shall provide such employer group with a written
2565statement that contains, at a minimum:
2566     a.  An explanation of those mandated benefits and providers
2567that are not covered by the policy or contract;
2568     b.  An explanation of the managed care and cost control
2569features of the policy or contract, along with all appropriate
2570mailing addresses and telephone numbers to be used by insureds
2571in seeking information or authorization; and
2572     c.  An explanation of the primary and preventive care
2573features of the policy or contract.
2574
2575Such disclosure statement must be presented in a clear and
2576understandable form and format and must be separate from the
2577policy or certificate or evidence of coverage provided to the
2578employer group.
2579     2.  Before a small employer carrier issues a standard
2580health benefit plan, a basic health benefit plan, or a limited
2581benefit policy or contract, it must obtain from the prospective
2582policyholder a signed written statement in which the prospective
2583policyholder:
2584     a.  Certifies as to eligibility for coverage under the
2585standard health benefit plan, basic health benefit plan, or
2586limited benefit policy or contract;
2587     b.  Acknowledges the limited nature of the coverage and an
2588understanding of the managed care and cost control features of
2589the policy or contract;
2590     c.  Acknowledges that if misrepresentations are made
2591regarding eligibility for coverage under a standard health
2592benefit plan, a basic health benefit plan, or a limited benefit
2593policy or contract, the person making such misrepresentations
2594forfeits coverage provided by the policy or contract; and
2595     d.  If a limited plan is requested, acknowledges that the
2596prospective policyholder had been offered, at the time of
2597application for the insurance policy or contract, the
2598opportunity to purchase any health benefit plan offered by the
2599carrier and that the prospective policyholder had rejected that
2600coverage.
2601
2602A copy of such written statement shall be provided to the
2603prospective policyholder no later than at the time of delivery
2604of the policy or contract, and the original of such written
2605statement shall be retained in the files of the small employer
2606carrier for the period of time that the policy or contract
2607remains in effect or for 5 years, whichever period is longer.
2608     3.  Any material statement made by an applicant for
2609coverage under a health benefit plan which falsely certifies as
2610to the applicant's eligibility for coverage serves as the basis
2611for terminating coverage under the policy or contract.
2612     4.  Each marketing communication that is intended to be
2613used in the marketing of a health benefit plan in this state
2614must be submitted for review by the office prior to use and must
2615contain the disclosures stated in this subsection.
2616     (e)  A small employer carrier may not use any policy,
2617contract, form, or rate under this section, including
2618applications, enrollment forms, policies, contracts,
2619certificates, evidences of coverage, riders, amendments,
2620endorsements, and disclosure forms, until the insurer has filed
2621it with the office and the office has approved it under ss.
2622627.410 and 627.411 and this section.
2623     (15)  SMALL EMPLOYERS ACCESS PROGRAM.--
2624     (a)  Popular name.--This subsection may be referred to by
2625the popular name "The Small Employers Access Program."
2626     (b)  Intent.--The Legislature finds that increased access
2627to health care coverage for small employers with up to 25
2628employees could improve employees' health and reduce the
2629incidence and costs of illness and disabilities among residents
2630in this state. Many employers do not offer health care benefits
2631to their employees citing the increased cost of this benefit. It
2632is the intent of the Legislature to create the Small Business
2633Health Plan to provide small employers the option and ability to
2634provide health care benefits to their employees at an affordable
2635cost through the creation of purchasing pools for employers with
2636up to 25 employees, and rural hospital employers and nursing
2637home employers regardless of the number of employees.
2638     (c)  Definitions.--For purposes of this subsection:
2639     1.  "Fair commission" means a commission structure
2640determined by the insurers and reflected in the insurers' rate
2641filings made pursuant to this subsection.
2642     2.  "Insurer" means any entity that provides health
2643insurance in this state. For purposes of this subsection,
2644insurer includes an insurance company holding a certificate of
2645authority pursuant to chapter 624 or a health maintenance
2646organization holding a certificate of authority pursuant to
2647chapter 641, which qualifies to provide coverage to small
2648employer groups pursuant to this section.
2649     3.  "Mutually supported benefit plan" means an optional
2650alternative coverage plan developed within a defined geographic
2651region which may include, but is not limited to, a minimum level
2652of primary care coverage in which the percentage of the premium
2653is distributed among the employer, the employee, and community-
2654generated revenue either alone or in conjunction with federal
2655matching funds.
2656     4.  "Office" means the Office of Insurance Regulation of
2657the Department of Financial Services.
2658     5.  "Participating insurer" means any insurer providing
2659health insurance to small employers that has been selected by
2660the office in accordance with this subsection for its designated
2661region.
2662     6.  "Program" means the Small Employer Access Program as
2663created by this subsection.
2664     (d)  Eligibility.--
2665     1.  Any small employer that is actively engaged in
2666business, has its principal place of business in this state,
2667employs up to 25 eligible employees on business days during the
2668preceding calendar year, employs at least 2 employees on the
2669first day of the plan year, and has had no prior coverage for
2670the last 6 months may participate.
2671     2.  Any municipality, county, school district, or hospital
2672employer located in a rural community as defined in s.
2673288.0656(2)(b), may participate.
2674     3.  Nursing home employers may participate.
2675     4.  Each dependent of a person eligible for coverage is
2676also eligible to participate.
2677
2678Any employer participating in the program must do so until the
2679end of the term for which the carrier providing the coverage is
2680obligated to provide such coverage to the program. Coverage for
2681a small employer group that ceases to meet the eligibility
2682requirements of this section may be terminated at the end of the
2683policy period for which the necessary premiums have been paid.
2684     (e)  Administration.--
2685     1.  The office shall by competitive bid, in accordance with
2686current state law, select an insurer to provide coverage through
2687the program to eligible small employers within an established
2688geographical area of this state. The office may develop
2689exclusive regions for the program similar to those used by the
2690Healthy Kids Corporation. However the office is not precluded
2691from developing, in conjunction with insurers, regions different
2692from those used by the Healthy Kids Corporation if the office
2693deems that such a region will carry out the intentions of this
2694subsection.
2695     2.  The office shall evaluate bids submitted based upon
2696criteria established by the office, which shall include, but not
2697be limited to:
2698     a.  The insurer's proven ability to handle health insurance
2699coverage to small employer groups.
2700     b.  The efficiency and timeliness of the insurer's claim
2701processing procedures.
2702     c.  The insurer's ability to apply effective cost-
2703containment programs and procedures and to administer the
2704program in a cost-efficient manner.
2705     d.  The financial condition and stability of the insurer.
2706e.  The insurer's ability to develop an optional mutually
2707supported benefit plan.
2708
2709The office may use any financial information available to it
2710through its regulatory duties to make this evaluation.
2711     (f)  Insurer qualifications.--The insurer shall be a duly
2712authorized insurer or health maintenance organization.
2713     (g)  Duties of the insurer.--The insurer shall:
2714     1.  Develop and implement a program to publicize the
2715existence of the program, program eligibility requirements, and
2716procedures for enrollment and maintain public awareness of the
2717program.
2718     2.  Maintain employer awareness of the program.
2719     3.  Demonstrate the ability to use delivery of cost-
2720effective health care services.
2721     4.  Encourage, educate, advise, and administer the
2722effective use of health savings accounts by covered employees
2723and dependents.
2724     5.  Serve for a period specified in the contract between
2725the office and the insurer, subject to removal for cause and
2726subject to any terms, conditions, and limitations of the
2727contract between the office and the insurer as may be specified
2728in the request for proposal.
2729     (h)  Contract term.--The contract term shall not exceed 3
2730years. At least 6 months prior to the expiration of each
2731contract period, the office shall invite eligible entities,
2732including the current insurer, to submit bids to serve as the
2733insurer for a designated geographic area. Selection of the
2734insurer for the succeeding period shall be made at least 3
2735months prior to the end of the current period. If a protest is
2736filed and not resolved by the end of the contract period, the
2737contract with the existing administrator may be extended for a
2738period not to exceed 6 months. During the contract extension
2739period, the administrator shall be paid at a rate to be
2740negotiated by the office.
2741     (i)  Insurer reporting requirements.--On March 1 following
2742the close of each calendar year, the insurer shall determine net
2743written and earned premiums, the expense of administration, and
2744the paid and incurred losses for the year and report this
2745information to the office on a form prescribed by the office.
2746     (j)  Application requirements.--The insurer shall permit or
2747allow any licensed and duly appointed health insurance agent
2748residing in the designated region to submit applications for
2749coverage, and such agent shall be paid a fair commission if
2750coverage is written. The agent must be appointed to at least one
2751insurer.
2752     (k)  Benefits.--The benefits provided by the plan shall be
2753the same as the coverage required for small employers under
2754subsection (12). Upon the approval of the office, the insurer
2755may also establish an optional mutually supported benefit plan
2756which is an alternative plan developed within a defined
2757geographic region of this state or any other such alternative
2758plan which will carry out the intent of this subsection. Any
2759small employer carrier issuing new health benefit plans may
2760offer a benefit plan with coverages similar to, but not less
2761than, any alternative coverage plan developed pursuant to this
2762subsection.
2763     (l)  Annual reporting.--The office shall make an annual
2764report to the Governor, the President of the Senate, and the
2765Speaker of the House of Representatives. The report shall
2766summarize the activities of the program in the preceding
2767calendar year, including the net written and earned premiums,
2768program enrollment, the expense of administration, and the paid
2769and incurred losses. The report shall be submitted no later than
2770March 15 following the close of the prior calendar year.
2771     (16)(15)  APPLICABILITY OF OTHER STATE LAWS.--
2772     (a)  Except as expressly provided in this section, a law
2773requiring coverage for a specific health care service or
2774benefit, or a law requiring reimbursement, utilization, or
2775consideration of a specific category of licensed health care
2776practitioner, does not apply to a standard or basic health
2777benefit plan policy or contract or a limited benefit policy or
2778contract offered or delivered to a small employer unless that
2779law is made expressly applicable to such policies or contracts.
2780A law restricting or limiting deductibles, coinsurance,
2781copayments, or annual or lifetime maximum payments does not
2782apply to any health plan policy, including a standard or basic
2783health benefit plan policy or contract, offered or delivered to
2784a small employer unless such law is made expressly applicable to
2785such policy or contract. However, every small employer carrier
2786must offer to eligible small employers the standard benefit plan
2787and the basic benefit plan, as required by subsection (5), as
2788such plans have been approved by the office pursuant to
2789subsection (12).
2790     (b)  Except as provided in this section, a standard or
2791basic health benefit plan policy or contract or limited benefit
2792policy or contract offered to a small employer is not subject to
2793any provision of this code which:
2794     1.  Inhibits a small employer carrier from contracting with
2795providers or groups of providers with respect to health care
2796services or benefits;
2797     2.  Imposes any restriction on a small employer carrier's
2798ability to negotiate with providers regarding the level or
2799method of reimbursing care or services provided under a health
2800benefit plan; or
2801     3.  Requires a small employer carrier to either include a
2802specific provider or class of providers when contracting for
2803health care services or benefits or to exclude any class of
2804providers that is generally authorized by statute to provide
2805such care.
2806     (c)  Any second tier assessment paid by a carrier pursuant
2807to paragraph (11)(j) may be credited against assessments levied
2808against the carrier pursuant to s. 627.6494.
2809     (d)  Notwithstanding chapter 641, a health maintenance
2810organization is authorized to issue contracts providing benefits
2811equal to the standard health benefit plan, the basic health
2812benefit plan, and the limited benefit policy authorized by this
2813section.
2814     (17)(16)  RULEMAKING AUTHORITY.--The commission may adopt
2815rules to administer this section, including rules governing
2816compliance by small employer carriers and small employers.
2817     Section 25.  Section 627.6405, Florida Statutes, is created
2818to read:
2819     627.6405  Decreasing inappropriate utilization of emergency
2820care.--
2821     (1)  The Legislature finds and declares it to be of vital
2822importance that emergency services and care be provided by
2823hospitals and physicians to every person in need of such care,
2824but with the double-digit increases in health insurance
2825premiums, health care providers and insurers should encourage
2826patients and the insured to assume responsibility for their
2827treatment, including emergency care. The Legislature finds that
2828inappropriate utilization of emergency department services
2829increases the overall cost of providing health care and these
2830costs are ultimately borne by the hospital, the insured
2831patients, and, many times, by the taxpayers of this state.
2832Finally, the Legislature declares that the providers and
2833insurers must share the responsibility of providing alternative
2834treatment options to urgent care patients outside of the
2835emergency department. Therefore, it is the intent of the
2836Legislature to place the obligation for educating consumers and
2837creating mechanisms for delivery of care that will decrease the
2838overutilization of emergency service on health insurers and
2839providers.
2840     (2)  Health insurers shall provide on their websites
2841information regarding appropriate utilization of emergency care
2842services which shall include, but not be limited to, a list of
2843alternative urgent care contracted providers, the types of
2844services offered by these providers, and what to do in the event
2845of a true emergency.
2846     (3)  Health insurers shall develop community emergency
2847department diversion programs. Such programs may include, at the
2848discretion of the insurer, but not be limited to, enlisting
2849providers to be on call to insurers after hours, coordinating
2850care through local community resources, and providing incentives
2851to providers for case management.
2852     (4)  As a disincentive for insureds to inappropriately use
2853emergency department services for nonemergency care, health
2854insurers may require higher copayments for urgent care or
2855primary care provided in an emergency department and higher
2856copayments for use of out-of-network emergency departments.
2857Higher copayments may not be charged for the utilization of the
2858emergency department for emergency care. For the purposes of
2859this section, the term "emergency care" has the same meaning as
2860provided in s. 395.002, and shall include services provided to
2861rule out an emergency medical condition.
2862     Section 26.  Section 641.31097, Florida Statutes, is
2863created to read:
2864     641.31097  Decreasing inappropriate utilization of
2865emergency care.--
2866     (1)  The Legislature finds and declares it to be of vital
2867importance that emergency services and care be provided by
2868hospitals and physicians to every person in need of such care,
2869but with the double-digit increases in health insurance
2870premiums, health care providers and insurers should encourage
2871patients and the insured to assume responsibility for their
2872treatment, including emergency care. The Legislature finds that
2873inappropriate utilization of emergency department services
2874increases the overall cost of providing health care and these
2875costs are ultimately borne by the hospital, by the insured
2876patients, and, many times, by the taxpayers of this state.
2877Finally, the Legislature declares that the providers and
2878insurers must share the responsibility of providing alternative
2879treatment options to urgent care patients outside of the
2880emergency department. Therefore, it is the intent of the
2881Legislature to place the obligation for educating consumers and
2882creating mechanisms for delivery of care that will decrease the
2883overutilization of emergency service on health maintenance
2884organizations and providers.
2885     (2)  Health maintenance organizations shall provide on
2886their Internet websites information regarding appropriate
2887utilization of emergency care services, which shall include, but
2888not be limited to, a list of alternative urgent care contracted
2889providers, the types of services offered by these providers, and
2890what to do in the event of a true emergency.
2891     (3)  Health maintenance organizations shall develop
2892community emergency department diversion programs. Such programs
2893may include at the discretion of the health maintenance
2894organization, but not be limited to, enlisting providers to be
2895on call to subscribers after hours, coordinating care through
2896local community resources, and providing incentives to providers
2897for case management.
2898     (4)  As a disincentive for subscribers to inappropriately
2899use emergency department services for nonemergency care, health
2900maintenance organizations may require higher copayments for
2901urgent care or primary care provided in an emergency department
2902and higher copayments for use of out-of-network emergency
2903departments. Higher copayments may not be charged for the
2904utilization of the emergency department for emergency care. For
2905the purposes of this section, the term "emergency care" has the
2906same meaning as provided in s. 395.002 and shall include
2907services provided to rule out an emergency medical condition.
2908     Section 27.  Subsection (1) of section 627.9175, Florida
2909Statutes, is amended to read:
2910     627.9175  Reports of information on health and accident
2911insurance.--
2912     (1)  Each health insurer, prepaid limited health services
2913organization, and health maintenance organization shall submit,
2914no later than April 1 of each year, annually to the office
2915information concerning health and accident insurance coverage
2916and medical plans being marketed and currently in force in this
2917state. The required information shall be described by market
2918segment, to include, but not be limited to:
2919     (a)  Issuing, servicing company, and entity contact
2920information.
2921     (b)  Information on all health and accident insurance
2922policies and prepaid limited health service organizations and
2923health maintenance organization contracts in force and issued in
2924the previous year. Such information shall include, but not be
2925limited to, direct premiums earned, direct losses incurred,
2926number of policies, number of certificates, number of covered
2927lives, and the average number of days taken to pay claims. as to
2928policies of individual health insurance:
2929     (a)  A summary of typical benefits, exclusions, and
2930limitations for each type of individual policy form currently
2931being issued in the state. The summary shall include, as
2932appropriate:
2933     1.  The deductible amount;
2934     2.  The coinsurance percentage;
2935     3.  The out-of-pocket maximum;
2936     4.  Outpatient benefits;
2937     5.  Inpatient benefits; and
2938     6.  Any exclusions for preexisting conditions.
2939
2940The commission shall determine other appropriate benefits,
2941exclusions, and limitations to be reported for inclusion in the
2942consumer's guide published pursuant to this section.
2943     (b)  A schedule of rates for each type of individual policy
2944form reflecting typical variations by age, sex, region of the
2945state, or any other applicable factor which is in use and is
2946determined to be appropriate for inclusion by the commission.
2947
2948The commission may establish rules governing shall provide by
2949rule a uniform format for the submission of this information
2950described in this section, including the use of uniform formats
2951and electronic data transmission order to allow for meaningful
2952comparisons of premiums charged for comparable benefits. The
2953office shall provide this information to the department, which
2954shall publish annually a consumer's guide which summarizes and
2955compares the information required to be reported under this
2956subsection.
2957     Section 28.  Chapter 636, Florida Statutes, entitled
2958"Prepaid Limited Health Service Organizations," is retitled as
2959"Prepaid Limited Health Service Organizations and Discount
2960Medical Plan Organizations."
2961     Section 29.  Sections 636.002 through 636.067, Florida
2962Statutes, are designated as part I of chapter 636, Florida
2963Statutes, and entitled "Prepaid Limited Health Service
2964Organizations."
2965     Section 30.  Paragraph (c) of subsection (7) of section
2966636.003, Florida Statutes, is amended to read:
2967     636.003  Definitions.--As used in this act, the term:
2968     (7)  "Prepaid limited health service organization" means
2969any person, corporation, partnership, or any other entity which,
2970in return for a prepayment, undertakes to provide or arrange
2971for, or provide access to, the provision of a limited health
2972service to enrollees through an exclusive panel of providers.
2973Prepaid limited health service organization does not include:
2974     (c)  Any person who is licensed pursuant to part II as a
2975discount medical plan organization, in exchange for fees, dues,
2976charges or other consideration, provides access to a limited
2977health service provider without assuming any responsibility for
2978payment for the limited health service or any portion thereof.
2979     Section 31.  Effective January 1, 2005, part II of chapter
2980636, Florida Statutes, consisting of sections 636.202, 636.204,
2981636.206, 636.208, 636.210, 636.212, 636.214, 636.216, 636.218,
2982636.220, 636.222, 636.224, 636.226, 636.228, 636.230, 636.232,
2983636.234, 636.236, 636.238, 636.240, 636.242, and 636.244, is
2984created to read:
2985
PART II
2986
DISCOUNT MEDICAL PLAN ORGANIZATIONS
2987     636.202  Definitions.--As used in this part, the term:
2988     (1)  "Discount medical plan" means a business arrangement
2989or contract in which a person, in exchange for fees, dues,
2990charges, or other consideration, provides access for plan
2991members to providers of medical services and the right to
2992receive medical services from those providers at a discount. The
2993term "discount medical plan" does not include any product
2994regulated under chapter 627, chapter 641, or part I of chapter
2995636.
2996     (2)  "Discount medical plan organization" means an entity
2997which, in exchange for fees, dues, charges, or other
2998consideration, provides access for plan members to providers of
2999medical services and the right to receive medical services from
3000those providers at a discount. The term "discount medical plan"
3001does not include any product regulated under chapter 627,
3002chapter 641, or part I of chapter 636.
3003     (3)  "Marketer" means a person or entity which markets,
3004promotes, sells, or distributes a discount medical plan,
3005including a private label entity which places its name on and
3006markets or distributes a discount medical plan but does not
3007operate a discount medical plan.
3008     (4)  "Medical services" means any care, service, or
3009treatment of illness or dysfunction of, or injury to, the human
3010body, including, but not limited to, physician care, inpatient
3011care, hospital surgical services, emergency services, ambulance
3012services, dental care services, vision care services, mental
3013health services, substance abuse services, chiropractic
3014services, podiatric care services, laboratory services, and
3015medical equipment and supplies. The term does not include
3016pharmaceutical supplies or prescriptions.
3017     (5)  "Member" means any person who pays fees, dues,
3018charges, or other consideration for the right to receive the
3019purported benefits of a discount medical plan.
3020     (6)  "Provider" means any person or institution which is
3021contracted, directly or indirectly, with a discount medical plan
3022organization to provide medical services to members.
3023     (7)  "Provider network" means an entity which negotiates on
3024behalf of more than one provider with a discount medical plan
3025organization to provide medical services to members.
3026     636.204  License required.--
3027     (1)  Before doing business in this state as a discount
3028medical plan organization, an entity must be a corporation,
3029incorporated under the laws of this state or, if a foreign
3030corporation, authorized to transact business in this state, and
3031must possess a license as a discount medical plan organization
3032from the office.
3033     (2)  An application for a license to operate as a discount
3034medical plan organization must be filed with the office on a
3035form prescribed by the commission. Such application must be
3036sworn to by an officer or authorized representative of the
3037applicant and be accompanied by the following:
3038     (a)  A copy of the applicant's articles of incorporation,
3039including all amendments.
3040     (b)  A copy of the corporation's bylaws.
3041     (c)  A list of the names, addresses, official positions,
3042and biographical information of the individuals who are
3043responsible for conducting the applicant's affairs, including,
3044but not limited to, all members of the board of directors, board
3045of trustees, executive committee, or other governing board or
3046committee, the officers, contracted management company
3047personnel, and any person or entity owning or having the right
3048to acquire 10 percent or more of the voting securities of the
3049applicant. Such listing must fully disclose the extent and
3050nature of any contracts or arrangements between any individual
3051who is responsible for conducting the applicant's affairs and
3052the discount medical plan organization, including any possible
3053conflicts of interest.
3054     (d)  A complete biographical statement, on forms prescribed
3055by the commission, an independent investigation report, and a
3056set of fingerprints, as provided in chapter 624, with respect to
3057each individual identified under paragraph (c).
3058     (e)  A statement generally describing the applicant, its
3059facilities and personnel, and the medical services to be
3060offered.
3061     (f)  A copy of the form of all contracts made or to be made
3062between the applicant and any providers or provider networks
3063regarding the provision of medical services to members.
3064     (g)  A copy of the form of any contract made or arrangement
3065to be made between the applicant and any person listed in
3066paragraph (c).
3067     (h)  A copy of the form of any contract made or to be made
3068between the applicant and any person, corporation, partnership,
3069or other entity for the performance on the applicant's behalf of
3070any function, including, but not limited to, marketing,
3071administration, enrollment, investment management, and
3072subcontracting for the provision of health services to members.
3073     (i)  A copy of the applicant's most recent financial
3074statements audited by an independent certified public
3075accountant.
3076     (j)  A description of the proposed method of marketing.
3077     (k)  A description of the subscriber complaint procedures
3078to be established and maintained.
3079     (l)  The fee for issuance of a license.
3080     (m)  Such other information as the commission or office may
3081reasonably require to make the determinations required by this
3082part.
3083     (3)  The office shall issue a license which shall expire 1
3084year later, and each year on that date thereafter, and which the
3085office shall renew if the licensee pays the annual license fee
3086of $50 and if the office is satisfied that the licensee is in
3087compliance with this part.
3088     (4)  Prior to licensure by the office, each discount
3089medical plan organization must establish an Internet website so
3090as to conform to the requirements of s. 636.226.
3091     (5)  The license fee under subsection (2) is $50 per year
3092per licensee. All amounts collected shall be deposited into the
3093General Revenue Fund.
3094     (6)  Nothing in this part requires a provider who provides
3095discounts to his or her own patients to obtain and maintain a
3096license as a discount medical plan organization.
3097     636.206  Examinations and investigations.--
3098     (1)  The office may examine or investigate the business and
3099affairs of any discount medical plan organization. The office
3100may order any discount medical plan organization or applicant to
3101produce any records, books, files, advertising and solicitation
3102materials, or other information and may take statements under
3103oath to determine whether the discount medical plan organization
3104or applicant is in violation of the law or is acting contrary to
3105the public interest. The expenses incurred in conducting any
3106examination or investigation must be paid by the discount
3107medical plan organization or applicant. Examinations and
3108investigations must be conducted as provided in chapter 624, and
3109discount medical plan organizations are subject to all
3110applicable provisions of the insurance code.
3111     (2)  Failure by the discount medical plan organization to
3112pay the expenses incurred under subsection (1) is grounds for
3113denial or revocation.
3114     636.208  Fees.--A discount medical plan organization may
3115charge a reasonable one-time processing fee and a periodic
3116charge. If a discount medical plan charges for a time period in
3117excess of one month, the plan must, in the event of cancellation
3118of the membership by either party, make a pro rata reimbursement
3119of the fees to the member.
3120     636.210  Prohibited activities of a discount medical plan
3121organization.--
3122     (1)  A discount medical plan organization may not:
3123     (a)  Use in its advertisements, marketing material,
3124brochures, and discount cards the term "insurance" except as
3125otherwise provided in this part;
3126     (b)  Use in its advertisements, marketing material,
3127brochures, and discount cards the terms "health plan,"
3128"coverage," "copay," "copayments," "preexisting conditions,"
3129"guaranteed issue," "premium," "enrollment," "PPO," "preferred
3130provider organization," or other terms that could reasonably
3131mislead a person into believing the discount medical plan was
3132health insurance;
3133     (c)  Have restrictions on free access to plan providers,
3134including, but not limited to, waiting periods and notification
3135periods; or
3136     (d)  Pay providers any fees for medical services.
3137     (2)  A discount medical plan organization may not collect
3138or accept money from a member for payment to a provider for
3139specific medical services furnished or to be furnished to the
3140member unless the organization has an active certificate of
3141authority from the office to act as an administrator.
3142     636.212  Disclosures.--The following disclosures must be
3143made in writing to any prospective member and must be on the
3144first page of any advertisements, marketing materials, or
3145brochures relating to a discount medical plan. The disclosures
3146must be printed in not less than 12-point type or no smaller
3147than the largest type on the page if larger than 12-point type:
3148     (1)  That the plan is not a health insurance policy.
3149     (2)  That the plan provides discounts at certain health
3150care providers for medical services.
3151     (3)  That the plan does not make payments directly to the
3152providers of medical services.
3153     (4)  That the plan member is obligated to pay for all
3154health care services but will receive a discount from those
3155health care providers who have contracted with the discount plan
3156organization.
3157     (5)  The corporate name and the locations of the licensed
3158discount medical plan organization.
3159     636.214  Provider agreements.--
3160     (1)  All providers offering medical services to members
3161under a discount medical plan must provide such services
3162pursuant to a written agreement. The agreement may be entered
3163into directly by the provider or by a provider network to which
3164the provider belongs.
3165     (2)  A provider agreement must provide the following:
3166     (a)  A list of the services and products to be provided at
3167a discount.
3168     (b)  The amount or amounts of the discounts or,
3169alternatively, a fee schedule which reflects the provider's
3170discounted rates.
3171     (c)  That the provider will not charge members more than
3172the discounted rates.
3173     (3)  A provider agreement between a discount medical plan
3174organization and a provider network shall require that the
3175provider network have written agreements with its providers
3176which:
3177     (a)  Contain the terms described in subsection (2).
3178     (b)  Authorize the provider network to contract with the
3179discount medical plan organization on behalf of the provider.
3180     (c)  Require the network to maintain an up-to-date list of
3181its contracted providers and to provide that list on a monthly
3182basis to the discount medical plan organization.
3183     (4)  The discount medical plan organization shall maintain
3184a copy of each active provider agreement.
3185     636.216  Form filings.--
3186     (1)  All charges to members must be filed with the office
3187and any charge to members greater than $30 per month or $360 per
3188year must be approved by the office before the charges can be
3189used. The discount medical plan organization has the burden of
3190proof that the charges bear a reasonable relation to the
3191benefits received by the member.
3192     (2)  There must be a written agreement between the discount
3193medical plan organization and the member specifying the benefits
3194under the discount medical plan and complying with the
3195disclosure requirements of this part.
3196     (3)  All forms used, including the written agreement
3197pursuant to subsection (2), must first be filed with and
3198approved by the office. Every form filed shall be identified by
3199a unique form number placed in the lower left corner of each
3200form.
3201     (4)  If such filings are disapproved, the office shall
3202notify the discount medical plan organization and shall specify
3203in the notice the reasons for disapproval. The discount medical
3204plan organization has 21 days from the date of receipt of notice
3205to request a hearing before the office pursuant to chapter 120.
3206     636.218  Annual reports.--
3207     (1)  Each discount medical plan organization must file with
3208the office, within 3 months after the end of each fiscal year,
3209an annual report.
3210     (2)  Such reports must be on forms prescribed by the
3211commission and must include:
3212     (a)  Audited financial statements prepared in accordance
3213with generally accepted accounting principles certified by an
3214independent certified public accountant, including the
3215organization's balance sheet, income statement, and statement of
3216changes in cash flow for the preceding year.
3217     (b)  A list of the names and residence addresses of all
3218persons responsible for the conduct of the organization's
3219affairs, together with a disclosure of the extent and nature of
3220any contracts or arrangements between such persons and the
3221discount medical plan organization, including any possible
3222conflicts of interest.
3223     (c)  The number of discount medical plan members.
3224     (d)  Such other information relating to the performance of
3225the discount medical plan organization as is reasonably required
3226by the commission or office.
3227     (3)  Every discount medical plan organization which fails
3228to file an annual report in the form and within the time
3229required by this section shall forfeit up to $500 for each day
3230for the first 10 days during which the neglect continues and
3231shall forfeit up to $1,000 for each day after the first 10 days
3232during which the neglect continues; and, upon notice by the
3233office to that effect, the organization's authority to enroll
3234new members or to do business in this state ceases while such
3235default continues. The office shall deposit all sums collected
3236by the office under this section to the credit of the Insurance
3237Regulatory Trust Fund. The office may not collect more than
3238$50,000 for each report.
3239     636.220  Minimum capital requirements.?-
3240     (1)  Each discount medical plan organization must at all
3241times maintain a net worth of at least $150,000.
3242     (2)  The office may not issue a license unless the discount
3243medical plan organization has a net worth of at least $150,000.
3244     636.222  Suspension or revocation of license; suspension of
3245enrollment of new members; terms of suspension.--
3246     (1)  The office may suspend the authority of a discount
3247medical plan organization to enroll new members, revoke any
3248license issued to a discount medical plan organization, or order
3249compliance if the office finds that any of the following
3250conditions exist:
3251     (a)  The organization is not operating in compliance with
3252this part.
3253     (b)  The organization does not have the minimum net worth
3254as required by this part.
3255     (c)  The organization has advertised, merchandised, or
3256attempted to merchandise its services in such a manner as to
3257misrepresent its services or capacity for service or has engaged
3258in deceptive, misleading, or unfair practices with respect to
3259advertising or merchandising.
3260     (d)  The organization is not fulfilling its obligations as
3261a medical discount medical plan organization.
3262     (e)  The continued operation of the organization would be
3263hazardous to its members.
3264     (2)  If the office has cause to believe that grounds for
3265the suspension or revocation of a license exist, the office
3266shall notify the discount medical plan organization in writing
3267specifically stating the grounds for suspension or revocation
3268and shall pursue a hearing on the matter in accordance with the
3269provisions of chapter 120.
3270     (3)  When the license of a discount medical plan
3271organization is surrendered or revoked, such organization must
3272proceed, immediately following the effective date of the order
3273of revocation, to wind up its affairs transacted under the
3274license. The organization may not engage in any further
3275advertising, solicitation, collecting of fees, or renewal of
3276contracts.
3277     (4)  The office shall, in its order suspending the
3278authority of a discount medical plan organization to enroll new
3279members, specify the period during which the suspension is to be
3280in effect and the conditions, if any, which must be met by the
3281discount medical plan organization prior to reinstatement of its
3282license to enroll new members. The order of suspension is
3283subject to rescission or modification by further order of the
3284office prior to the expiration of the suspension period.
3285Reinstatement may not be made unless requested by the discount
3286medical plan organization; however, the office may not grant
3287reinstatement if it finds that the circumstances for which the
3288suspension occurred still exist or are likely to recur.
3289     636.224  Notice of change of name or address of discount
3290medical plan organization.--Each discount medical plan
3291organization must provide the office at least 30 days' advance
3292notice of any change in the discount medical plan organization's
3293name, address, principal business address, or mailing address.
3294     636.226  Provider name listing.?-Each discount medical plan
3295organization must maintain an up-to-date list of the names and
3296addresses of the providers with which it has contracted, on an
3297Internet website page, the address of which shall be prominently
3298displayed on all its advertisements, marketing materials,
3299brochures, and discount cards. This section applies to those
3300providers with whom the discount medical plan organization has
3301contracted directly, as well as those who are members of a
3302provider network with which the discount medical plan
3303organization has contracted.
3304     636.228  Marketing of discount medical plans.--
3305     (1)  All advertisements, marketing materials, brochures,
3306and discount cards used by marketers must be approved in writing
3307for such use by the discount medical plan organization.
3308     (2)  The discount medical plan organization shall have an
3309executed written agreement with a marketer prior to the
3310marketer's marketing, promoting, selling, or distributing the
3311discount medical plan and shall be responsible and financially
3312liable for any acts of its marketers that do not comply with the
3313provisions of this part.
3314     636.230  Bundling discount medical plans with other
3315insurance products.?-When a marketer or discount medical plan
3316organization sells a discount medical plan together with any
3317other product, the fees for each individual product must be
3318provided in writing to the member and itemized.
3319     636.232  Rules.--The commission may adopt rules to
3320administer this part, including rules for the licensing of
3321discount medical plan organizations; establishing standards for
3322evaluating forms, advertisements, marketing materials,
3323brochures, and discount cards; providing for the collection of
3324data; relating to disclosures to plan members; and defining
3325terms used in this part.
3326     636.234  Service of process on a discount medical plan
3327organization.-?Sections 624.422 and 624.423 apply to a discount
3328medical plan organization as if the discount medical plan
3329organization were an insurer.
3330     636.236  Security deposit.--
3331     (1)  A licensed discount medical plan organization must
3332deposit and maintain deposited in trust with the department
3333securities eligible for deposit under s. 625.52, having at all
3334times a value of not less than $35,000, for use by the office in
3335protecting plan members.
3336     (2)  No judgment creditor or other claimant of a discount
3337medical plan organization, other than the office or department,
3338shall have the right to levy upon any of the assets or
3339securities held in this state as a deposit under subsection (1).
3340     636.238  Penalties for violation of this part.--
3341     (1)  Except as provided in subsection (2), a person who
3342violates any provision of this part commits a misdemeanor of the
3343second degree, punishable as provided in s. 775.082 or s.
3344775.083.
3345     (2)  A person who operates as or aids and abets another
3346operating as a discount medical plan organization in violation
3347of s. 636.204(1) commits a felony punishable as provided for in
3348s. 624.401(4)(b), as if the unlicensed discount medical plan
3349organization were an unauthorized insurer, and the fees, dues,
3350charges, or other consideration collected from the members by
3351the unlicensed discount medical plan organization or marketer
3352were insurance premium.
3353     (3)  A person who collects fees for purported membership in
3354a discount medical plan but fails to provide the promised
3355benefits commits a theft, punishable as provided in s. 812.014.
3356     636.240  Injunctions.--
3357     (1)  In addition to the penalties and other enforcement
3358provisions of this part, the office may seek both temporary and
3359permanent injunctive relief when:
3360     (a)  A discount medical plan is being operated by any
3361person or entity that is not licensed pursuant to this part.
3362     (b)  Any person, entity, or discount medical plan
3363organization has engaged in any activity prohibited by this part
3364or any rule adopted pursuant to this part.
3365     (2)  The venue for any proceeding bought pursuant to this
3366section shall be in the Circuit Court of Leon County.
3367     (3)  The office's authority to seek injunctive relief is
3368not conditioned on having conducted any proceeding pursuant to
3369chapter 120.
3370     636.242  Civil remedies.--Any person damaged by the acts of
3371a person in violation of this part may bring a civil action
3372against the person committing the violation in the circuit court
3373of the county in which the alleged violator resides or has a
3374principal place of business or in the county in which the
3375alleged violation occurred. Upon an adverse adjudication, the
3376defendant is liable for damages, together with court costs and
3377reasonable attorney's fees incurred by the plaintiff. When so
3378awarded, court costs and attorney's fees must be included in the
3379judgment or decree rendered in the case. If it appears to the
3380court that the suit brought by the plaintiff is frivolous or
3381brought for purposes of harassment, the court may apply
3382sanctions in accordance with chapter 57.
3383     636.244  Unlicensed discount medical plan
3384organizations.--The provisions of ss. 626.901-626.912 apply to
3385The provisions of ss. 626.901-626.912 apply to the activities of
3386an unlicensed discount medical plan organization as if the
3387unlicensed discount medical plan organization were an
3388unauthorized insurer.
3389     Section 32.  Section 627.65626, Florida Statutes, is
3390created to read:
3391     627.65626  Insurance rebates for healthy lifestyles.--
3392     (1)  Any rate, rating schedule, or rating manual for a
3393health insurance policy filed with the office shall provide for
3394an appropriate rebate of premiums paid in the last calendar year
3395when the majority of members of a health plan have enrolled and
3396maintained participation in any health wellness, maintenance, or
3397improvement program offered by the employer. The employer must
3398provide evidence of demonstrative maintenance or improvement of
3399the enrollees' health status as determined by assessments of
3400agreed-upon health status indicators between the employer and
3401the health insurer, including, but not limited to, reduction in
3402weight, body mass index, and smoking cessation. Any rebate
3403provided by the health insurer is presumed to be appropriate
3404unless credible data demonstrates otherwise, but shall not
3405exceed 10 percent of paid premiums.
3406     (2)  The premium rebate authorized by this section shall be
3407effective for an insured on an annual basis, unless the number
3408of participating employees becomes less than the majority of the
3409employees eligible for participation in the wellness program.
3410     Section 33.  Section 627.6402, Florida Statutes, is created
3411to read:
3412     627.6402  Insurance rebates for healthy lifestyles.--
3413     (1)  Any rate, rating schedule, or rating manual for an
3414individual health insurance policy filed with the office shall
3415provide for an appropriate rebate of premiums paid in the last
3416calendar year when the individual covered by such plan is
3417enrolled in and maintains participation in any health wellness,
3418maintenance, or improvement program approved by the health plan.
3419The individual must provide evidence of demonstrative
3420maintenance or improvement of the individual's health status as
3421determined by assessments of agreed-upon health status
3422indicators between the individual and the health insurer,
3423including, but not limited to, reduction in weight, body mass
3424index, and smoking cessation. Any rebate provided by the health
3425insurer is presumed to be appropriate unless credible data
3426demonstrates otherwise, but shall not exceed 10 percent of paid
3427premiums.
3428     (2)  The premium rebate authorized by this section shall be
3429effective for an insured on an annual basis, unless the
3430individual fails to maintain or improve his or her health status
3431while participating in an approved wellness program, or credible
3432evidence demonstrates that the individual is not participating
3433in the approved wellness program.
3434     Section 34.  Subsection (38) of section 641.31, Florida
3435Statutes, is amended, and subsection (40) is added to said
3436section, to read:
3437     641.31  Health maintenance contracts.--
3438     (38)(a)  Notwithstanding any other provision of this part,
3439a health maintenance organization that meets the requirements of
3440paragraph (b) may, through a point-of-service rider to its
3441contract providing comprehensive health care services, include a
3442point-of-service benefit. Under such a rider, a subscriber or
3443other covered person of the health maintenance organization may
3444choose, at the time of covered service, a provider with whom the
3445health maintenance organization does not have a health
3446maintenance organization provider contract. The rider may not
3447require a referral from the health maintenance organization for
3448the point-of-service benefits.
3449     (b)  A health maintenance organization offering a point-of-
3450service rider under this subsection must have a valid
3451certificate of authority issued under the provisions of the
3452chapter, must have been licensed under this chapter for a
3453minimum of 3 years, and must at all times that it has riders in
3454effect maintain a minimum surplus of $5 million. A health
3455maintenance organization offering a point-of-service rider to
3456its contract providing comprehensive health care services may
3457offer the rider to employers who have employees living and
3458working outside the health maintenance organization's approved
3459geographic service area without having to obtain a health care
3460provider certificate, as long as the master group contract is
3461issued to an employer that maintains its primary place of
3462business within the health maintenance organization's approved
3463service area. Any member or subscriber that lives and works
3464outside the health maintenance organization's service area and
3465elects coverage under the health maintenance organization's
3466point-of-service rider must provide a statement to the health
3467maintenance organization that indicates the member or subscriber
3468understands the limitations of his or her policy and that only
3469those benefits under the point-of-service rider will be covered
3470when services are provided outside the service area.
3471     (c)  Premiums paid in for the point-of-service riders may
3472not exceed 15 percent of total premiums for all health plan
3473products sold by the health maintenance organization offering
3474the rider. If the premiums paid for point-of-service riders
3475exceed 15 percent, the health maintenance organization must
3476notify the office and, once this fact is known, must immediately
3477cease offering such a rider until it is in compliance with the
3478rider premium cap.
3479     (d)  Notwithstanding the limitations of deductibles and
3480copayment provisions in this part, a point-of-service rider may
3481require the subscriber to pay a reasonable copayment for each
3482visit for services provided by a noncontracted provider chosen
3483at the time of the service. The copayment by the subscriber may
3484either be a specific dollar amount or a percentage of the
3485reimbursable provider charges covered by the contract and must
3486be paid by the subscriber to the noncontracted provider upon
3487receipt of covered services. The point-of-service rider may
3488require that a reasonable annual deductible for the expenses
3489associated with the point-of-service rider be met and may
3490include a lifetime maximum benefit amount. The rider must
3491include the language required by s. 627.6044 and must comply
3492with copayment limits described in s. 627.6471. Section 641.3154
3493does not apply to a point-of-service rider authorized under this
3494subsection.
3495     (e)  The point-of-service rider must contain provisions
3496that comply with s. 627.6044.
3497     (f)(e)  The term "point of service" may not be used by a
3498health maintenance organization except with riders permitted
3499under this section or with forms approved by the office in which
3500a point-of-service product is offered with an indemnity carrier.
3501     (g)(f)  A point-of-service rider must be filed and approved
3502under ss. 627.410 and 627.411.
3503     (40)(a)  Any rate, rating schedule, or rating manual for a
3504health maintenance organization policy filed with the office
3505shall provide for an appropriate rebate of premiums paid in the
3506last calendar year when the individual covered by such plan is
3507enrolled in and maintains participation in any health wellness,
3508maintenance, or improvement program approved by the health plan.
3509The individual must provide evidence of demonstrative
3510maintenance or improvement of his or her health status as
3511determined by assessments of agreed-upon health status
3512indicators between the individual and the health insurer,
3513including, but not limited to, reduction in weight, body mass
3514index, and smoking cessation. Any rebate provided by the health
3515insurer is presumed to be appropriate unless credible data
3516demonstrates otherwise, but shall not exceed 10 percent of paid
3517premiums.
3518     (b)  The premium rebate authorized by this section shall be
3519effective for an insured on an annual basis, unless the
3520individual fails to maintain or improve his or her health status
3521while participating in an approved wellness program, or credible
3522evidence demonstrates that the individual is not participating
3523in the approved wellness program.
3524     Section 35.  Section 626.191, Florida Statutes, is amended
3525to read:
3526     626.191  Repeated applications.--The failure of an
3527applicant to secure a license upon an application shall not
3528preclude the applicant him or her from applying again as many
3529times as desired, but the department or office shall not give
3530consideration to or accept any further application by the same
3531individual for a similar license dated or filed within 30 days
3532subsequent to the date the department or office denied the last
3533application, except as provided in s. 626.281.
3534     Section 36.  Subsection (1) of section 626.201, Florida
3535Statutes, is amended to read:
3536     626.201  Investigation.--
3537     (1)  The department or office may propound any reasonable
3538interrogatories in addition to those contained in the
3539application, to any applicant for license or appointment, or on
3540any renewal, reinstatement, or continuation thereof, relating to
3541the applicant's his or her qualifications, residence,
3542prospective place of business, and any other matter which, in
3543the opinion of the department or office, is deemed necessary or
3544advisable for the protection of the public and to ascertain the
3545applicant's qualifications.
3546     Section 37.  Section 626.593, Florida Statutes, is created
3547to read:
3548     626.593  Insurance agent; written contract for
3549compensation.--
3550     (1)  No person licensed as an insurance agent may receive
3551any fee or commission or any other thing of value in addition to
3552the rates filed pursuant to chapter 627 for examining any group
3553health insurance or any group health benefit plan for the
3554purpose of giving or offering advice, counsel, recommendation,
3555or information in respect to terms, conditions, benefits,
3556coverage, or premium of any such policy or contract unless such
3557compensation is based upon a written contract signed by the
3558party to be charged and specifying or clearly defining the
3559amount or extent of such compensation and informing the party to
3560be charged that any commission received from an insurer will be
3561rebated to the party in accordance with subsection (3). In
3562addition, all compensation to be paid to the insurance agent
3563must be disclosed in the contract.
3564     (2)  A copy of every such contract shall be retained by the
3565licensee for not less than 3 years after such services have been
3566fully performed.
3567     (3)  Notwithstanding the provisions of s. 626.572, all
3568commissions received by an insurance agent from an insurer in
3569connection with the issuance of a policy, when a separate fee or
3570other consideration has been paid to the insurance agent by an
3571insured, shall be rebated to the insured or other party being
3572charged within 30 days after receipt of such commission by the
3573insurance agent.
3574     (4)  This section is subject to the unfair insurance trade
3575practices provisions of s. 626.9541(1)(g).
3576     Section 38.  Notwithstanding the amendment to s.
3577627.6699(5)(c), Florida Statutes, by this act, any right to an
3578open enrollment offer of health benefit coverage for groups of
3579fewer than two employees, pursuant to s. 627.6699(5)(c), Florida
3580Statutes, as it existed immediately before the effective date of
3581this act, shall remain in full force and effect until the
3582enactment of s. 627.64872, Florida Statutes, and the subsequent
3583date upon which such plan begins to accept new risks or members.
3584     Section 39.  Section 465.0244, Florida Statutes, is created
3585to read:
3586     465.0244  Information disclosure.--Every pharmacy shall
3587make available on its Internet website a link to the performance
3588outcome and financial data that is published by the Agency for
3589Health Care Administration pursuant to s. 408.05(3)(l) and shall
3590place in the area where customers receive filled prescriptions
3591notice that such information is available electronically and the
3592address of its Internet website.
3593     Section 40.  Section 627.6499, Florida Statutes, is amended
3594to read:
3595     627.6499  Reporting by insurers and third-party
3596administrators.--
3597     (1)  The office may require any insurer, third-party
3598administrator, or service company to report any information
3599reasonably required to assist the board in assessing insurers as
3600required by this act.
3601     (2)  Each health insurance issuer shall make available on
3602its Internet website a link to the performance outcome and
3603financial data that is published by the Agency for Health Care
3604Administration pursuant to s. 408.05(3)(l) and shall include in
3605every policy delivered or issued for delivery to any person in
3606the state or any materials provided as required by s. 627.64725
3607notice that such information is available electronically and the
3608address of its Internet website.
3609     Section 41.  Subsections (6) and (7) are added to section
3610641.54, Florida Statutes, to read:
3611     641.54  Information disclosure.--
3612     (6)  Each health maintenance organization shall make
3613available to its subscribers the estimated copay, coinsurance
3614percentage, or deductible, whichever is applicable, for any
3615covered services, the status of the subscriber's maximum annual
3616out-of-pocket payments for a covered individual or family, and
3617the status of the subscriber's maximum lifetime benefit. Such
3618estimate shall not preclude the actual copay, coinsurance
3619percentage, or deductible, whichever is applicable, from
3620exceeding the estimate.
3621     (7)  Each health maintenance organization shall make
3622available on its Internet website a link to the performance
3623outcome and financial data that is published by the Agency for
3624Health Care Administration pursuant to s. 408.05(3)(l) and shall
3625include in every policy delivered or issued for delivery to any
3626person in the state or any materials provided as required by s.
3627627.64725 notice that such information is available
3628electronically and the address of its Internet website.
3629     Section 42.  Section 408.02, Florida Statutes, is repealed.
3630     Section 43.  The sum of $250,000 is appropriated from the
3631Insurance Regulatory Trust Fund in the Department of Financial
3632Services to the Office of Insurance Regulation for the purpose
3633of implementing the provisions in this act relating to the Small
3634Employers Access Program.
3635     Section 44.  The sum of $250,000 is appropriated from the
3636Insurance Regulatory Trust Fund to enable the board of the
3637Florida Health Insurance Plan to conduct an actuarial study
3638required under s. 627.64872, Florida Statutes.
3639     Section 45.  The sum of $169,069 is appropriated from the
3640Insurance Regulatory Trust Fund in the Department of Financial
3641Services to the Office of Insurance Regulation, and three full-
3642time equivalent positions are authorized, for the purpose of
3643implementing the provisions in this act relating to the
3644regulation of Discount Medical Plan Organizations.
3645     Section 46.  The sum of $650,000 is appropriated from the
3646General Revenue Fund to the Agency for Health Care
3647Administration for the purposes of implementing the Florida
3648Patient Safety Corporation. The sum of $350,000 shall be used as
3649startup funds for the Florida Patient Safety Corporation and
3650$300,000 shall be used for the "near miss" project within the
3651Florida Patient Safety Corporation.
3652     Section 47.  The sum of $1,136,171 is appropriated from the
3653General Revenue Fund to the Agency for Health Care
3654Administration, and 11 full-time equivalent positions are
3655authorized, for the purposes of implementing the provisions of
3656this act relating to the reporting of performance and cost data
3657for hospitals, physicians, and pharmacies.
3658     Section 48.  Except as otherwise provided herein, this act
3659shall take effect July 1, 2004.


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