September 23, 2020
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HB 1629

1
A bill to be entitled
2An act relating to affordable health care; providing a
3popular name; providing purpose; amending s. 381.026,
4F.S.; requiring certain licensed facilities to provide
5public Internet access to certain financial information;
6providing a definition; amending s. 381.734, F.S.;
7including participation by health care providers, small
8businesses, and health insurers in the Healthy
9Communities, Healthy People Program; requiring the
10Department of Health to provide public Internet access to
11certain public health programs; requiring the department
12to monitor and assess the effectiveness of such programs;
13requiring a report; requiring the Office of Program Policy
14and Government Accountability to evaluate the
15effectiveness of such programs; requiring a report;
16amending s. 395.1041, F.S.; authorizing hospitals to
17develop certain emergency room diversion programs;
18amending s. 395.1055, F.S.; requiring licensed facilities
19to make certain patient charge and performance outcome
20data available on Internet websites; amending s. 395.1065,
21F.S.; authorizing the Agency for Health Care
22Administration to charge a fine for failure to provide
23such information; amending s. 395.301, F.S.; requiring
24certain licensed facilities to provide prospective
25patients certain estimates of charges for services;
26requiring such facilities to provide patients with certain
27bill verification information; providing for a fine for
28failure to provide such information; providing charge
29limitations; requiring such facilities to establish a
30patient question review and response methodology;
31providing requirements; requiring certain licensed
32facilities to provide public Internet access to certain
33financial information; requiring posting of a notice of
34the availability of such information; amending s. 408.061,
35F.S.; requiring the Agency for Health Care Administration
36to require health care facilities, health care providers,
37and health insurers to submit certain information;
38providing requirements; requiring the agency to adopt
39certain risk and severity adjustment methodologies;
40requiring the agency to adopt certain rules; requiring
41certain information to be certified; amending s. 408.062,
42F.S.; requiring the agency to conduct certain health care
43costs and access research, analyses, and studies;
44expanding the scope of such studies to include collection
45of pharmacy retail price data, use of emergency
46departments, physician information, and Internet patient
47charge information availability; requiring a report;
48requiring the agency to conduct additional data-based
49studies and make recommendations to the Legislature;
50requiring the agency to develop and implement a strategy
51to adopt and use electronic health records; authorizing
52the agency to develop rules to protect electronic records
53confidentiality; requiring a report to the Governor and
54Legislature; amending s. 408.05, F.S.; requiring the
55agency to develop a plan to make performance outcome and
56financial data available to consumers for health care
57services comparison purposes; requiring submittal of the
58plan to the Governor and Legislature; requiring the agency
59to update the plan; requiring the agency to make the plan
60available electronically; providing plan requirements;
61amending s. 409.9066, F.S.; requiring the agency to
62provide certain information relating to the Medicare
63prescription discount program; amending s. 408.7056, F.S.;
64renaming the Statewide Provider and Subscriber Assistance
65Program as the Subscriber Assistance Program; revising
66provisions to conform; expanding certain records
67availability provisions; revising membership provisions
68relating to a subscriber grievance hearing panel; revising
69a list of grievances the panel may consider; providing
70hearing procedures; amending s. 641.3154, F.S., to conform
71to the renaming of the Subscriber Assistance Program;
72amending s. 641.511, F.S., to conform to the renaming of
73the Subscriber Assistance Program; adopting and
74incorporating by reference the Employee Retirement Income
75Security Act of 1974, as implemented by federal
76regulations; amending s. 641.58, F.S., to conform to the
77renaming of the Subscriber Assistance Program; amending s.
78408.909, F.S.; expanding a definition of "health flex plan
79entity" to include public-private partnerships; making a
80pilot health flex plan program apply permanently
81statewide; providing additional program requirements;
82creating s. 381.0271, F.S.; providing definitions;
83creating the Florida Patient Safety Corporation;
84authorizing the corporation to create additional not-for-
85profit corporate subsidiaries for certain purposes;
86specifying application of public records and public
87meetings requirements; exempting the corporation and
88subsidiaries from public procurement provisions; providing
89purposes; providing for a board of directors; providing
90for membership; authorizing the corporation to establish
91certain advisory committees; providing for organization of
92the corporation; providing for meetings; providing powers
93and duties of the corporation; requiring the corporation
94to collect, analyze, and evaluate patient safety data and
95related information; requiring the corporation to
96establish a reporting system to identify and report near
97misses relating to patient safety; requiring the
98corporation to work with state agencies to develop
99electronic health records; providing for an active library
100of evidence-based medicine and patient safety practices;
101requiring the corporation to develop and recommend core
102competencies in patient safety and public education
103programs; requiring an annual report; providing report
104requirements; authorizing the corporation to seek funding
105and apply for grants; requiring the Office of Program
106Policy Analysis and Government Accountability, the
107Department of Health, and the Agency for Health Care
108Administration to develop performance standards to
109evaluate the corporation; amending s. 409.91255, F.S.;
110expanding assistance to certain health centers to include
111community emergency room diversion programs and urgent
112care services; amending s. 627.410, F.S.; requiring
113insurers to file certain rates with the Office of
114Insurance Regulation; creating s. 627.64872, F.S.;
115providing legislative intent; creating the Florida Health
116Insurance Plan for certain purposes; providing
117definitions; providing exclusions; providing requirements
118for operation of the plan; providing for a board of
119directors; providing for appointment of members; providing
120for terms; specifying service without compensation;
121providing for travel and per diem expenses; requiring a
122plan of operation; providing requirements; providing for
123powers of the plan; requiring reports to the Governor and
124Legislature; providing for an actuarial study; providing
125certain immunity from liability for plan obligations;
126authorizing the board to provide for indemnification of
127certain costs; requiring an annually audited financial
128statement; providing for eligibility for coverage under
129the plan; providing criteria, requirements, and
130limitations; specifying certain activity as an unfair
131trade practice; providing for a plan administrator;
132providing criteria; providing requirements; providing term
133limits for the plan administrator; providing duties;
134providing for paying the administrator; providing for
135premium rates for plan coverage; providing rate
136limitations; providing for sources of additional revenue;
137specifying benefits under the plan; providing criteria,
138requirements, and limitations; providing for
139nonduplication of benefits; providing for annual and
140maximum lifetime benefits; providing for tax exempt
141status; providing for abolition of the Florida
142Comprehensive Health Association upon implementation of
143the plan; providing for continued operation of the Florida
144Comprehensive Health Association until adoption of a plan
145of operation for the Florida Health Insurance Plan;
146providing for enrollment in the plan of persons enrolled
147in the association; requiring insurers to pay certain
148assessments to the board for certain purposes; providing
149criteria, requirements, and limitations for such
150assessments; providing for repeal of ss. 627.6488,
151627.6489, 627.649, 627.6492, 627.6494, 627.6496, and
152627.6498, F.S., relating to the Florida Comprehensive
153Health Association, upon implementation of the plan;
154amending s. 627.662, F.S.; providing for application of
155certain claim payment methodologies to certain types of
156insurance; providing for certain actions relating to
157inappropriate utilization of emergency care; amending s.
158627.6699, F.S.; revising provisions requiring small
159employer carriers to offer certain health benefit plans;
160preserving a right to open enrollment for certain small
161groups; requiring small employer carriers to file and
162provide coverage under certain high deductible plans;
163including high deductible plans and health reimbursement
164arrangements under certain required plan provisions;
165creating the Small Employers Access Program; providing
166legislative intent; providing definitions; providing
167participation eligibility requirements and criteria;
168requiring the Office of Insurance Regulation to administer
169the program by selecting an insurer through competitive
170bidding; providing requirements; specifying insurer
171qualifications; providing duties of the insurer; providing
172a contract term; providing insurer reporting requirements;
173providing application requirements; providing for benefits
174under the program; requiring the office to annually report
175to the Governor and Legislature; creating ss. 627.6405 and
176641.31097, F.S.; providing for decreasing inappropriate
177use of emergency care; providing legislative findings and
178intent; requiring health maintenance organizations and
179providers to provide certain information electronically
180and develop community emergency department diversion
181programs; authorizing health maintenance organizations to
182require higher copayments for certain uses of emergency
183departments; amending s. 627.9175, F.S.; requiring certain
184health insurers to annually report certain coverage
185information to the office; providing requirements;
186deleting certain reporting requirements; retitling ch.
187636, F.S.; designating ss. 636.002-636.067, F.S., as pt. I
188of ch. 636, F.S.; providing a part title; amending s.
189636.003, F.S.; revising the definition of "prepaid limited
190health service organization" to exclude discount medical
191plan organizations; creating pt. II of ch. 636, F.S.,
192consisting of ss. 636.202-636.244, F.S.; providing a part
193title; providing definitions; providing for regulation and
194operation of discount medical plan organizations;
195requiring corporate licensure before doing business as a
196discount medical plan; specifying application
197requirements; requiring license fees; providing for
198expiration and renewal of licenses; requiring such
199organizations to establish an Internet website; requiring
200publication of certain information on the website;
201specifying collection and deposit of the licensing fee;
202authorizing the office to examine or investigate the
203business affairs of such organizations; requiring
204examinations and investigations; authorizing the office to
205order production of documents and take statements;
206requiring organizations to pay certain expenses;
207specifying grounds for denial or revocation under certain
208circumstances; authorizing discount medical plan
209organizations to charge certain fees under certain
210circumstances; providing reimbursement requirements;
211prohibiting certain activities; requiring certain
212disclosures to prospective members; requiring provider
213agreements to provide services under a medical discount
214plan; providing agreement requirements; requiring forms
215and rates to be filed with the office; requiring annual
216reports to be filed with the office; providing
217requirements; providing for fines and administrative
218sanctions for failing to file annual reports; establishing
219minimum capital requirements; providing for suspension or
220revocation of licenses under certain circumstances;
221providing for suspension of enrollment of new members
222under certain circumstances; providing terms of
223suspensions; requiring notice of any change of an
224organization's name; requiring discount medical plan
225organizations to maintain provider names listings;
226specifying marketing requirements of discount medical
227plans; providing limitations; specifying fee disclosure
228requirements for bundling discount medical plans with
229other insurance products; authorizing the commission to
230adopt rules; applying insurer service of process
231requirements on discount medical plan organizations;
232requiring a security deposit; prohibiting levy on certain
233deposit assets or securities under certain circumstances;
234providing criminal penalties; authorizing the office to
235seek certain injunctive relief under certain
236circumstances; providing limitations; providing for civil
237actions for damages for certain violations; providing for
238awards of court costs and attorney fees; specifying
239application of unauthorized insurer provisions of law to
240unlicensed discount medical plan organizations; creating
241ss. 627.65626 and 627.6402, F.S.; providing for insurance
242rebates for healthy lifestyles; providing for rebate of
243certain premiums for participation in health wellness,
244maintenance, or improvement programs under certain
245circumstances; providing requirements; amending s. 641.31,
246F.S.; authorizing health maintenance organizations
247offering certain point-of-service riders to offer such
248riders to certain employers for certain employees;
249providing requirements and limitations; providing for
250application of certain claim payment methodologies to
251certain types of insurance; providing for rebate of
252certain premiums for participation in health wellness,
253maintenance, or improvement programs under certain
254circumstances; providing requirements; creating s.
255626.593, F.S.; providing fee and commission limitations
256for health insurance agents; requiring a written contract
257for compensation; providing contract requirements;
258requiring a rebate of commission under certain
259circumstances; amending ss. 626.191 and 626.201, F.S.;
260clarifying certain application requirements; preserving
261certain rights to enrollment in certain health benefit
262coverage programs for certain groups under certain
263circumstances; creating s. 465.0244, F.S.; requiring each
264pharmacy to make available on its Internet website a link
265to certain performance outcome and financial data of the
266Agency for Health Care Administration and a notice of the
267availability of such information; amending s. 627.6499,
268F.S.; requiring each health insurer to make available on
269its Internet website a link to certain performance outcome
270and financial data of the Agency for Health Care
271Administration and a notice in policies of the
272availability of such information; amending s. 641.54,
273F.S.; requiring health maintenance organizations to make
274certain insurance financial information available to
275subscribers; requiring health maintenance organizations to
276make available on its Internet website a link to certain
277performance outcome and financial data of the Agency for
278Health Care Administration and a notice in policies of the
279availability of such information; repealing s. 408.02,
280F.S., relating to the development, endorsement,
281implementation, and evaluation of patient management
282practice parameters by the Agency for Health Care
283Administration; providing appropriations; providing
284effective dates.
285
286     WHEREAS, according to the Kaiser Family Foundation, eight
287out of ten uninsured Americans are workers or dependents of
288workers and nearly eight out of ten uninsured Americans have
289family incomes above the poverty level, and
290     WHEREAS, fifty-five percent of those who do not have
291insurance state the reason they don't have insurance is lack of
292affordability, and
293     WHEREAS, average health insurance premium increases for the
294last two years have been in the range of ten to twenty percent
295for Florida's employers, and
296     WHEREAS, an increasing number of employers are opting to
297cease providing insurance coverage to their employees due to the
298high cost, and
299     WHEREAS, an increasing number of employers who continue
300providing coverage are forced to shift more premium cost to
301their employees, thus diminishing the value of employee wage
302increases, and
303     WHEREAS, according to studies, the rate of avoidable
304hospitalization is fifty to seventy percent lower for the
305insured versus the uninsured, and
306     WHEREAS, according to Florida Cancer Registry data, the
307uninsured have a seventy percent greater chance of a late
308diagnosis, thus decreasing the chances of a positive health
309outcome, and
310     WHEREAS, according to the Agency for Health Care
311Administration's 2002 financial data, uncompensated care in
312Florida's hospitals is growing at the rate of twelve to thirteen
313percent per year, and, at $4.3 billion in 2001, this cost, when
314shifted to Floridians who remain insured, is not sustainable,
315and
316     WHEREAS, the Florida Legislature, through the creation of
317Health Flex, has already identified the need for lower cost
318alternatives, and
319     WHEREAS, it is of vital importance and in the best
320interests of the people of the State of Florida that the issue
321of available, affordable health care insurance be addressed in a
322cohesive and meaningful manner, and
323     WHEREAS, there is general recognition that the issues
324surrounding the problem of access to affordable health insurance
325are complicated and multifaceted, and
326     WHEREAS, on August 14, 2003, Speaker Johnnie Byrd created
327the Select Committee on Affordable Health Care for Floridians in
328an effort to address the issue of affordable and accessible
329employment-based insurance, and
330     WHEREAS, the Select Committee on Affordable Health Care for
331Floridians held public hearings with predetermined themes around
332the state, specifically, in Orlando, Miami, Jacksonville, Tampa,
333Pensacola, Boca Raton, and Tallahassee, from October through
334November 2003 to effectively probe the operation of the private
335insurance marketplace, to understand the health insurance market
336trends, to learn from past policy initiatives, and to identify,
337explore, and debate new ideas for change, and
338     WHEREAS, recommendations from the Select Committee on
339Affordable Health Care were adopted on February 4, 2004, to
340address the multifaceted issues attributed to the increase in
341health care cost, and
342     WHEREAS, these recommendations were presented to the
343Speaker of the House of Representatives in a final report from
344the committee on February 18, 2004, and subsequent legislation
345was drafted creating the "The 2004 Affordable Health Care for
346Floridians Act," NOW, THEREFORE,
347
348Be It Enacted by the Legislature of the State of Florida:
349
350     Section 1.  This act may be referred to by the popular name
351"The 2004 Affordable Health Care for Floridians Act."
352     Section 2.  The purpose of this act is to address the
353underlying cause of the double-digit increases in health
354insurance premiums by mitigating the overall growth in health
355care costs.
356     Section 3.  Paragraph (c) of subsection (4) of section
357381.026, Florida Statutes, is amended to read:
358     381.026  Florida Patient's Bill of Rights and
359Responsibilities.--
360     (4)  RIGHTS OF PATIENTS.--Each health care facility or
361provider shall observe the following standards:
362     (c)  Financial information and disclosure.--
363     1.  A patient has the right to be given, upon request, by
364the responsible provider, his or her designee, or a
365representative of the health care facility full information and
366necessary counseling on the availability of known financial
367resources for the patient's health care.
368     2.  A health care provider or a health care facility shall,
369upon request, disclose to each patient who is eligible for
370Medicare, in advance of treatment, whether the health care
371provider or the health care facility in which the patient is
372receiving medical services accepts assignment under Medicare
373reimbursement as payment in full for medical services and
374treatment rendered in the health care provider's office or
375health care facility.
376     3.  A health care provider or a health care facility shall,
377upon request, furnish a person patient, prior to provision of
378medical services, a reasonable estimate of charges for such
379services. Such reasonable estimate shall not preclude the health
380care provider or health care facility from exceeding the
381estimate or making additional charges based on changes in the
382patient's condition or treatment needs.
383     4.  Each licensed facility not operated by the state shall
384make available to the public on its Internet website or by other
385electronic means a description of and a link to the performance
386outcome and financial data that is published by the agency
387pursuant to s. 408.05(3)(l). The facility shall place a notice
388in the reception area that such information is available
389electronically and the website address. The licensed facility
390may indicate that the pricing information is based on a
391compilation of charges for the average patient and that each
392patient's bill may vary from the average depending upon the
393severity of illness and individual resources consumed. The
394licensed facility may also indicate that the price of service is
395negotiable for eligible patients based upon the patient's
396ability to pay.
397     5.4.  A patient has the right to receive a copy of an
398itemized bill upon request. A patient has a right to be given an
399explanation of charges upon request.
400     Section 4.  Subsection (1) and paragraph (g) of subsection
401(3) of section 381.734, Florida Statutes, are amended, and
402subsections (4), (5), and (6) are added to said section, to
403read:
404     381.734  Healthy Communities, Healthy People Program.--
405     (1)  The department shall develop and implement the Healthy
406Communities, Healthy People Program, a comprehensive and
407community-based health promotion and wellness program. The
408program shall be designed to reduce major behavioral risk
409factors associated with chronic diseases, including those
410chronic diseases identified in chapter 385, by enhancing the
411knowledge, skills, motivation, and opportunities for
412individuals, organizations, health care providers, small
413businesses, health insurers, and communities to develop and
414maintain healthy lifestyles.
415     (3)  The program shall include:
416     (g)  The establishment of a comprehensive program to inform
417the public, health care professionals, health insurers, and
418communities about the prevalence of chronic diseases in the
419state; known and potential risks, including social and
420behavioral risks; and behavior changes that would reduce risks.
421     (4)  The department shall make available on its Internet
422website, no later than October 1, 2004, and in a hard-copy
423format upon request, a listing of age-specific, disease-
424specific, and community-specific health promotion, preventive
425care, and wellness programs offered and established under the
426Healthy Communities, Healthy People Program. The website shall
427also provide residents with information to identify behavior
428risk factors that lead to diseases that are preventable by
429maintaining a healthy lifestyle. The website shall allow
430consumers to select by county or region disease-specific
431statistical information.
432     (5)  The department shall monitor and assess the
433effectiveness of such programs. The department shall submit a
434status report based on this monitoring and assessment to the
435Governor, the Speaker of the House of Representatives, the
436President of the Senate, and the substantive committees of each
437house of the Legislature, with the first annual report due
438January 31, 2005.
439     (6)  The Office of Program Policy and Government
440Accountability shall evaluate and report to the Governor, the
441President of the Senate, and the Speaker of the House of
442Representatives, by March 1, 2005, on the effectiveness of the
443department's monitoring and assessment of the program's
444effectiveness.
445     Section 5.  Subsection (7) is added to section 395.1041,
446Florida Statutes, to read:
447     395.1041  Access to emergency services and care.--
448     (7)  EMERGENCY ROOM DIVERSION PROGRAMS.--Hospitals may
449develop emergency room diversion programs, including, but not
450limited to, an "Emergency Hotline" which allows patients to help
451determine if emergency department services are appropriate or if
452other health care settings may be more appropriate for care, and
453a "Fast Track" program allowing nonemergency patients to be
454treated at an alternative site. Alternative sites may include
455health care programs funded with local tax revenue and federally
456funded community health centers, county health departments, or
457other nonhospital providers of health care services. The program
458may include provisions for followup care and case management.
459     Section 6.  Paragraph (h) is added to subsection (1) of
460section 395.1055, Florida Statutes, to read:
461     395.1055  Rules and enforcement.--
462     (1)  The agency shall adopt rules pursuant to ss.
463120.536(1) and 120.54 to implement the provisions of this part,
464which shall include reasonable and fair minimum standards for
465ensuring that:
466     (h)  Licensed facilities make available on their Internet
467websites, no later than October 1, 2004, and in a hard-copy
468format upon request, a description of and a link to the patient
469charge and performance outcome data collected from licensed
470facilities pursuant to s. 408.061.
471     Section 7.  Subsection (7) is added to section 395.1065,
472Florida Statutes, to read:
473     395.1065  Criminal and administrative penalties;
474injunctions; emergency orders; moratorium.--
475     (7)  The agency shall impose a fine of $500 for each
476instance of the facility's failure to provide the information
477required by rules adopted pursuant to s. 395.1055(1)(h).
478     Section 8.  Subsections (1), (2), and (3) of section
479395.301, Florida Statutes, are amended, and subsections (7),
480(8), (9), and (10) are added to said section, to read:
481     395.301  Itemized patient bill; form and content prescribed
482by the agency.--
483     (1)  A licensed facility not operated by the state shall
484notify each patient during admission and at discharge of his or
485her right to receive an itemized bill upon request. Within 7
486days following the patient's discharge or release from a
487licensed facility not operated by the state, or within 7 days
488after the earliest date at which the loss or expense from the
489service may be determined, the licensed facility providing the
490service shall, upon request, submit to the patient, or to the
491patient's survivor or legal guardian as may be appropriate, an
492itemized statement detailing in language comprehensible to an
493ordinary layperson the specific nature of charges or expenses
494incurred by the patient, which in the initial billing shall
495contain a statement of specific services received and expenses
496incurred for such items of service, enumerating in detail the
497constituent components of the services received within each
498department of the licensed facility and including unit price
499data on rates charged by the licensed facility, as prescribed by
500the agency.
501     (2)(a)  Each such statement submitted pursuant to this
502section:
503     1.(a)  May not include charges of hospital-based physicians
504if billed separately.
505     2.(b)  May not include any generalized category of expenses
506such as "other" or "miscellaneous" or similar categories.
507     3.(c)  Shall list drugs by brand or generic name and not
508refer to drug code numbers when referring to drugs of any sort.
509     4.(d)  Shall specifically identify therapy treatment as to
510the date, type, and length of treatment when therapy treatment
511is a part of the statement.
512     (b)  Any person receiving a statement pursuant to this
513section shall be fully and accurately informed as to each charge
514and service provided by the institution preparing the statement.
515     (3)  On each such itemized statement submitted pursuant to
516subsection (1) there shall appear the words "A FOR-PROFIT (or
517NOT-FOR-PROFIT or PUBLIC) HOSPITAL (or AMBULATORY SURGICAL
518CENTER) LICENSED BY THE STATE OF FLORIDA" or substantially
519similar words sufficient to identify clearly and plainly the
520ownership status of the licensed facility. Each itemized
521statement must prominently display the phone number of the
522medical facility's patient liaison who is responsible for
523expediting the resolution of any billing dispute between the
524patient, or his or her representative, and the billing
525department.
526     (7)  Each licensed facility not operated by the state shall
527provide, prior to provision of any nonemergency medical
528services, a written good-faith estimate of reasonably
529anticipated charges for the facility to treat the patient's
530condition upon written request of a prospective patient. The
531estimate shall be provided to the prospective patient within 7
532business days after the receipt of the request. The estimate may
533be the average charges for that diagnosis related group or the
534average charges for that procedure. Upon request, the facility
535shall notify the patient of any revision to the good-faith
536estimate. Such estimate shall not preclude the actual charges
537from exceeding the estimate. The facility shall place a notice
538in the reception area that such information is available.
539Failure to provide the estimate within the provisions
540established pursuant to this section shall result in a fine of
541$500 for each instance of the facility's failure to provide the
542requested information.
543     (8)  A licensed facility shall make available to a patient
544all records necessary for verification of the accuracy of the
545patient's bill within 30 business days after the request for
546such records. The verification information must be made
547available in the facility's offices. Such records shall be
548available to the patient prior to and after payment of the bill
549or claim. The facility may not charge the patient for making
550such verification records available; however, the facility may
551charge its usual fee for providing copies of records as
552specified in s. 395.3025.
553     (9)  Each facility shall establish a method for reviewing
554and responding to questions from patients concerning the
555patient's itemized bill. Such response shall be provided within
55630 days after the date a question is received. If the patient is
557not satisfied with the response, the facility must provide the
558patient with the address of the agency to which the issue may be
559sent for review.
560     (10)  Each licensed facility shall make available on its
561Internet website a link to the performance outcome and financial
562data that is published by the Agency for Health Care
563Administration pursuant to s. 408.05(3)(l). The facility shall
564place a notice in the reception area that the information is
565available electronically and the facility's Internet website
566address.
567     Section 9.  Subsection (1) of section 408.061, Florida
568Statutes, is amended to read:
569     408.061  Data collection; uniform systems of financial
570reporting; information relating to physician charges;
571confidential information; immunity.--
572     (1)  The agency shall may require the submission by health
573care facilities, health care providers, and health insurers of
574data necessary to carry out the agency's duties. Specifications
575for data to be collected under this section shall be developed
576by the agency with the assistance of technical advisory panels
577including representatives of affected entities, consumers,
578purchasers, and such other interested parties as may be
579determined by the agency.
580     (a)  Data to be submitted by health care facilities,
581including the facilities as defined in chapter 395, shall may
582include, but are not limited to: case-mix data, patient
583admission and or discharge data, hospital emergency department
584data which shall include the number of patients treated in the
585emergency department of a licensed hospital reported by patient
586acuity level, data on hospital-acquired infections as specified
587by rule, data on complications as specified by rule, data on
588readmissions as specified by rule, with patient and provider-
589specific identifiers included, actual charge data by diagnostic
590groups, financial data, accounting data, operating expenses,
591expenses incurred for rendering services to patients who cannot
592or do not pay, interest charges, depreciation expenses based on
593the expected useful life of the property and equipment involved,
594and demographic data. The agency shall adopt nationally
595recognized risk adjustment methodologies or software consistent
596with the standards of the Agency for Healthcare Research and
597Quality and as selected by the agency for all data submitted as
598required by this section. Data may be obtained from documents
599such as, but not limited to: leases, contracts, debt
600instruments, itemized patient bills, medical record abstracts,
601and related diagnostic information. Reported data elements shall
602be reported electronically in accordance with Rule 59E-7.012,
603Florida Administrative Code. Data submitted shall be certified
604by the chief executive officer or an appropriate and duly
605authorized representative or employee of the licensed facility
606that the information submitted is true and accurate.
607     (b)  Data to be submitted by health care providers may
608include, but are not limited to: Medicare and Medicaid
609participation, types of services offered to patients, amount of
610revenue and expenses of the health care provider, and such other
611data which are reasonably necessary to study utilization
612patterns. Data submitted shall be certified by the appropriate
613duly authorized representative or employee of the health care
614provider that the information submitted is true and accurate.
615     (c)  Data to be submitted by health insurers may include,
616but are not limited to: claims, premium, administration, and
617financial information. Data submitted shall be certified by the
618chief financial officer, an appropriate and duly authorized
619representative, or an employee of the insurer that the
620information submitted is true and accurate.
621     (d)  Data required to be submitted by health care
622facilities, health care providers, or health insurers shall not
623include specific provider contract reimbursement information.
624However, such specific provider reimbursement data shall be
625reasonably available for onsite inspection by the agency as is
626necessary to carry out the agency's regulatory duties. Any such
627data obtained by the agency as a result of onsite inspections
628may not be used by the state for purposes of direct provider
629contracting and are confidential and exempt from the provisions
630of s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
631     (e)  A requirement to submit data shall be adopted by rule
632if the submission of data is being required of all members of
633any type of health care facility, health care provider, or
634health insurer. Rules are not required, however, for the
635submission of data for a special study mandated by the
636Legislature or when information is being requested for a single
637health care facility, health care provider, or health insurer.
638     Section 10.  Subsections (1) and (4) of section 408.062,
639Florida Statutes, are amended, and subsection (5) is added to
640said section, to read:
641     408.062  Research, analyses, studies, and reports.--
642     (1)  The agency shall have the authority to conduct
643research, analyses, and studies relating to health care costs
644and access to and quality of health care services as access and
645quality are affected by changes in health care costs. Such
646research, analyses, and studies shall include, but not be
647limited to, research and analysis relating to:
648     (a)  The financial status of any health care facility or
649facilities subject to the provisions of this chapter.
650     (b)  The impact of uncompensated charity care on health
651care facilities and health care providers.
652     (c)  The state's role in assisting to fund indigent care.
653     (d)  In conjunction with the Office of Insurance
654Regulation, the availability and affordability of health
655insurance for small businesses.
656     (e)  Total health care expenditures in the state according
657to the sources of payment and the type of expenditure.
658     (f)  The quality of health services, using techniques such
659as small area analysis, severity adjustments, and risk-adjusted
660mortality rates.
661     (g)  The development of physician information payment
662systems which are capable of providing data for health care
663consumers taking into account the amount of resources consumed,
664including such information at licensed facilities as defined in
665chapter 395, and the outcomes produced in the delivery of care.
666     (h)  The collection of a statistically valid sample of data
667on the retail prices charged by pharmacies for the 50 most
668frequently prescribed medicines from any pharmacy licensed by
669this state as a special study authorized by the Legislature to
670be performed by the agency quarterly. If the drug is available
671generically, price data shall be reported for the generic drug
672and price data of a brand-named drug for which the generic drug
673is the equivalent shall be reported. The agency shall make
674available on its Internet website for each pharmacy, no later
675than October 1, 2005, drug prices for a 30-day supply at a
676standard dose. The data collected shall be reported for each
677drug by pharmacy and by metropolitan statistical area or region
678and updated quarterly The impact of subacute admissions on
679hospital revenues and expenses for purposes of calculating
680adjusted admissions as defined in s. 408.07.
681     (i)  The use of emergency department services by patient
682acuity level and the implication of increasing hospital cost by
683providing nonurgent care in emergency departments. The agency
684shall submit an annual report based on this monitoring and
685assessment to the Governor, the Speaker of the House of
686Representatives, the President of the Senate, and the
687substantive legislative committees with the first report due
688January 1, 2006.
689     (j)  The making available on its Internet website no later
690than October 1, 2004, and in a hard-copy format upon request, of
691patient charge, volumes, length of stay, and performance outcome
692indicators collected from health care facilities pursuant to s.
693408.061(1)(a) for specific medical conditions, surgeries, and
694procedures provided in inpatient and outpatient facilities as
695determined by the agency. In making the determination of
696specific medical conditions, surgeries, and procedures to
697include, the agency shall consider such factors as volume,
698severity of the illness, urgency of admission, individual and
699societal costs, and whether the condition is acute or chronic.
700Performance outcome indicators shall be risk adjusted or
701severity adjusted, as applicable, using nationally recognized
702risk adjustment methodologies or software consistent with the
703standards of the Agency for Healthcare Research and Quality and
704as selected by the agency. The website shall also provide an
705interactive search that allows consumers to view and compare the
706information for specific facilities, a map that allows consumers
707to select a county or region, definitions of all of the data,
708descriptions of each procedure, and an explanation about why the
709data may differ from facility to facility. Such public data
710shall be updated quarterly. The agency shall submit an annual
711status report on the collection of data and publication of
712performance outcome indicators to the Governor, the Speaker of
713the House of Representatives, the President of the Senate, and
714the substantive legislative committees with the first status
715report due January 1, 2005.
716     (4)(a)  The agency shall may conduct data-based studies and
717evaluations and make recommendations to the Legislature and the
718Governor concerning exemptions, the effectiveness of limitations
719of referrals, restrictions on investment interests and
720compensation arrangements, and the effectiveness of public
721disclosure. Such analysis shall may include, but need not be
722limited to, utilization of services, cost of care, quality of
723care, and access to care. The agency may require the submission
724of data necessary to carry out this duty, which may include, but
725need not be limited to, data concerning ownership, Medicare and
726Medicaid, charity care, types of services offered to patients,
727revenues and expenses, patient-encounter data, and other data
728reasonably necessary to study utilization patterns and the
729impact of health care provider ownership interests in health-
730care-related entities on the cost, quality, and accessibility of
731health care.
732     (b)  The agency may collect such data from any health
733facility or licensed health care provider as a special study.
734     (5)  The agency shall develop and implement a strategy for
735the adoption and use of electronic health records. The agency
736may develop rules to facilitate the functionality and protect
737the confidentiality of electronic health records. The agency
738shall report to the Governor, the Speaker of the House of
739Representatives, and the President of the Senate on legislative
740recommendations to protect the confidentiality of electronic
741health records.
742     Section 11.  Paragraph (l) is added to subsection (3) of
743section 408.05, Florida Statutes, to read:
744     408.05  State Center for Health Statistics.--
745     (3)  COMPREHENSIVE HEALTH INFORMATION SYSTEM.--In order to
746produce comparable and uniform health information and
747statistics, the agency shall perform the following functions:
748     (l)  Develop, in conjunction with the State Comprehensive
749Health Information System Advisory Council, and implement a
750long-range plan for making available performance outcome and
751financial data that will allow consumers to compare health care
752services. The performance outcomes and financial data the agency
753must make available shall include, but is not limited to,
754pharmaceuticals, physicians, health care facilities, and health
755plans and managed care entities. The agency shall submit the
756initial plan to the Governor, the President of the Senate, and
757the Speaker of the House of Representatives by March 1, 2005,
758and shall update the plan and report on the status of its
759implementation annually thereafter. The agency shall also make
760the plan and status report available to the public on its
761Internet website. As part of the plan, the agency shall identify
762the process and timeframes for implementation, any barriers to
763implementation, and recommendations of changes in the law that
764may be enacted by the Legislature to eliminate the barriers. As
765preliminary elements of the plan, the agency shall:
766     1.  Make available performance outcome and patient charge
767data collected from health care facilities pursuant to s.
768408.061(1)(a) and (2). The agency shall determine which
769conditions and procedures, performance outcomes, and patient
770charge data to disclose based upon input from the council. When
771determining which conditions and procedures are to be disclosed,
772the council and the agency shall consider variation in costs,
773variation in outcomes, and magnitude of variations and other
774relevant information. When determining which performance
775outcomes to disclose, the agency:
776     a.  Shall consider such factors as volume of cases; average
777patient charges; average length of stay; complication rates;
778mortality rates; and infection rates, among others, which shall
779be adjusted for case mix and severity, if applicable.
780     b.  May consider such additional measures that are adopted
781by the Centers for Medicare and Medicaid Studies, National
782Quality Forum, the Joint Commission on Accreditation of
783Healthcare Organizations, the Agency for Healthcare Research and
784Quality, or a similar national entity that establishes standards
785to measure the performance of health care providers, or by other
786states.
787
788When determining which patient charge data to disclose, the
789agency shall consider such measures as average charge, average
790net revenue per adjusted patient day, average cost per adjusted
791patient day, and average cost per admission, among others.
792     2.  Make available performance measures, benefit design,
793and premium cost data from health plans licensed pursuant to
794chapter 627 or chapter 641. The agency shall determine which
795performance outcome and member and subscriber cost data to
796disclose, based upon input from the council. When determining
797which data to disclose, the agency shall consider information
798that may be required by either individual or group purchasers to
799assess the value of the product, which may include membership
800satisfaction, quality of care, current enrollment or membership,
801coverage areas, accreditation status, premium costs, plan costs,
802premium increases, range of benefits, copayments and
803deductibles, accuracy and speed of claims payment, credentials
804of physicians, number of providers, names of network providers,
805and hospitals in the network. Health plans shall make available
806to the agency any such data or information that is not currently
807reported to the agency or the office.
808     3.  Determine the method and format for public disclosure
809of data reported pursuant to this paragraph. The agency shall
810make its determination based upon input from the Comprehensive
811Health Information System Advisory Council. At a minimum, the
812data shall be made available on the agency's Internet website in
813a manner that allows consumers to conduct an interactive search
814that allows them to view and compare the information for
815specific providers. The website must include such additional
816information as is determined necessary to ensure that the
817website enhances informed decision making among consumers and
818health care purchasers, which shall include, at a minimum,
819appropriate guidance on how to use the data and an explanation
820of why the data may vary from provider to provider. The data
821specified in subparagraph 1. shall be released no later than
822March 1, 2005. The data specified in subparagraph 2. shall be
823released no later than March 1, 2006.
824     Section 12.  Subsection (3) of section 409.9066, Florida
825Statutes, is amended to read:
826     409.9066  Medicare prescription discount program.--
827     (3)  The Agency for Health Care Administration shall
828publish, on a free website available to the public, the most
829recent average wholesale prices for the 200 drugs most
830frequently dispensed to the elderly and, to the extent possible,
831shall provide a mechanism that consumers may use to calculate
832the retail price and the price that should be paid after the
833discount required in subsection (1) is applied. The agency shall
834provide retail information by geographic area and retail
835information by provider within geographical areas.
836     Section 13.  Section 408.7056, Florida Statutes, is amended
837to read:
838     408.7056  Statewide Provider and Subscriber Assistance
839Program.--
840     (1)  As used in this section, the term:
841     (a)  "Agency" means the Agency for Health Care
842Administration.
843     (b)  "Department" means the Department of Financial
844Services.
845     (c)  "Grievance procedure" means an established set of
846rules that specify a process for appeal of an organizational
847decision.
848     (d)  "Health care provider" or "provider" means a state-
849licensed or state-authorized facility, a facility principally
850supported by a local government or by funds from a charitable
851organization that holds a current exemption from federal income
852tax under s. 501(c)(3) of the Internal Revenue Code, a licensed
853practitioner, a county health department established under part
854I of chapter 154, a prescribed pediatric extended care center
855defined in s. 400.902, a federally supported primary care
856program such as a migrant health center or a community health
857center authorized under s. 329 or s. 330 of the United States
858Public Health Services Act that delivers health care services to
859individuals, or a community facility that receives funds from
860the state under the Community Alcohol, Drug Abuse, and Mental
861Health Services Act and provides mental health services to
862individuals.
863     (e)  "Managed care entity" means a health maintenance
864organization or a prepaid health clinic certified under chapter
865641, a prepaid health plan authorized under s. 409.912, or an
866exclusive provider organization certified under s. 627.6472.
867     (f)  "Office" means the Office of Insurance Regulation of
868the Financial Services Commission.
869     (g)  "Panel" means a statewide provider and subscriber
870assistance panel selected as provided in subsection (11).
871     (2)  The agency shall adopt and implement a program to
872provide assistance to subscribers and providers, including those
873whose grievances are not resolved by the managed care entity to
874the satisfaction of the subscriber or provider. The program
875shall consist of one or more panels that meet as often as
876necessary to timely review, consider, and hear grievances and
877recommend to the agency or the office any actions that should be
878taken concerning individual cases heard by the panel. The panel
879shall hear every grievance filed by subscribers and providers on
880behalf of subscribers, unless the grievance:
881     (a)  Relates to a managed care entity's refusal to accept a
882provider into its network of providers;
883     (b)  Is part of an internal grievance in a Medicare managed
884care entity or a reconsideration appeal through the Medicare
885appeals process which does not involve a quality of care issue;
886     (c)  Is related to a health plan not regulated by the state
887such as an administrative services organization, third-party
888administrator, or federal employee health benefit program;
889     (d)  Is related to appeals by in-plan suppliers and
890providers, unless related to quality of care provided by the
891plan;
892     (e)  Is part of a Medicaid fair hearing pursued under 42
893C.F.R. ss. 431.220 et seq.;
894     (f)  Is the basis for an action pending in state or federal
895court;
896     (g)  Is related to an appeal by nonparticipating providers,
897unless related to the quality of care provided to a subscriber
898by the managed care entity and the provider is involved in the
899care provided to the subscriber;
900     (h)  Was filed before the subscriber or provider completed
901the entire internal grievance procedure of the managed care
902entity, the managed care entity has complied with its timeframes
903for completing the internal grievance procedure, and the
904circumstances described in subsection (6) do not apply;
905     (i)  Has been resolved to the satisfaction of the
906subscriber or provider who filed the grievance, unless the
907managed care entity's initial action is egregious or may be
908indicative of a pattern of inappropriate behavior;
909     (j)  Is limited to seeking damages for pain and suffering,
910lost wages, or other incidental expenses, including accrued
911interest on unpaid balances, court costs, and transportation
912costs associated with a grievance procedure;
913     (k)  Is limited to issues involving conduct of a health
914care provider or facility, staff member, or employee of a
915managed care entity which constitute grounds for disciplinary
916action by the appropriate professional licensing board and is
917not indicative of a pattern of inappropriate behavior, and the
918agency, office, or department has reported these grievances to
919the appropriate professional licensing board or to the health
920facility regulation section of the agency for possible
921investigation; or
922     (l)  Is withdrawn by the subscriber or provider. Failure of
923the subscriber or the provider to attend the hearing shall be
924considered a withdrawal of the grievance; or
925     (3)  The agency shall review all grievances within 60 days
926after receipt and make a determination whether the grievance
927shall be heard. Once the agency notifies the panel, the
928subscriber or provider, and the managed care entity that a
929grievance will be heard by the panel, the panel shall hear the
930grievance either in the network area or by teleconference no
931later than 120 days after the date the grievance was filed. The
932agency shall notify the parties, in writing, by facsimile
933transmission, or by phone, of the time and place of the hearing.
934The panel may take testimony under oath, request certified
935copies of documents, and take similar actions to collect
936information and documentation that will assist the panel in
937making findings of fact and a recommendation. The panel shall
938issue a written recommendation, supported by findings of fact,
939to the provider or subscriber, to the managed care entity, and
940to the agency or the office no later than 15 working days after
941hearing the grievance. If at the hearing the panel requests
942additional documentation or additional records, the time for
943issuing a recommendation is tolled until the information or
944documentation requested has been provided to the panel. The
945proceedings of the panel are not subject to chapter 120.
946     (4)  If, upon receiving a proper patient authorization
947along with a properly filed grievance, the agency requests
948medical records from a health care provider or managed care
949entity, the health care provider or managed care entity that has
950custody of the records has 10 days to provide the records to the
951agency. Records include medical records, communication logs
952associated with the grievance both to and from the subscriber,
953and contracts. Failure to provide requested medical records may
954result in the imposition of a fine of up to $500. Each day that
955records are not produced is considered a separate violation.
956     (5)  Grievances that the agency determines pose an
957immediate and serious threat to a subscriber's health must be
958given priority over other grievances. The panel may meet at the
959call of the chair to hear the grievances as quickly as possible
960but no later than 45 days after the date the grievance is filed,
961unless the panel receives a waiver of the time requirement from
962the subscriber. The panel shall issue a written recommendation,
963supported by findings of fact, to the office or the agency
964within 10 days after hearing the expedited grievance.
965     (6)  When the agency determines that the life of a
966subscriber is in imminent and emergent jeopardy, the chair of
967the panel may convene an emergency hearing, within 24 hours
968after notification to the managed care entity and to the
969subscriber, to hear the grievance. The grievance must be heard
970notwithstanding that the subscriber has not completed the
971internal grievance procedure of the managed care entity. The
972panel shall, upon hearing the grievance, issue a written
973emergency recommendation, supported by findings of fact, to the
974managed care entity, to the subscriber, and to the agency or the
975office for the purpose of deferring the imminent and emergent
976jeopardy to the subscriber's life. Within 24 hours after receipt
977of the panel's emergency recommendation, the agency or office
978may issue an emergency order to the managed care entity. An
979emergency order remains in force until:
980     (a)  The grievance has been resolved by the managed care
981entity;
982     (b)  Medical intervention is no longer necessary; or
983     (c)  The panel has conducted a full hearing under
984subsection (3) and issued a recommendation to the agency or the
985office, and the agency or office has issued a final order.
986     (7)  After hearing a grievance, the panel shall make a
987recommendation to the agency or the office which may include
988specific actions the managed care entity must take to comply
989with state laws or rules regulating managed care entities.
990     (8)  A managed care entity, subscriber, or provider that is
991affected by a panel recommendation may within 10 days after
992receipt of the panel's recommendation, or 72 hours after receipt
993of a recommendation in an expedited grievance, furnish to the
994agency or office written evidence in opposition to the
995recommendation or findings of fact of the panel.
996     (9)  No later than 30 days after the issuance of the
997panel's recommendation and, for an expedited grievance, no later
998than 10 days after the issuance of the panel's recommendation,
999the agency or the office may adopt the panel's recommendation or
1000findings of fact in a proposed order or an emergency order, as
1001provided in chapter 120, which it shall issue to the managed
1002care entity. The agency or office may issue a proposed order or
1003an emergency order, as provided in chapter 120, imposing fines
1004or sanctions, including those contained in ss. 641.25 and
1005641.52. The agency or the office may reject all or part of the
1006panel's recommendation. All fines collected under this
1007subsection must be deposited into the Health Care Trust Fund.
1008     (10)  In determining any fine or sanction to be imposed,
1009the agency and the office may consider the following factors:
1010     (a)  The severity of the noncompliance, including the
1011probability that death or serious harm to the health or safety
1012of the subscriber will result or has resulted, the severity of
1013the actual or potential harm, and the extent to which provisions
1014of chapter 641 were violated.
1015     (b)  Actions taken by the managed care entity to resolve or
1016remedy any quality-of-care grievance.
1017     (c)  Any previous incidents of noncompliance by the managed
1018care entity.
1019     (d)  Any other relevant factors the agency or office
1020considers appropriate in a particular grievance.
1021     (11)(a)  The panel shall consist of the Insurance Consumer
1022Advocate, or designee thereof, established by s. 627.0613; at
1023least two members employed by the agency and at least two
1024members employed by the department, chosen by their respective
1025agencies; a consumer appointed by the Governor; a physician
1026appointed by the Governor, as a standing member; and, if
1027necessary, physicians who have expertise relevant to the case to
1028be heard, on a rotating basis. The agency may contract with a
1029medical director, and a primary care physician, or both, who
1030shall provide additional technical expertise to the panel but
1031shall not be voting members of the panel. The medical director
1032shall be selected from a health maintenance organization with a
1033current certificate of authority to operate in Florida.
1034     (b)  A majority of those panel members required under
1035paragraph (a) shall constitute a quorum for any meeting or
1036hearing of the panel. A grievance may not be heard or voted upon
1037at any panel meeting or hearing unless a quorum is present,
1038except that a minority of the panel may adjourn a meeting or
1039hearing until a quorum is present. A panel convened for the
1040purpose of hearing a subscriber's grievance in accordance with
1041subsections (2) and (3) shall not consist of more than 11
1042members.
1043     (12)  Every managed care entity shall submit a quarterly
1044report to the agency, the office, and the department listing the
1045number and the nature of all subscribers' and providers'
1046grievances which have not been resolved to the satisfaction of
1047the subscriber or provider after the subscriber or provider
1048follows the entire internal grievance procedure of the managed
1049care entity. The agency shall notify all subscribers and
1050providers included in the quarterly reports of their right to
1051file an unresolved grievance with the panel.
1052     (13)  A proposed order issued by the agency or office which
1053only requires the managed care entity to take a specific action
1054under subsection (7) is subject to a summary hearing in
1055accordance with s. 120.574, unless all of the parties agree
1056otherwise. If the managed care entity does not prevail at the
1057hearing, the managed care entity must pay reasonable costs and
1058attorney's fees of the agency or the office incurred in that
1059proceeding.
1060     (14)(a)  Any information that identifies a subscriber which
1061is held by the panel, agency, or department pursuant to this
1062section is confidential and exempt from the provisions of s.
1063119.07(1) and s. 24(a), Art. I of the State Constitution.
1064However, at the request of a subscriber or managed care entity
1065involved in a grievance procedure, the panel, agency, or
1066department shall release information identifying the subscriber
1067involved in the grievance procedure to the requesting subscriber
1068or managed care entity.
1069     (b)  Meetings of the panel shall be open to the public
1070unless the provider or subscriber whose grievance will be heard
1071requests a closed meeting or the agency or the department
1072determines that information which discloses the subscriber's
1073medical treatment or history or information relating to internal
1074risk management programs as defined in s. 641.55(5)(c), (6), and
1075(8) may be revealed at the panel meeting, in which case that
1076portion of the meeting during which a subscriber's medical
1077treatment or history or internal risk management program
1078information is discussed shall be exempt from the provisions of
1079s. 286.011 and s. 24(b), Art. I of the State Constitution. All
1080closed meetings shall be recorded by a certified court reporter.
1081     Section 14.  Paragraph (c) of subsection (4) of section
1082641.3154, Florida Statutes, is amended to read:
1083     641.3154  Organization liability; provider billing
1084prohibited.--
1085     (4)  A provider or any representative of a provider,
1086regardless of whether the provider is under contract with the
1087health maintenance organization, may not collect or attempt to
1088collect money from, maintain any action at law against, or
1089report to a credit agency a subscriber of an organization for
1090payment of services for which the organization is liable, if the
1091provider in good faith knows or should know that the
1092organization is liable. This prohibition applies during the
1093pendency of any claim for payment made by the provider to the
1094organization for payment of the services and any legal
1095proceedings or dispute resolution process to determine whether
1096the organization is liable for the services if the provider is
1097informed that such proceedings are taking place. It is presumed
1098that a provider does not know and should not know that an
1099organization is liable unless:
1100     (c)  The office or agency makes a final determination that
1101the organization is required to pay for such services subsequent
1102to a recommendation made by the Statewide Provider and
1103Subscriber Assistance Panel pursuant to s. 408.7056; or
1104     Section 15.  Subsection (1), paragraphs (b) and (e) of
1105subsection (3), paragraph (d) of subsection (4), subsection (5),
1106paragraph (g) of subsection (6), and subsections (9), (10), and
1107(11) of section 641.511, Florida Statutes, are amended to read:
1108     641.511  Subscriber grievance reporting and resolution
1109requirements.--
1110     (1)  Every organization must have a grievance procedure
1111available to its subscribers for the purpose of addressing
1112complaints and grievances. Every organization must notify its
1113subscribers that a subscriber must submit a grievance within 1
1114year after the date of occurrence of the action that initiated
1115the grievance, and may submit the grievance for review to the
1116Statewide Provider and Subscriber Assistance Program panel as
1117provided in s. 408.7056 after receiving a final disposition of
1118the grievance through the organization's grievance process. An
1119organization shall maintain records of all grievances and shall
1120report annually to the agency the total number of grievances
1121handled, a categorization of the cases underlying the
1122grievances, and the final disposition of the grievances.
1123     (3)  Each organization's grievance procedure, as required
1124under subsection (1), must include, at a minimum:
1125     (b)  The names of the appropriate employees or a list of
1126grievance departments that are responsible for implementing the
1127organization's grievance procedure. The list must include the
1128address and the toll-free telephone number of each grievance
1129department, the address of the agency and its toll-free
1130telephone hotline number, and the address of the Statewide
1131Provider and Subscriber Assistance Program and its toll-free
1132telephone number.
1133     (e)  A notice that a subscriber may voluntarily pursue
1134binding arbitration in accordance with the terms of the contract
1135if offered by the organization, after completing the
1136organization's grievance procedure and as an alternative to the
1137Statewide Provider and Subscriber Assistance Program. Such
1138notice shall include an explanation that the subscriber may
1139incur some costs if the subscriber pursues binding arbitration,
1140depending upon the terms of the subscriber's contract.
1141     (4)
1142     (d)  In any case when the review process does not resolve a
1143difference of opinion between the organization and the
1144subscriber or the provider acting on behalf of the subscriber,
1145the subscriber or the provider acting on behalf of the
1146subscriber may submit a written grievance to the Statewide
1147Provider and Subscriber Assistance Program.
1148     (5)  Except as provided in subsection (6), the organization
1149shall resolve a grievance within 60 days after receipt of the
1150grievance, or within a maximum of 90 days if the grievance
1151involves the collection of information outside the service area.
1152These time limitations are tolled if the organization has
1153notified the subscriber, in writing, that additional information
1154is required for proper review of the grievance and that such
1155time limitations are tolled until such information is provided.
1156After the organization receives the requested information, the
1157time allowed for completion of the grievance process resumes.
1158The Employee Retirement Income Security Act of 1974, as
1159implemented by 29 C.F.R. 2560.503-1, is adopted and incorporated
1160by reference as applicable to all organizations that administer
1161small and large group health plans that are subject to 29 C.F.R.
11622560.503-1. The claims procedures of the regulations of the
1163Employee Retirement Income Security Act of 1974 as implemented
1164by 29 C.F.R. 2560.503-1 shall be the minimum standards for
1165grievance processes for claims for benefits for small and large
1166group health plans that are subject to 29 C.F.R. 2560.503-1.
1167     (6)
1168     (g)  In any case when the expedited review process does not
1169resolve a difference of opinion between the organization and the
1170subscriber or the provider acting on behalf of the subscriber,
1171the subscriber or the provider acting on behalf of the
1172subscriber may submit a written grievance to the Statewide
1173Provider and Subscriber Assistance Program.
1174     (9)(a)  The agency shall advise subscribers with grievances
1175to follow their organization's formal grievance process for
1176resolution prior to review by the Statewide Provider and
1177Subscriber Assistance Program. The subscriber may, however,
1178submit a copy of the grievance to the agency at any time during
1179the process.
1180     (b)  Requiring completion of the organization's grievance
1181process before the Statewide Provider and Subscriber Assistance
1182Program panel's review does not preclude the agency from
1183investigating any complaint or grievance before the organization
1184makes its final determination.
1185     (10)  Each organization must notify the subscriber in a
1186final decision letter that the subscriber may request review of
1187the organization's decision concerning the grievance by the
1188Statewide Provider and Subscriber Assistance Program, as
1189provided in s. 408.7056, if the grievance is not resolved to the
1190satisfaction of the subscriber. The final decision letter must
1191inform the subscriber that the request for review must be made
1192within 365 days after receipt of the final decision letter, must
1193explain how to initiate such a review, and must include the
1194addresses and toll-free telephone numbers of the agency and the
1195Statewide Provider and Subscriber Assistance Program.
1196     (11)  Each organization, as part of its contract with any
1197provider, must require the provider to post a consumer
1198assistance notice prominently displayed in the reception area of
1199the provider and clearly noticeable by all patients. The
1200consumer assistance notice must state the addresses and toll-
1201free telephone numbers of the Agency for Health Care
1202Administration, the Statewide Provider and Subscriber Assistance
1203Program, and the Department of Financial Services. The consumer
1204assistance notice must also clearly state that the address and
1205toll-free telephone number of the organization's grievance
1206department shall be provided upon request. The agency may adopt
1207rules to implement this section.
1208     Section 16.  Subsection (4) of section 641.58, Florida
1209Statutes, is amended to read:
1210     641.58  Regulatory assessment; levy and amount; use of
1211funds; tax returns; penalty for failure to pay.--
1212     (4)  The moneys received and deposited into the Health Care
1213Trust Fund shall be used to defray the expenses of the agency in
1214the discharge of its administrative and regulatory powers and
1215duties under this part, including conducting an annual survey of
1216the satisfaction of members of health maintenance organizations;
1217contracting with physician consultants for the Statewide
1218Provider and Subscriber Assistance Panel; maintaining offices
1219and necessary supplies, essential equipment, and other
1220materials, salaries and expenses of required personnel; and
1221discharging the administrative and regulatory powers and duties
1222imposed under this part.
1223     Section 17.  Paragraph (f) of subsection (2) and
1224subsections (3) and (9) of section 408.909, Florida Statutes,
1225are amended to read:
1226     408.909  Health flex plans.--
1227     (2)  DEFINITIONS.--As used in this section, the term:
1228     (f)  "Health flex plan entity" means a health insurer,
1229health maintenance organization, health-care-provider-sponsored
1230organization, local government, health care district, or other
1231public or private community-based organization, or public-
1232private partnership that develops and implements an approved
1233health flex plan and is responsible for administering the health
1234flex plan and paying all claims for health flex plan coverage by
1235enrollees of the health flex plan.
1236     (3)  PILOT PROGRAM.--The agency and the office shall each
1237approve or disapprove health flex plans that provide health care
1238coverage for eligible participants who reside in the three areas
1239of the state that have the highest number of uninsured persons,
1240as identified in the Florida Health Insurance Study conducted by
1241the agency and in Indian River County. A health flex plan may
1242limit or exclude benefits otherwise required by law for insurers
1243offering coverage in this state, may cap the total amount of
1244claims paid per year per enrollee, may limit the number of
1245enrollees, or may take any combination of those actions. A
1246health flex plan offering may include the option of a
1247catastrophic plan supplementing the health flex plan.
1248     (a)  The agency shall develop guidelines for the review of
1249applications for health flex plans and shall disapprove or
1250withdraw approval of plans that do not meet or no longer meet
1251minimum standards for quality of care and access to care. The
1252agency shall ensure that the health flex plans follow
1253standardized grievance procedures similar to those required of
1254health maintenance organizations.
1255     (b)  The office shall develop guidelines for the review of
1256health flex plan applications and provide regulatory oversight
1257of health flex plan advertisement and marketing procedures. The
1258office shall disapprove or shall withdraw approval of plans
1259that:
1260     1.  Contain any ambiguous, inconsistent, or misleading
1261provisions or any exceptions or conditions that deceptively
1262affect or limit the benefits purported to be assumed in the
1263general coverage provided by the health flex plan;
1264     2.  Provide benefits that are unreasonable in relation to
1265the premium charged or contain provisions that are unfair or
1266inequitable or contrary to the public policy of this state, that
1267encourage misrepresentation, or that result in unfair
1268discrimination in sales practices; or
1269     3.  Cannot demonstrate that the health flex plan is
1270financially sound and that the applicant is able to underwrite
1271or finance the health care coverage provided.
1272     (c)  The agency and the Financial Services Commission may
1273adopt rules as needed to administer this section.
1274     (9)  PROGRAM EVALUATION.--The agency and the office shall
1275evaluate the pilot program and its effect on the entities that
1276seek approval as health flex plans, on the number of enrollees,
1277and on the scope of the health care coverage offered under a
1278health flex plan; shall provide an assessment of the health flex
1279plans and their potential applicability in other settings; shall
1280use health flex plans to gather more information to evaluate
1281low-income consumer driven benefit packages; and shall, by
1282January 1, 2005, and annually thereafter 2004, jointly submit a
1283report to the Governor, the President of the Senate, and the
1284Speaker of the House of Representatives.
1285     Section 18.  Section 381.0271, Florida Statutes, is created
1286to read:
1287     381.0271  Florida Patient Safety Corporation.--
1288     (1)  DEFINITIONS.--As used in this section, the term:
1289     (a)  "Adverse incident" has the same meanings provided in
1290ss. 395.0197, 458.351, and 459.026.
1291     (b)  "Corporation" means the Florida Patient Safety
1292Corporation.
1293     (c)  "Patient safety data" has the same meaning provided in
1294s. 766.1016.
1295     (2)  CREATION.--
1296     (a)  The Florida Patient Safety Corporation is created as a
1297not-for-profit corporation and shall be registered,
1298incorporated, organized, and operated in compliance with chapter
1299617. The corporation may create not-for-profit corporate
1300subsidiaries that are organized under the provisions of chapter
1301617, upon the prior approval of the board of directors, as
1302necessary, to fulfill its mission.
1303     (b)  The corporation and any authorized and approved
1304subsidiary are not an agency as defined in s. 20.03(11).
1305     (c)  The corporation and any authorized and approved
1306subsidiary are subject to the public meetings and records
1307requirements of s. 24, Art. I of the State Constitution, chapter
1308119, and s. 286.011.
1309     (d)  The corporation and any authorized and approved
1310subsidiary are not subject to the provisions of chapter 287.
1311     (e)  The corporation is a patient safety organization as
1312defined in s. 766.1016.
1313     (3)  PURPOSE.--
1314     (a)  The purpose of the corporation is to serve as a
1315learning organization dedicated to assisting health care
1316providers in this state to improve the quality and safety of
1317health care rendered and to reduce harm to patients. The
1318corporation shall promote the development of a culture of
1319patient safety in the health care system in this state. The
1320corporation shall not regulate health care providers in this
1321state.
1322     (b)  In fulfilling its purpose, the corporation shall work
1323with a consortium of patient safety centers and other patient
1324safety programs.
1325     (4)  BOARD OF DIRECTORS; MEMBERSHIP.--The corporation shall
1326be governed by a board of directors. The board of directors
1327shall consist of:
1328     (a)  The chair of the Florida Council of Medical School
1329Deans.
1330     (b)  Two representatives with expertise in patient safety
1331issues for the authorized health insurer and authorized health
1332maintenance organization with the largest market shares,
1333respectively, as measured by premiums written in the state for
1334the most recent calendar year, appointed by such insurer.
1335     (c)  A representative of an authorized medical malpractice
1336insurer appointed by the Florida Insurance Council.
1337     (d)  The president of the Central Florida Health Care
1338Coalition.
1339     (e)  Two representatives of a hospital in this state that
1340is implementing innovative patient safety initiatives, appointed
1341by the Florida Hospital Association.
1342     (f)  A physician with expertise in patient safety,
1343appointed by the Florida Medical Association.
1344     (g)  A physician with expertise in patient safety,
1345appointed by the Florida Osteopathic Medical Association.
1346     (h)  A physician with expertise in patient safety,
1347appointed by the Florida Podiatric Medical Association.
1348     (i)  A physician with expertise in patient safety,
1349appointed by the Florida Chiropractic Association.
1350     (j)  A dentist with expertise in patient safety, appointed
1351by the Florida Dental Association.
1352     (k)  A nurse with expertise in patient safety, appointed by
1353the Florida Nurses Association.
1354     (l)  An institutional pharmacist, appointed by the Florida
1355Society of Health-System Pharmacists.
1356     (m)  A representative of Florida AARP, appointed by the
1357state director of Florida AARP.
1358     (5)  ADVISORY COMMITTEES.--In addition to any committees
1359that the corporation may establish, the corporation shall
1360establish the following advisory committees:
1361     (a)  A scientific research advisory committee that
1362includes, at a minimum, a representative from each patient
1363safety center or other patient safety program in the
1364universities of the state who are physicians licensed pursuant
1365to chapter 458 or chapter 459, with experience in patient safety
1366and evidenced-based medicine. The duties of the advisory
1367committee shall include, but not be limited to, the analysis of
1368existing data and research to improve patient safety and
1369encourage evidence-based medicine.
1370     (b)  A technology advisory committee that includes, at a
1371minimum, a representative of a hospital that has implemented a
1372computerized physician order entry system and a health care
1373provider that has implemented an electronic medical records
1374system. The duties of the advisory committee shall include, but
1375not be limited to, implementation of new technologies, including
1376electronic medical records.
1377     (c)  A health care provider advisory committee that
1378includes, at a minimum, representatives of hospitals, ambulatory
1379surgical centers, physicians, nurses, and pharmacists licensed
1380in this state and a representative of the Veterans Integrated
1381Service Network 8, Virginia Patient Safety Center. The duties of
1382the advisory committee shall include, but not be limited to,
1383promotion of a culture of patient safety that reduces errors.
1384     (d)  A health care consumer advisory committee that
1385includes, at a minimum, representatives of businesses that
1386provide health insurance coverage to their employees, consumer
1387advocacy groups, and representatives of patient safety
1388organizations. The duties of the advisory committee shall
1389include, but not be limited to, incentives to encourage patient
1390safety and the efficiency and quality of care.
1391     (e)  A state agency advisory committee that includes, at a
1392minimum, a representative from each state agency that has
1393regulatory responsibilities related to patient safety. The
1394duties of the advisory committee shall include, but not be
1395limited to, interagency coordination of patient safety efforts.
1396     (f)  A litigation alternatives advisory committee that
1397includes, at a minimum, representatives of medical malpractice
1398attorneys for plaintiffs and defendants and a representative of
1399each law school in the state. The duties of the advisory
1400committee shall include, but not be limited to, alternatives
1401systems to compensate for injuries.
1402     (g)  An education advisory committee that includes, at a
1403minimum, the associate dean for education, or the equivalent
1404position, as a representative from each medicine, nursing,
1405public health, or allied health service to provide advice on the
1406development, implementation, and measurement of core
1407competencies for patient safety to be considered for
1408incorporation in the educational programs of the universities
1409and colleges of this state.
1410     (6)  ORGANIZATION; MEETINGS.--
1411     (a)  The Agency for Health Care Administration shall assist
1412the corporation in its organizational activities required under
1413chapter 617, including, but not limited to:
1414     1.  Eliciting appointments for the initial board of
1415directors.
1416     2.  Convening the first meeting of the board of directors
1417and assisting with other meetings of the board of directors,
1418upon request of the board of directors, during the first year of
1419operation of the corporation.
1420     3.  Drafting articles of incorporation for the board of
1421directors and, upon request of the board of directors,
1422delivering articles of incorporation to the Department of State
1423for filing.
1424     4.  Drafting proposed bylaws for the corporation.
1425     5.  Paying fees related to incorporation.
1426     6.  Providing office space and administrative support, at
1427the request of the board of directors, but not beyond July 1,
14282005.
1429     (b)  The board of directors must conduct its first meeting
1430no later than August 1, 2004, and shall meet thereafter as
1431frequently as necessary to carry out the duties of the
1432corporation.
1433     (7)  POWERS AND DUTIES.--
1434     (a)  In addition to the powers and duties prescribed in
1435chapter 617, and the articles and bylaws adopted under that
1436chapter, the corporation shall, directly or through contract:
1437     1.  Secure staff necessary to properly administer the
1438corporation.
1439     2.  Collect, analyze, and evaluate patient safety data and
1440quality and patient safety indicators, medical malpractice
1441closed claims, and adverse incidents reported to the Agency for
1442Health Care Administration and the Department of Health for the
1443purpose of recommending changes in practices and procedures that
1444may be implemented by health care practitioners and health care
1445facilities to improve health care quality and to prevent future
1446adverse incidents. Notwithstanding any other provision of law,
1447the Agency for Health Care Administration and the Department of
1448Health shall make available to the corporation any adverse
1449incident report submitted under ss. 395.0197, 458.351, and
1450459.026. To the extent that adverse incident reports submitted
1451under s. 395.0197 are confidential and exempt, the confidential
1452and exempt status of such reports shall be maintained by the
1453corporation.
1454     3.  Establish a "near-miss" patient safety reporting
1455system. The purpose of the near-miss reporting system is to:
1456identify potential systemic problems that could lead to adverse
1457incidents; enable publication of systemwide alerts of potential
1458harm; and facilitate development of both facility-specific and
1459statewide options to avoid adverse incidents and improve patient
1460safety. The reporting system shall record "near misses"
1461submitted by hospitals, birthing centers, and ambulatory
1462surgical centers and other providers. For the purpose of the
1463reporting system:
1464     a.  The term "near miss" means any potentially harmful
1465event that could have had an adverse result but, through chance
1466or intervention in which, harm was prevented.
1467     b.  The near-miss reporting system shall be voluntary and
1468anonymous and independent of mandatory reporting systems used
1469for regulatory purposes.
1470     c.  Near-miss data submitted to the corporation is patient
1471safety data as defined in s. 766.1016.
1472     d.  Reports of near-miss data shall be published on a
1473regular basis and special alerts shall be published as needed
1474regarding newly identified, significant risks.
1475     e.  Aggregated data shall be made available publicly.
1476     f.  The corporation shall report the performance and
1477results of the near-miss project in its annual report.
1478     4.  Work collaboratively with the appropriate state
1479agencies in the development of electronic health records.
1480     5.  Provide for access to an active library of evidence-
1481based medicine and patient safety practices, together with the
1482emerging evidence supporting their retention or modification,
1483and make this information available to health care
1484practitioners, health care facilities, and the public. Support
1485for implementation of evidence-based medicine shall include:
1486     a.  A report to the Governor, the President of the Senate,
1487the Speaker of the House of Representatives, and the Agency for
1488Health Care Administration by January 1, 2005, on:
1489     (I)  The ability to join or support efforts for the use of
1490evidence-based medicine already underway, such as those of the
1491Leapfrog Group, the international group Bandolier, and the
1492Healthy Florida Foundation.
1493     (II)  The means by which to promote research using Medicaid
1494and other data collected by the Agency for Health Care
1495Administration to identify and quantify the most cost-effective
1496treatment and interventions, including disease management and
1497prevention programs.
1498     (III)  The means by which to encourage development of
1499systems to measure and reward providers who implement evidence-
1500based medical practices.
1501     (IV)  The review of other state and private initiatives and
1502published literature for promising approaches and the
1503dissemination of information about them to providers.
1504     (V)  The encouragement of the Florida health care boards
1505under the Department of Health to regularly publish findings
1506related to the cost-effectiveness of disease-specific, evidence-
1507based standards.
1508     (VI)  Public and private sector initiatives related to
1509evidence-based medicine and communication systems for the
1510sharing of clinical information among caregivers.
1511     (VII)  Regulatory barriers that interfere with the sharing
1512of clinical information among caregivers.
1513     b.  An implementation plan reported to the Governor, the
1514President of the Senate, the Speaker of the House of
1515Representatives, and the Agency for Health Care Administration
1516by September 1, 2005, that must include, but need not be limited
1517to: estimated costs and savings, capital investment
1518requirements, recommended investment incentives, initial
1519committed provider participation by region, standards of
1520functionality and features, a marketing plan, and implementation
1521schedules for key components.
1522     6.  Develop and recommend core competencies in patient
1523safety that can be incorporated into the undergraduate and
1524graduate curricula in schools of medicine, nursing, and allied
1525health in the state.
1526     7.  Develop and recommend programs to educate the public
1527about the role of health care consumers in promoting patient
1528safety.
1529     8.  Provide recommendations for interagency coordination of
1530patient safety efforts in the state.
1531     (b)  In carrying out its powers and duties, the corporation
1532may also:
1533     1.  Assess the patient safety culture at volunteering
1534hospitals and recommend methods to improve the working
1535environment related to patient safety at these hospitals.
1536     2.  Inventory the information technology capabilities
1537related to patient safety of health care facilities and health
1538care practitioners and recommend a plan for expediting the
1539implementation of patient safety technologies statewide.
1540     3.  Recommend continuing medical education regarding
1541patient safety to practicing health care practitioners.
1542     4.  Study and facilitate the testing of alternative systems
1543of compensating injured patients as a means of reducing and
1544preventing medical errors and promoting patient safety.
1545     5.  Conduct other activities identified by the board of
1546directors to promote patient safety in this state.
1547     (8)  ANNUAL REPORT.--By December 1, 2004, the corporation
1548shall prepare a report on the startup activities of the
1549corporation and any proposals for legislative action that are
1550needed for the corporation to fulfill its purposes under this
1551section. By December 1 of each year thereafter, the corporation
1552shall prepare a report for the preceding fiscal year. The
1553report, at a minimum, must include:
1554     (a)  A description of the activities of the corporation
1555under this section.
1556     (b)  Progress made in improving patient safety and reducing
1557medical errors.
1558     (c)  Policies and programs that have been implemented and
1559their outcomes.
1560     (d)  A compliance and financial audit of the accounts and
1561records of the corporation at the end of the preceding fiscal
1562year conducted by an independent certified public accountant.
1563     (e)  Recommendations for legislative action needed to
1564improve patient safety in the state.
1565     (f)  An assessment of the ability of the corporation to
1566fulfill the duties specified in this section and the
1567appropriateness of those duties for the corporation.
1568
1569The corporation shall submit the report to the Governor, the
1570President of the Senate, and the Speaker of the House of
1571Representatives.
1572     (9)  FUNDING.--The corporation is required to seek private
1573sector funding and apply for grants to accomplish its goals and
1574duties.
1575     (10)  PERFORMANCE EXPECTATIONS.--The Office of Program
1576Policy Analysis and Government Accountability, the Agency for
1577Health Care Administration, and the Department of Health shall
1578develop performance standards by which to measure the success of
1579the corporation in fulfilling the purposes established in this
1580section. Using the performance standards, the Office of Program
1581Policy Analysis and Government Accountability shall conduct a
1582performance audit of the corporation during 2006 and shall
1583submit a report to the Governor, the President of the Senate,
1584and the Speaker of the House of Representatives by January 1,
15852007.
1586     Section 19.  Subsection (3) of section 409.91255, Florida
1587Statutes, is amended to read:
1588     409.91255  Federally qualified health center access
1589program.--
1590     (3)  ASSISTANCE TO FEDERALLY QUALIFIED HEALTH CENTERS.--The
1591Department of Health shall develop a program for the expansion
1592of federally qualified health centers for the purpose of
1593providing comprehensive primary and preventive health care and
1594urgent care services, including services that may reduce the
1595morbidity, mortality, and cost of care among the uninsured
1596population of the state. The program shall provide for
1597distribution of financial assistance to federally qualified
1598health centers that apply and demonstrate a need for such
1599assistance in order to sustain or expand the delivery of primary
1600and preventive health care services. In selecting centers to
1601receive this financial assistance, the program:
1602     (a)  Shall give preference to communities that have few or
1603no community-based primary care services or in which the current
1604services are unable to meet the community's needs.
1605     (b)  Shall require that primary care services be provided
1606to the medically indigent using a sliding fee schedule based on
1607income.
1608     (c)  Shall allow innovative and creative uses of federal,
1609state, and local health care resources.
1610     (d)  Shall require that the funds provided be used to pay
1611for operating costs of a projected expansion in patient
1612caseloads or services or for capital improvement projects.
1613Capital improvement projects may include renovations to existing
1614facilities or construction of new facilities, provided that an
1615expansion in patient caseloads or services to a new patient
1616population will occur as a result of the capital expenditures.
1617The department shall include in its standard contract document a
1618requirement that any state funds provided for the purchase of or
1619improvements to real property are contingent upon the contractor
1620granting to the state a security interest in the property at
1621least to the amount of the state funds provided for at least 5
1622years from the date of purchase or the completion of the
1623improvements or as further required by law. The contract must
1624include a provision that, as a condition of receipt of state
1625funding for this purpose, the contractor agrees that, if it
1626disposes of the property before the department's interest is
1627vacated, the contractor will refund the proportionate share of
1628the state's initial investment, as adjusted by depreciation.
1629     (e)  May require in-kind support from other sources.
1630     (f)  May encourage coordination among federally qualified
1631health centers, other private-sector providers, and publicly
1632supported programs.
1633     (g)  Shall allow the development of community emergency
1634room diversion programs in conjunction with local resources,
1635providing extended hours of operation to urgent care patients.
1636Diversion programs shall include case management for emergency
1637room followup care.
1638     Section 20.  Paragraph (a) of subsection (6) of section
1639627.410, Florida Statutes, is amended to read:
1640     627.410  Filing, approval of forms.--
1641     (6)(a)  An insurer shall not deliver or issue for delivery
1642or renew in this state any health insurance policy form until it
1643has filed with the office a copy of every applicable rating
1644manual, rating schedule, change in rating manual, and change in
1645rating schedule; if rating manuals and rating schedules are not
1646applicable, the insurer must file with the office order
1647applicable premium rates and any change in applicable premium
1648rates. This paragraph does not apply to group health insurance
1649policies, effectuated and delivered in this state, insuring
1650groups of 51 or more persons, except for Medicare supplement
1651insurance, long-term care insurance, and any coverage under
1652which the increase in claim costs over the lifetime of the
1653contract due to advancing age or duration is prefunded in the
1654premium.
1655     Section 21.  Section 627.64872, Florida Statutes, is
1656created to read:
1657     627.64872  Florida Health Insurance Plan.--
1658     (1)  LEGISLATIVE INTENT.--
1659     (a)  The Legislature recognizes that to secure a more
1660stable and orderly health insurance market, the establishment of
1661a plan to assume risks deemed uninsurable by the private
1662marketplace is required.
1663     (b)  The Florida Health Insurance Plan is to make coverage
1664available to individuals who have no other option for similar
1665coverage, at a premium that is commensurate with the risk and
1666benefits provided, and with benefit designs that are reasonable
1667in relation to the general market. While plan operations may
1668include supplementary funding, the plan shall fundamentally
1669operate on sound actuarial principles, using basic insurance
1670management techniques to ensure that the plan is run in an
1671economical, cost-efficient, and sound manner, conserving plan
1672resources to serve the maximum number of people possible in a
1673sustainable fashion.
1674     (2)  DEFINITIONS.--As used in this section:
1675     (a)  "Board" means the board of directors of the plan.
1676     (b)  "Dependent" means a resident spouse or resident
1677unmarried child under the age of 19 years, a child who is a
1678student under the age of 25 years and who is financially
1679dependent upon the parent, or a child of any age who is disabled
1680and dependent upon the parent.
1681     (c)  "Director" means the director of the Office of
1682Insurance Regulation.
1683     (d)  "Health insurance" means any hospital or medical
1684expense incurred policy or health maintenance organization
1685subscriber contract pursuant to chapter 641. The term does not
1686include short-term, accident, dental-only, vision-only, fixed-
1687indemnity, limited-benefit, or credit insurance; disability
1688income insurance; coverage for onsite medical clinics; insurance
1689coverage specified in federal regulations issued pursuant to
1690Pub. L. No. 104-191, under which benefits for medical care are
1691secondary or incidental to other insurance benefits; benefits
1692for long-term care, nursing home care, home health care,
1693community-based care, or any combination thereof, or other
1694similar, limited benefits specified in federal regulations
1695issued pursuant to Pub. L. No. 104-191; benefits provided under
1696a separate policy, certificate, or contract of insurance, under
1697which there is no coordination between the provision of the
1698benefits and any exclusion of benefits under any group health
1699plan maintained by the same plan sponsor and the benefits are
1700paid with respect to an event without regard to whether benefits
1701are provided with respect to such an event under any group
1702health plan maintained by the same plan sponsor, such as for
1703coverage only for a specified disease or illness; hospital
1704indemnity or other fixed indemnity insurance; coverage offered
1705as a separate policy, certificate, or contract of insurance,
1706such as Medicare supplemental health insurance as defined under
1707s. 1882(g)(1) of the Social Security Act; coverage supplemental
1708to the coverage provided under chapter 55 of Title 10, United
1709States Code, the Civilian Health and Medical Program of the
1710Uniformed Services (CHAMPUS); similar supplemental coverage
1711provided to coverage under a group health plan; coverage issued
1712as a supplement to liability insurance; insurance arising out of
1713a workers' compensation or similar law; automobile medical
1714payment insurance; or insurance under which benefits are payable
1715with or without regard to fault and which is statutorily
1716required to be contained in any liability insurance policy or
1717equivalent selfinsurance.
1718     (e)  "Implementation" means the effective date after the
1719first meeting of the board when legal authority and
1720administrative ability exists for the board to subsume the
1721transfer of all statutory powers, duties, functions, assets,
1722records, personnel, and property of the Florida Comprehensive
1723Health Association as specified in s. 627.6488.
1724     (f)  "Insurer" means any entity that provides health
1725insurance in this state. For purposes of this section, insurer
1726includes an insurance company with a valid certificate in
1727accordance with chapter 624, a health maintenance organization
1728with a valid certificate of authority in accordance with part I
1729or part III of chapter 641, a prepaid health clinic authorized
1730to transact business in this state pursuant to part II of
1731chapter 641, multiple employer welfare arrangements authorized
1732to transact business in this state pursuant to ss. 624.436-
1733624.45, or a fraternal benefit society providing health benefits
1734to its members as authorized pursuant to chapter 632.
1735     (g)  "Medicare" means coverage under both Parts A and B of
1736Title XVIII of the Social Security Act, 42 USC 1395 et seq., as
1737amended.
1738     (h)  "Medicaid" means coverage under Title XIX of the
1739Social Security Act.
1740     (i)  "Office" means the Office of Insurance Regulation of
1741the Financial Services Commission.
1742     (j)  "Participating insurer" means any insurer providing
1743health insurance to citizens of this state.
1744     (k)  "Provider" means any physician, hospital, or other
1745institution, organization, or person that furnishes health care
1746services and is licensed or otherwise authorized to practice in
1747the state.
1748     (l)  "Plan" means the Florida Health Insurance Plan created
1749in subsection (1).
1750     (m)  "Plan of operation" means the articles, bylaws, and
1751operating rules and procedures adopted by the board pursuant to
1752this section.
1753     (n)  "Resident" means an individual who has been legally
1754domiciled in this state for a period of at least 6 months.
1755     (3)  BOARD OF DIRECTORS.--
1756     (a)  The plan shall operate subject to the supervision and
1757control of the board. The board shall consist of the director or
1758his or her designated representative, who shall serve as a
1759member of the board and shall be its chair, and an additional
1760eight members, five of whom shall be appointed by the Governor,
1761at least two of whom shall be individuals not representative of
1762insurers or health care providers, one of whom shall be
1763appointed by the President of the Senate, one of whom shall be
1764appointed by the Speaker of the House of Representatives, and
1765one of whom shall be appointed by the Chief Financial Officer.
1766     (b)  The term to be served on the board by the director of
1767the Office of Insurance Regulation shall be determined by
1768continued employment in such position. The remaining initial
1769board members shall serve for a period of time as follows: two
1770members appointed by the Governor and the members appointed by
1771the President of the Senate and the Speaker of the House of
1772Representatives shall serve a term of 2 years; and three members
1773appointed by the Governor and the Chief Financial Officer shall
1774serve a term of 4 years. Subsequent board members shall serve
1775for a term of 3 years. A board member's term shall continue
1776until his or her successor is appointed.
1777     (c)  Vacancies on the board shall be filled by the
1778appointing authority, such authority being the Governor, the
1779President of the Senate, the Speaker of the House of
1780Representatives, or the Chief Financial Officer. The appointing
1781authority may remove board members for cause.
1782     (d)  The director, or his or her recognized representative,
1783shall be responsible for any organizational requirements
1784necessary for the initial meeting of the board which shall take
1785place no later than September 1, 2004.
1786     (e)  Members shall not be compensated in their capacity as
1787board members but shall be reimbursed for reasonable expenses
1788incurred in the necessary performance of their duties in
1789accordance with s. 112.061.
1790     (f)  The board shall submit to the Financial Services
1791Commission a plan of operation for the plan and any amendments
1792thereto necessary or suitable to ensure the fair, reasonable,
1793and equitable administration of the plan. The plan of operation
1794shall ensure that the plan qualifies to apply for any available
1795funding from the Federal Government that adds to the financial
1796viability of the plan. The plan of operation shall become
1797effective upon approval in writing by the Financial Services
1798Commission consistent with the date on which the coverage under
1799this section must be made available. If the board fails to
1800submit a suitable plan of operation within 1 year after the
1801appointment of the board of directors, or at any time thereafter
1802fails to submit suitable amendments to the plan of operation,
1803the Financial Services Commission shall adopt such rules as are
1804necessary or advisable to effectuate the provisions of this
1805section. Such rules shall continue in force until modified by
1806the office or superseded by a plan of operation submitted by the
1807board and approved by the Financial Services Commission.
1808     (4)  PLAN OF OPERATION.--The plan of operation shall:
1809     (a)  Establish procedures for operation of the plan.
1810     (b)  Establish procedures for selecting an administrator in
1811accordance with subsection (11).
1812     (c)  Establish procedures to create a fund, under
1813management of the board, for administrative expenses.
1814     (d)  Establish procedures for the handling, accounting, and
1815auditing of assets, moneys, and claims of the plan and the plan
1816administrator.
1817     (e)  Develop and implement a program to publicize the
1818existence of the plan, plan eligibility requirements, and
1819procedures for enrollment and maintain public awareness of the
1820plan.
1821     (f)  Establish procedures under which applicants and
1822participants may have grievances reviewed by a grievance
1823committee appointed by the board. The grievances shall be
1824reported to the board after completion of the review, with the
1825committee's recommendation for grievance resolution. The board
1826shall retain all written grievances regarding the plan for at
1827least 3 years.
1828     (g)  Provide for other matters as may be necessary and
1829proper for the execution of the board's powers, duties, and
1830obligations under this section.
1831     (5)  POWERS OF THE PLAN.--The plan shall have the general
1832powers and authority granted under the laws of this state to
1833health insurers and, in addition thereto, the specific authority
1834to:
1835     (a)  Enter into such contracts as are necessary or proper
1836to carry out the provisions and purposes of this section,
1837including the authority, with the approval of the Chief
1838Financial Officer, to enter into contracts with similar plans of
1839other states for the joint performance of common administrative
1840functions, or with persons or other organizations for the
1841performance of administrative functions.
1842     (b)  Take any legal actions necessary or proper to recover
1843or collect assessments due the plan.
1844     (c)  Take such legal action as is necessary to:
1845     1.  Avoid payment of improper claims against the plan or
1846the coverage provided by or through the plan;
1847     2.  Recover any amounts erroneously or improperly paid by
1848the plan;
1849     3.  Recover any amounts paid by the plan as a result of
1850mistake of fact or law; or
1851     4.  Recover other amounts due the plan.
1852     (d)  Establish, and modify as appropriate, rates, rate
1853schedules, rate adjustments, expense allowances, agents'
1854commissions, claims reserve formulas, and any other actuarial
1855functions appropriate to the operation of the plan. Rates and
1856rate schedules may be adjusted for appropriate factors such as
1857age, sex, and geographic variation in claim cost and shall take
1858into consideration appropriate factors in accordance with
1859established actuarial and underwriting practices. For purposes
1860of this paragraph, usual and customary agent's commissions shall
1861be paid for the initial placement of coverage with the plan and
1862for one renewal only.
1863     (e)  Issue policies of insurance in accordance with the
1864requirements of this section.
1865     (f)  Appoint appropriate legal, actuarial, investment, and
1866other committees as necessary to provide technical assistance in
1867the operation of the plan and develop and educate its
1868policyholders regarding health savings accounts, policy and
1869contract design, and any other function within the authority of
1870the plan.
1871     (g)  Borrow money to effectuate the purposes of the plan.
1872Any notes or other evidence of indebtedness of the plan not in
1873default shall be legal investments for insurers and may be
1874carried as admitted assets.
1875     (h)  Employ and fix the compensation of employees.
1876     (i)  Prepare and distribute certificate of eligibility
1877forms and enrollment instruction forms to insurance producers
1878and to the general public.
1879     (j)  Provide for reinsurance of risks incurred by the plan.
1880     (k)  Provide for and employ cost-containment measures and
1881requirements, including, but not limited to, preadmission
1882screening, second surgical opinion, concurrent utilization
1883review, and individual case management for the purpose of making
1884the plan more cost-effective.
1885     (l)  Design, use, contract, or otherwise arrange for the
1886delivery of cost-effective health care services, including, but
1887not limited to, establishing or contracting with preferred
1888provider organizations, health maintenance organizations, and
1889other limited network provider arrangements.
1890     (m)  Adopt such bylaws, policies, and procedures as may be
1891necessary or convenient for the implementation of this section
1892and the operation of the plan.
1893     (n)  Subsume the transfer of statutory powers, duties,
1894functions, assets, records, personnel, and property of the
1895Florida Comprehensive Health Association as specified in ss.
1896627.6488, 627.6489, 627.649, 627.6492, 627.6496, 627.6498, and
1897627.6499, unless otherwise specified by law.
1898     (6)  INTERIM REPORT; ANNUAL REPORT.--
1899     (a)  By no later than December 1, 2004, the board shall
1900report to the Governor, the President of the Senate, and the
1901Speaker of the House of Representatives the results of an
1902actuarial study conducted by the board to determine, including,
1903but not limited to:
1904     1.  The impact the creation of the plan will have on the
1905small group insurance market and the individual market on
1906premiums paid by insureds. This shall include an estimate of the
1907total anticipated aggregate savings for all small employers in
1908the state.
1909     2.  The number of individuals the pool could reasonably
1910cover at various funding levels, specifically, the number of
1911people the pool may cover at each of those funding levels.
1912     3.  A recommendation as to the best source of funding for
1913the anticipated deficits of the pool.
1914     4.  The effect on the individual and small group market by
1915including in the Florida Health Insurance Plan persons eligible
1916for coverage under s. 627.6487, as well as the cost of including
1917these individuals.
1918
1919The board shall take no action to implement the Florida Health
1920Insurance Plan, other than the completion of the actuarial study
1921authorized in this paragraph, until funds are appropriated for
1922startup cost and any projected deficits.
1923     (b)  No later than December 1, 2005, and annually
1924thereafter, the board shall submit to the Governor, the
1925President of the Senate, the Speaker of the House of
1926Representatives, and the substantive legislative committees of
1927the Legislature a report which includes an independent actuarial
1928study to determine, including, but not be limited to:
1929     1.  The impact the creation of the plan has on the small
1930group and individual insurance market, specifically on the
1931premiums paid by insureds. This shall include an estimate of the
1932total anticipated aggregate savings for all small employers in
1933the state.
1934     2.  The actual number of individuals covered at the current
1935funding and benefit level, the projected number of individuals
1936that may seek coverage in the forthcoming fiscal year, and the
1937projected funding needed to cover anticipated increase or
1938decrease in plan participation.
1939     3.  A recommendation as to the best source of funding for
1940the anticipated deficits of the pool.
1941     4.  A summarization of the activities of the plan in the
1942preceding calendar year, including the net written and earned
1943premiums, plan enrollment, the expense of administration, and
1944the paid and incurred losses.
1945     5.  A review of the operation of the plan as to whether the
1946plan has met the intent of this section.
1947     (7)  LIABILITY OF THE PLAN.--Neither the board nor its
1948employees shall be liable for any obligations of the plan. No
1949member or employee of the board shall be liable, and no cause of
1950action of any nature may arise against a member or employee of
1951the board, for any act or omission related to the performance of
1952any powers and duties under this section, unless such act or
1953omission constitutes willful or wanton misconduct. The board may
1954provide in its bylaws or rules for indemnification of, and legal
1955representation for, its members and employees.
1956     (8)  AUDITED FINANCIAL STATEMENT.--No later than June 1
1957following the close of each calendar year, the plan shall submit
1958to the Financial Services Commission an audited financial
1959statement prepared in accordance with statutory accounting
1960principles as adopted by the National Association of Insurance
1961Commissioners.
1962     (9)  ELIGIBILITY.--
1963     (a)  Any individual person who is and continues to be a
1964resident of this state shall be eligible for coverage under the
1965plan if:
1966     1.  Evidence is provided that the person received notices
1967of rejection or refusal to issue substantially similar coverage
1968for health reasons from at least two health insurers or health
1969maintenance organizations. A rejection or refusal by an insurer
1970offering only stoploss, excess of loss, or reinsurance coverage
1971with respect to the applicant shall not be sufficient evidence
1972under this paragraph.
1973     2.  The person is enrolled in the Florida Comprehensive
1974Health Association as of the date the plan is implemented.
1975     (b)  Each resident dependent of a person who is eligible
1976for coverage under the plan shall also be eligible for such
1977coverage.
1978     (c)  A person shall not be eligible for coverage under the
1979plan if:
1980     1.  The person has or obtains health insurance coverage
1981substantially similar to or more comprehensive than a plan
1982policy, or would be eligible to obtain such coverage, unless a
1983person may maintain other coverage for the period of time the
1984person is satisfying any preexisting condition waiting period
1985under a plan policy or may maintain plan coverage for the period
1986of time the person is satisfying a preexisting condition waiting
1987period under another health insurance policy intended to replace
1988the plan policy.
1989     2.  The person is determined to be eligible for health care
1990benefits under Medicaid, Medicare, the state's children's health
1991insurance program, or any other federal, state, or local
1992government program that provides health benefits;
1993     3.  The person voluntarily terminated plan coverage unless
199412 months have elapsed since such termination;
1995     4.  The person is an inmate or resident of a public
1996institution; or
1997     5.  The person's premiums are paid for or reimbursed under
1998any government-sponsored program or by any government agency or
1999health care provider.
2000     (d)  Coverage shall cease:
2001     1.  On the date a person is no longer a resident of this
2002state;
2003     2.  On the date a person requests coverage to end;
2004     3.  Upon the death of the covered person;
2005     4.  On the date state law requires cancellation or
2006nonrenewal of the policy; or
2007     5.  At the option of the plan, 30 days after the plan makes
2008any inquiry concerning the person's eligibility or place of
2009residence to which the person does not reply.
2010     6.  Upon failure of the insured to pay for continued
2011coverage.
2012     (e)  Except under the circumstances described in this
2013subsection, coverage of a person who ceases to meet the
2014eligibility requirements of this subsection shall be terminated
2015at the end of the policy period for which the necessary premiums
2016have been paid.
2017     (10)  UNFAIR REFERRAL TO PLAN.--It is an unfair trade
2018practice for the purposes of part IX of chapter 626 or s.
2019641.3901 for an insurer, health maintenance organization
2020insurance agent, insurance broker, or third-party administrator
2021to refer an individual employee to the plan, or arrange for an
2022individual employee to apply to the plan, for the purpose of
2023separating that employee from group health insurance coverage
2024provided in connection with the employee's employment.
2025     (11)  PLAN ADMINISTRATOR.--The board shall select through a
2026competitive bidding process a plan administrator to administer
2027the plan. The board shall evaluate bids submitted based on
2028criteria established by the board, which shall include:
2029     (a)  The plan administrator's proven ability to handle
2030health insurance coverage to individuals.
2031     (b)  The efficiency and timeliness of the plan
2032administrator's claim processing procedures.
2033     (c)  An estimate of total charges for administering the
2034plan.
2035     (d)  The plan administrator's ability to apply effective
2036cost-containment programs and procedures and to administer the
2037plan in a cost-efficient manner.
2038     (e)  The financial condition and stability of the plan
2039administrator.
2040
2041The administrator shall be an insurer, a health maintenance
2042organization, or a third-party administrator, or another
2043organization duly authorized to provide insurance pursuant to
2044the Florida Insurance Code.
2045     (12)  ADMINISTRATOR TERM LIMITS.--The plan administrator
2046shall serve for a period specified in the contract between the
2047plan and the plan administrator subject to removal for cause and
2048subject to any terms, conditions, and limitations of the
2049contract between the plan and the plan administrator. At least 1
2050year prior to the expiration of each period of service by a plan
2051administrator, the board shall invite eligible entities,
2052including the current plan administrator, to submit bids to
2053serve as the plan administrator. Selection of the plan
2054administrator for each succeeding period shall be made at least
20556 months prior to the end of the current period.
2056     (13)  DUTIES OF THE PLAN ADMINISTRATOR.--
2057     (a)  The plan administrator shall perform such functions
2058relating to the plan as may be assigned to it, including, but
2059not limited to:
2060     1.  Determination of eligibility.
2061     2.  Payment of claims.
2062     3.  Establishment of a premium billing procedure for
2063collection of premiums from persons covered under the plan.
2064     4.  Other necessary functions to ensure timely payment of
2065benefits to covered persons under the plan.
2066     (b)  The plan administrator shall submit regular reports to
2067the board regarding the operation of the plan. The frequency,
2068content, and form of the reports shall be specified in the
2069contract between the board and the plan administrator.
2070     (c)  On March 1 following the close of each calendar year,
2071the plan administrator shall determine net written and earned
2072premiums, the expense of administration, and the paid and
2073incurred losses for the year and report this information to the
2074board and the Governor on a form prescribed by the Governor.
2075     (14)  PAYMENT OF THE PLAN ADMINISTRATOR.--The plan
2076administrator shall be paid as provided in the contract between
2077the plan and the plan administrator.
2078     (15)  FUNDING OF THE PLAN.--
2079     (a)  Premiums.--
2080     1.  The plan shall establish premium rates for plan
2081coverage as provided in this section. Separate schedules of
2082premium rates based on age, sex, and geographical location may
2083apply for individual risks. Premium rates and schedules shall be
2084submitted to the office for approval prior to use.
2085     2.  Initial rates for plan coverage shall be limited to no
2086more than 300 percent of rates established for individual
2087standard risks as specified in s. 627.6675(3)(c). Subject to the
2088limits provided in this paragraph, subsequent rates shall be
2089established to provide fully for the expected costs of claims,
2090including recovery of prior losses, expenses of operation,
2091investment income of claim reserves, and any other cost factors
2092subject to the limitations described herein, but in no event
2093shall premiums exceed the 300-percent rate limitation provided
2094in this section. Notwithstanding the 300-percent rate
2095limitation, sliding scale premium surcharges based upon the
2096insured's income may apply to all enrollees.
2097     (b)  Sources of additional revenue.--Any deficit incurred
2098by the plan shall be primarily funded through amounts
2099appropriated by the Legislature from general revenue sources,
2100including, but not limited to, a portion of the annual growth in
2101existing net insurance premium taxes. The board shall operate
2102the plan in such a manner that the estimated cost of providing
2103health insurance during any fiscal year will not exceed total
2104income the plan expects to receive from policy premiums and
2105funds appropriated by the Legislature, including any interest on
2106investments. After determining the amount of funds appropriated
2107to the board for a fiscal year, the board shall estimate the
2108number of new policies it believes the plan has the financial
2109capacity to insure during that year so that costs do not exceed
2110income. The board shall take steps necessary to ensure that plan
2111enrollment does not exceed the number of residents it has
2112estimated it has the financial capacity to insure.
2113     (16)  BENEFITS.--
2114     (a)  The benefits provided shall be the same as the
2115standard and basic plans for small employers as outlined in s.
2116627.6699. The board shall also establish an option of
2117alternative coverage such as catastrophic coverage that includes
2118a minimum level of primary care coverage and a high deductible
2119plan that meets the federal requirements of a health savings
2120account.
2121     (b)  In establishing the plan coverage, the board shall
2122take into consideration the levels of health insurance provided
2123in the state and such medical economic factors as may be deemed
2124appropriate and adopt benefit levels, deductibles, copayments,
2125coinsurance factors, exclusions, and limitations determined to
2126be generally reflective of and commensurate with health
2127insurance provided through a representative number of large
2128employers in the state.
2129     (c)  The board may adjust any deductibles and coinsurance
2130factors annually according to the medical component of the
2131Consumer Price Index.
2132     (d)1.  Plan coverage shall exclude charges or expenses
2133incurred during the first 6 months following the effective date
2134of coverage for any condition for which medical advice, care, or
2135treatment was recommended or received for such condition during
2136the 6-month period immediately preceding the effective date of
2137coverage.
2138     2.  Such preexisting condition exclusions shall be waived
2139to the extent that similar exclusions, if any, have been
2140satisfied under any prior health insurance coverage which was
2141involuntarily terminated, provided application for pool coverage
2142is made not later than 63 days following such involuntary
2143termination. In such case, coverage under the plan shall be
2144effective from the date on which such prior coverage was
2145terminated and the applicant is not eligible for continuation or
2146conversion rights that would provide coverage substantially
2147similar to plan coverage.
2148     (17)  NONDUPLICATION OF BENEFITS.--
2149     (a)  The plan shall be payor of last resort of benefits
2150whenever any other benefit or source of third-party payment is
2151available. Benefits otherwise payable under plan coverage shall
2152be reduced by all amounts paid or payable through any other
2153health insurance, by all hospital and medical expense benefits
2154paid or payable under any workers' compensation coverage,
2155automobile medical payment, or liability insurance, whether
2156provided on the basis of fault or nonfault, and by any hospital
2157or medical benefits paid or payable under or provided pursuant
2158to any state or federal law or program.
2159     (b)  The plan shall have a cause of action against an
2160eligible person for the recovery of the amount of benefits paid
2161that are not for covered expenses. Benefits due from the plan
2162may be reduced or refused as a setoff against any amount
2163recoverable under this paragraph.
2164     (18)  ANNUAL AND MAXIMUM BENEFITS.--Maximum benefits under
2165the plan shall be determined by the board.
2166     (19)  TAXATION.--The plan is exempt from any tax imposed by
2167this state. The plan shall apply for federal tax exemption
2168status.
2169     (20)  COMBINING MEMBERSHIP OF THE FLORIDA COMPREHENSIVE
2170HEALTH ASSOCIATION; ASSESSMENT.--
2171     (a)1. Upon implementation of the Florida Health Insurance
2172Plan, the Florida Comprehensive Health Association, as specified
2173in s. 627.6488, is abolished as a separate nonprofit entity and
2174shall be subsumed under the board of directors of the Florida
2175Health Insurance Plan. All individuals actively enrolled in the
2176Florida Comprehensive Health Association shall be enrolled in
2177the plan subject to its rules and requirements, except as
2178otherwise specified in this section. Maximum lifetime benefits
2179paid to an individual in the plan shall not exceed the amount
2180established under subsection (16), and benefits previously paid
2181for any individual by the Florida Comprehensive Health
2182Association shall be used in the determination of total lifetime
2183benefits paid under the plan.
2184     2.  All persons enrolled in the Florida Comprehensive
2185Health Association upon implementation of the Florida Health
2186Insurance Plan are only eligible for the benefits authorized
2187under subsection (16). Persons identified by this section shall
2188convert to the benefits authorized under subsection (16) no
2189later than January 1, 2005.
2190     3.  Except as otherwise provided in this section, the
2191administration of the coverage of persons actively enrolled in
2192the Florida Comprehensive Health Association shall operate under
2193the existing plan of operation without modification until the
2194adoption of the new plan of operation for the Florida Health
2195Insurance Plan.
2196     (b)1.  As a condition of doing business in this state, an
2197insurer shall pay an assessment to the board in the amount
2198prescribed by this section. For operating losses incurred on or
2199after July 1, 2004, by persons enrolled in the Florida
2200Comprehensive Health Association, each insurer shall annually be
2201assessed by the board in the following calendar year a portion
2202of such incurred operating losses of the plan. Such portion
2203shall be determined by multiplying such operating losses by a
2204fraction, the numerator of which equals the insurer's earned
2205premium pertaining to direct writings of health insurance in the
2206state during the calendar year preceding that for which the
2207assessment is levied, and the denominator of which equals the
2208total of all such premiums earned by insurers in the state
2209during such calendar year.
2210     2.  The total of all assessments under this paragraph upon
2211an insurer shall not exceed 1 percent of such insurer's health
2212insurance premium earned in this state during the calendar year
2213preceding the year for which the assessments were levied.
2214     3.  All rights, title, and interest in the assessment funds
2215collected under this paragraph shall vest in this state.
2216However, all of such funds and interest earned shall be used by
2217the plan to pay claims and administrative expenses.
2218     (c)  If assessments and other receipts by the plan, board,
2219or plan administrator exceed the actual losses and
2220administrative expenses of the plan, the excess shall be held in
2221interest and used by the board to offset future losses. As used
2222in this subsection, the term "future losses" includes reserves
2223for claims incurred but not reported.
2224     (d)  Each insurer's assessment shall be determined annually
2225by the board or plan administrator based on annual statements
2226and other reports deemed necessary by the board or plan
2227administrator and filed with the board or plan administrator by
2228the insurer. Any deficit incurred under the plan by persons
2229previously enrolled in the Florida Comprehensive Health
2230Association shall be recouped by the assessments against
2231insurers by the board or plan administrator in the manner
2232provided in paragraph (b), and the insurers may recover the
2233assessment in the normal course of their respective businesses
2234without time limitation.
2235     (e)  If a person actively enrolled in the Florida
2236Comprehensive Health Association after implementation of the
2237plan loses eligibility for participation in the Florida
2238Comprehensive Health Association, such person shall not be
2239included in the calculation of the assessment if the person
2240later regains eligibility for participation in the plan.
2241     (f)  When all persons actively enrolled in the Florida
2242Comprehensive Health Association as of the date of
2243implementation of the plan are no longer eligible for
2244participation in the Florida Comprehensive Health Association,
2245the board of directors and plan administrator shall no longer be
2246allowed to assess insurers in this state for incurred losses in
2247the Florida Comprehensive Health Association.
2248     Section 22.  Upon implementation, as defined in s.
2249627.64872(2), Florida Statutes, and as provided in s.
2250627.64872(20), Florida Statutes, of the Florida Health Insurance
2251Plan created under s. 627.64872, Florida Statutes, sections
2252627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and
2253627.6498, Florida Statutes, are repealed.
2254     Section 23.  Subsections (12) and (13) are added to section
2255627.662, Florida Statutes, to read:
2256     627.662  Other provisions applicable.--The following
2257provisions apply to group health insurance, blanket health
2258insurance, and franchise health insurance:
2259     (12)  Section 627.6044, relating to the use of specific
2260methodology for payment of claims.
2261     (13)  Section 627.6405, relating to the inappropriate
2262utilization of emergency care.
2263     Section 24.  Paragraphs (c) and (d) of subsection (5),
2264paragraph (b) of subsection (6), and subsection (12) of section
2265627.6699, Florida Statutes, are amended, subsections (15) and
2266(16) of said section are renumbered as subsections (16) and
2267(17), respectively, present subsection (15) of said section is
2268amended, and new subsections (15) and (18) are added to said
2269section, to read:
2270     627.6699  Employee Health Care Access Act.--
2271     (5)  AVAILABILITY OF COVERAGE.--
2272     (c)  Every small employer carrier must, as a condition of
2273transacting business in this state:
2274     1.  Offer and issue all small employer health benefit plans
2275on a guaranteed-issue basis to every eligible small employer,
2276with 2 to 50 eligible employees, that elects to be covered under
2277such plan, agrees to make the required premium payments, and
2278satisfies the other provisions of the plan. A rider for
2279additional or increased benefits may be medically underwritten
2280and may only be added to the standard health benefit plan. The
2281increased rate charged for the additional or increased benefit
2282must be rated in accordance with this section.
2283     2.  In the absence of enrollment availability in the
2284Florida Health Insurance Plan, offer and issue basic and
2285standard small employer health benefit plans on a guaranteed-
2286issue basis, during a 31-day open enrollment period of August 1
2287through August 31 of each year, to every eligible small
2288employer, with fewer than two eligible employees, which small
2289employer is not formed primarily for the purpose of buying
2290health insurance and which elects to be covered under such plan,
2291agrees to make the required premium payments, and satisfies the
2292other provisions of the plan. Coverage provided under this
2293subparagraph shall begin on October 1 of the same year as the
2294date of enrollment, unless the small employer carrier and the
2295small employer agree to a different date. A rider for additional
2296or increased benefits may be medically underwritten and may only
2297be added to the standard health benefit plan. The increased rate
2298charged for the additional or increased benefit must be rated in
2299accordance with this section. For purposes of this subparagraph,
2300a person, his or her spouse, and his or her dependent children
2301constitute a single eligible employee if that person and spouse
2302are employed by the same small employer and either that person
2303or his or her spouse has a normal work week of less than 25
2304hours. Any right to an open enrollment of health benefit
2305coverage for groups of fewer than two employees, pursuant to
2306this section, shall remain in full force and effect in the
2307absence of the availability of new enrollment into the Florida
2308Health Insurance Plan.
2309     3.  This paragraph does not limit a carrier's ability to
2310offer other health benefit plans to small employers if the
2311standard and basic health benefit plans are offered and
2312rejected.
2313     (d)  A small employer carrier must file with the office, in
2314a format and manner prescribed by the committee, a standard
2315health care plan, a high deductible plan that meets the federal
2316requirements of a health savings account plan or a health
2317reimbursement arrangement, and a basic health care plan to be
2318used by the carrier. The provisions of this section requiring
2319the filing of a high deductible plan are effective September 1,
23202004.
2321     (6)  RESTRICTIONS RELATING TO PREMIUM RATES.--
2322     (b)  For all small employer health benefit plans that are
2323subject to this section and are issued by small employer
2324carriers on or after January 1, 1994, premium rates for health
2325benefit plans subject to this section are subject to the
2326following:
2327     1.  Small employer carriers must use a modified community
2328rating methodology in which the premium for each small employer
2329must be determined solely on the basis of the eligible
2330employee's and eligible dependent's gender, age, family
2331composition, tobacco use, or geographic area as determined under
2332paragraph (5)(j) and in which the premium may be adjusted as
2333permitted by this paragraph.
2334     2.  Rating factors related to age, gender, family
2335composition, tobacco use, or geographic location may be
2336developed by each carrier to reflect the carrier's experience.
2337The factors used by carriers are subject to office review and
2338approval.
2339     3.  Small employer carriers may not modify the rate for a
2340small employer for 12 months from the initial issue date or
2341renewal date, unless the composition of the group changes or
2342benefits are changed. However, a small employer carrier may
2343modify the rate one time prior to 12 months after the initial
2344issue date for a small employer who enrolls under a previously
2345issued group policy that has a common anniversary date for all
2346employers covered under the policy if:
2347     a.  The carrier discloses to the employer in a clear and
2348conspicuous manner the date of the first renewal and the fact
2349that the premium may increase on or after that date.
2350     b.  The insurer demonstrates to the office that
2351efficiencies in administration are achieved and reflected in the
2352rates charged to small employers covered under the policy.
2353     4.  A carrier may issue a group health insurance policy to
2354a small employer health alliance or other group association with
2355rates that reflect a premium credit for expense savings
2356attributable to administrative activities being performed by the
2357alliance or group association if such expense savings are
2358specifically documented in the insurer's rate filing and are
2359approved by the office. Any such credit may not be based on
2360different morbidity assumptions or on any other factor related
2361to the health status or claims experience of any person covered
2362under the policy. Nothing in this subparagraph exempts an
2363alliance or group association from licensure for any activities
2364that require licensure under the insurance code. A carrier
2365issuing a group health insurance policy to a small employer
2366health alliance or other group association shall allow any
2367properly licensed and appointed agent of that carrier to market
2368and sell the small employer health alliance or other group
2369association policy. Such agent shall be paid the usual and
2370customary commission paid to any agent selling the policy.
2371     5.  Any adjustments in rates for claims experience, health
2372status, or duration of coverage may not be charged to individual
2373employees or dependents. For a small employer's policy, such
2374adjustments may not result in a rate for the small employer
2375which deviates more than 15 percent from the carrier's approved
2376rate. Any such adjustment must be applied uniformly to the rates
2377charged for all employees and dependents of the small employer.
2378A small employer carrier may make an adjustment to a small
2379employer's renewal premium, not to exceed 10 percent annually,
2380due to the claims experience, health status, or duration of
2381coverage of the employees or dependents of the small employer.
2382Semiannually, small group carriers shall report information on
2383forms adopted by rule by the commission, to enable the office to
2384monitor the relationship of aggregate adjusted premiums actually
2385charged policyholders by each carrier to the premiums that would
2386have been charged by application of the carrier's approved
2387modified community rates. If the aggregate resulting from the
2388application of such adjustment exceeds the premium that would
2389have been charged by application of the approved modified
2390community rate by 4 5 percent for the current reporting period,
2391the carrier shall limit the application of such adjustments only
2392to minus adjustments beginning not more than 60 days after the
2393report is sent to the office. For any subsequent reporting
2394period, if the total aggregate adjusted premium actually charged
2395does not exceed the premium that would have been charged by
2396application of the approved modified community rate by 4 5
2397percent, the carrier may apply both plus and minus adjustments.
2398A small employer carrier may provide a credit to a small
2399employer's premium based on administrative and acquisition
2400expense differences resulting from the size of the group. Group
2401size administrative and acquisition expense factors may be
2402developed by each carrier to reflect the carrier's experience
2403and are subject to office review and approval.
2404     6.  A small employer carrier rating methodology may include
2405separate rating categories for one dependent child, for two
2406dependent children, and for three or more dependent children for
2407family coverage of employees having a spouse and dependent
2408children or employees having dependent children only. A small
2409employer carrier may have fewer, but not greater, numbers of
2410categories for dependent children than those specified in this
2411subparagraph.
2412     7.  Small employer carriers may not use a composite rating
2413methodology to rate a small employer with fewer than 10
2414employees. For the purposes of this subparagraph, a "composite
2415rating methodology" means a rating methodology that averages the
2416impact of the rating factors for age and gender in the premiums
2417charged to all of the employees of a small employer.
2418     8.a.  A carrier may separate the experience of small
2419employer groups with less than 2 eligible employees from the
2420experience of small employer groups with 2-50 eligible employees
2421for purposes of determining an alternative modified community
2422rating.
2423     b.  If a carrier separates the experience of small employer
2424groups as provided in sub-subparagraph a., the rate to be
2425charged to small employer groups of less than 2 eligible
2426employees may not exceed 150 percent of the rate determined for
2427small employer groups of 2-50 eligible employees. However, the
2428carrier may charge excess losses of the experience pool
2429consisting of small employer groups with less than 2 eligible
2430employees to the experience pool consisting of small employer
2431groups with 2-50 eligible employees so that all losses are
2432allocated and the 150-percent rate limit on the experience pool
2433consisting of small employer groups with less than 2 eligible
2434employees is maintained. Notwithstanding s. 627.411(1), the rate
2435to be charged to a small employer group of fewer than 2 eligible
2436employees, insured as of July 1, 2002, may be up to 125 percent
2437of the rate determined for small employer groups of 2-50
2438eligible employees for the first annual renewal and 150 percent
2439for subsequent annual renewals.
2440     (12)  STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED HEALTH
2441BENEFIT PLANS.--
2442     (a)1.  The Chief Financial Officer shall appoint a health
2443benefit plan committee composed of four representatives of
2444carriers which shall include at least two representatives of
2445HMOs, at least one of which is a staff model HMO, two
2446representatives of agents, four representatives of small
2447employers, and one employee of a small employer. The carrier
2448members shall be selected from a list of individuals recommended
2449by the board. The Chief Financial Officer may require the board
2450to submit additional recommendations of individuals for
2451appointment.
2452     2.  The plans shall comply with all of the requirements of
2453this subsection.
2454     3.  The plans must be filed with and approved by the office
2455prior to issuance or delivery by any small employer carrier.
2456     4.  After approval of the revised health benefit plans, if
2457the office determines that modifications to a plan might be
2458appropriate, the Chief Financial Officer shall appoint a new
2459health benefit plan committee in the manner provided in
2460subparagraph 1. to submit recommended modifications to the
2461office for approval.
2462     (b)1.  Each small employer carrier issuing new health
2463benefit plans shall offer to any small employer, upon request, a
2464standard health benefit plan, and a basic health benefit plan,
2465and a high deductible plan that meets the requirements of a
2466health savings account plan as defined by federal law or a
2467health reimbursement arrangement as authorized by the Internal
2468Revenue Service, that meet meets the criteria set forth in this
2469section.
2470     2.  For purposes of this subsection, the terms "standard
2471health benefit plan," and "basic health benefit plan," and "high
2472deductible plan" mean policies or contracts that a small
2473employer carrier offers to eligible small employers that
2474contain:
2475     a.  An exclusion for services that are not medically
2476necessary or that are not covered preventive health services;
2477and
2478     b.  A procedure for preauthorization by the small employer
2479carrier, or its designees.
2480     3.  A small employer carrier may include the following
2481managed care provisions in the policy or contract to control
2482costs:
2483     a.  A preferred provider arrangement or exclusive provider
2484organization or any combination thereof, in which a small
2485employer carrier enters into a written agreement with the
2486provider to provide services at specified levels of
2487reimbursement or to provide reimbursement to specified
2488providers. Any such written agreement between a provider and a
2489small employer carrier must contain a provision under which the
2490parties agree that the insured individual or covered member has
2491no obligation to make payment for any medical service rendered
2492by the provider which is determined not to be medically
2493necessary. A carrier may use preferred provider arrangements or
2494exclusive provider arrangements to the same extent as allowed in
2495group products that are not issued to small employers.
2496     b.  A procedure for utilization review by the small
2497employer carrier or its designees.
2498
2499This subparagraph does not prohibit a small employer carrier
2500from including in its policy or contract additional managed care
2501and cost containment provisions, subject to the approval of the
2502office, which have potential for controlling costs in a manner
2503that does not result in inequitable treatment of insureds or
2504subscribers. The carrier may use such provisions to the same
2505extent as authorized for group products that are not issued to
2506small employers.
2507     4.  The standard health benefit plan shall include:
2508     a.  Coverage for inpatient hospitalization;
2509     b.  Coverage for outpatient services;
2510     c.  Coverage for newborn children pursuant to s. 627.6575;
2511     d.  Coverage for child care supervision services pursuant
2512to s. 627.6579;
2513     e.  Coverage for adopted children upon placement in the
2514residence pursuant to s. 627.6578;
2515     f.  Coverage for mammograms pursuant to s. 627.6613;
2516     g.  Coverage for handicapped children pursuant to s.
2517627.6615;
2518     h.  Emergency or urgent care out of the geographic service
2519area; and
2520     i.  Coverage for services provided by a hospice licensed
2521under s. 400.602 in cases where such coverage would be the most
2522appropriate and the most cost-effective method for treating a
2523covered illness.
2524     5.  The standard health benefit plan and the basic health
2525benefit plan may include a schedule of benefit limitations for
2526specified services and procedures. If the committee develops
2527such a schedule of benefits limitation for the standard health
2528benefit plan or the basic health benefit plan, a small employer
2529carrier offering the plan must offer the employer an option for
2530increasing the benefit schedule amounts by 4 percent annually.
2531     6.  The basic health benefit plan shall include all of the
2532benefits specified in subparagraph 4.; however, the basic health
2533benefit plan shall place additional restrictions on the benefits
2534and utilization and may also impose additional cost containment
2535measures.
2536     7.  Sections 627.419(2), (3), and (4), 627.6574, 627.6612,
2537627.66121, 627.66122, 627.6616, 627.6618, 627.668, and 627.66911
2538apply to the standard health benefit plan and to the basic
2539health benefit plan. However, notwithstanding said provisions,
2540the plans may specify limits on the number of authorized
2541treatments, if such limits are reasonable and do not
2542discriminate against any type of provider.
2543     8.  The high deductible plan associated with a health
2544savings account or a health reimbursement arrangement shall
2545include all the benefits specified in subparagraph 4.
2546     9.8.  Each small employer carrier that provides for
2547inpatient and outpatient services by allopathic hospitals may
2548provide as an option of the insured similar inpatient and
2549outpatient services by hospitals accredited by the American
2550Osteopathic Association when such services are available and the
2551osteopathic hospital agrees to provide the service.
2552     (c)  If a small employer rejects, in writing, the standard
2553health benefit plan, and the basic health benefit plan, and the
2554high deductible health savings account plan or a health
2555reimbursement arrangement, the small employer carrier may offer
2556the small employer a limited benefit policy or contract.
2557     (d)1.  Upon offering coverage under a standard health
2558benefit plan, a basic health benefit plan, or a limited benefit
2559policy or contract for any small employer, the small employer
2560carrier shall provide such employer group with a written
2561statement that contains, at a minimum:
2562     a.  An explanation of those mandated benefits and providers
2563that are not covered by the policy or contract;
2564     b.  An explanation of the managed care and cost control
2565features of the policy or contract, along with all appropriate
2566mailing addresses and telephone numbers to be used by insureds
2567in seeking information or authorization; and
2568     c.  An explanation of the primary and preventive care
2569features of the policy or contract.
2570
2571Such disclosure statement must be presented in a clear and
2572understandable form and format and must be separate from the
2573policy or certificate or evidence of coverage provided to the
2574employer group.
2575     2.  Before a small employer carrier issues a standard
2576health benefit plan, a basic health benefit plan, or a limited
2577benefit policy or contract, it must obtain from the prospective
2578policyholder a signed written statement in which the prospective
2579policyholder:
2580     a.  Certifies as to eligibility for coverage under the
2581standard health benefit plan, basic health benefit plan, or
2582limited benefit policy or contract;
2583     b.  Acknowledges the limited nature of the coverage and an
2584understanding of the managed care and cost control features of
2585the policy or contract;
2586     c.  Acknowledges that if misrepresentations are made
2587regarding eligibility for coverage under a standard health
2588benefit plan, a basic health benefit plan, or a limited benefit
2589policy or contract, the person making such misrepresentations
2590forfeits coverage provided by the policy or contract; and
2591     d.  If a limited plan is requested, acknowledges that the
2592prospective policyholder had been offered, at the time of
2593application for the insurance policy or contract, the
2594opportunity to purchase any health benefit plan offered by the
2595carrier and that the prospective policyholder had rejected that
2596coverage.
2597
2598A copy of such written statement shall be provided to the
2599prospective policyholder no later than at the time of delivery
2600of the policy or contract, and the original of such written
2601statement shall be retained in the files of the small employer
2602carrier for the period of time that the policy or contract
2603remains in effect or for 5 years, whichever period is longer.
2604     3.  Any material statement made by an applicant for
2605coverage under a health benefit plan which falsely certifies as
2606to the applicant's eligibility for coverage serves as the basis
2607for terminating coverage under the policy or contract.
2608     4.  Each marketing communication that is intended to be
2609used in the marketing of a health benefit plan in this state
2610must be submitted for review by the office prior to use and must
2611contain the disclosures stated in this subsection.
2612     (e)  A small employer carrier may not use any policy,
2613contract, form, or rate under this section, including
2614applications, enrollment forms, policies, contracts,
2615certificates, evidences of coverage, riders, amendments,
2616endorsements, and disclosure forms, until the insurer has filed
2617it with the office and the office has approved it under ss.
2618627.410 and 627.411 and this section.
2619     (15)  SMALL EMPLOYERS ACCESS PROGRAM.--
2620     (a)  Popular name.--This subsection may be referred to by
2621the popular name "The Small Employers Access Program."
2622     (b)  Intent.--The Legislature finds that increased access
2623to health care coverage for small employers with up to 25
2624employees could improve employees' health and reduce the
2625incidence and costs of illness and disabilities among residents
2626in this state. Many employers do not offer health care benefits
2627to their employees citing the increased cost of this benefit. It
2628is the intent of the Legislature to create the Small Business
2629Health Plan to provide small employers the option and ability to
2630provide health care benefits to their employees at an affordable
2631cost through the creation of purchasing pools for employers with
2632up to 25 employees, and rural hospital employers and nursing
2633home employers regardless of the number of employees.
2634     (c)  Definitions.--For purposes of this subsection:
2635     1.  "Fair commission" means a commission structure
2636determined by the insurers and reflected in the insurers' rate
2637filings made pursuant to this subsection.
2638     2.  "Insurer" means any entity that provides health
2639insurance in this state. For purposes of this subsection,
2640insurer includes an insurance company holding a certificate of
2641authority pursuant to chapter 624 or a health maintenance
2642organization holding a certificate of authority pursuant to
2643chapter 641, which qualifies to provide coverage to small
2644employer groups pursuant to this section.
2645     3.  "Mutually supported benefit plan" means an optional
2646alternative coverage plan developed within a defined geographic
2647region which may include, but is not limited to, a minimum level
2648of primary care coverage in which the percentage of the premium
2649is distributed among the employer, the employee, and community-
2650generated revenue either alone or in conjunction with federal
2651matching funds.
2652     4.  "Office" means the Office of Insurance Regulation of
2653the Department of Financial Services.
2654     5.  "Participating insurer" means any insurer providing
2655health insurance to small employers that has been selected by
2656the office in accordance with this subsection for its designated
2657region.
2658     6.  "Program" means the Small Employer Access Program as
2659created by this subsection.
2660     (d)  Eligibility.--
2661     1.  Any small employer that is actively engaged in
2662business, has its principal place of business in this state,
2663employs up to 25 eligible employees on business days during the
2664preceding calendar year, employs at least 2 employees on the
2665first day of the plan year, and has had no prior coverage for
2666the last 6 months may participate.
2667     2.  Any municipality, county, school district, or hospital
2668employer located in a rural community as defined in s.
2669288.0656(2)(b), may participate.
2670     3.  Nursing home employers may participate.
2671     4.  Each dependent of a person eligible for coverage is
2672also eligible to participate.
2673
2674Any employer participating in the program must do so until the
2675end of the term for which the carrier providing the coverage is
2676obligated to provide such coverage to the program. Coverage for
2677a small employer group that ceases to meet the eligibility
2678requirements of this section may be terminated at the end of the
2679policy period for which the necessary premiums have been paid.
2680     (e)  Administration.--
2681     1.  The office shall by competitive bid, in accordance with
2682current state law, select an insurer to provide coverage through
2683the program to eligible small employers within an established
2684geographical area of this state. The office may develop
2685exclusive regions for the program similar to those used by the
2686Healthy Kids Corporation. However the office is not precluded
2687from developing, in conjunction with insurers, regions different
2688from those used by the Healthy Kids Corporation if the office
2689deems that such a region will carry out the intentions of this
2690subsection.
2691     2.  The office shall evaluate bids submitted based upon
2692criteria established by the office, which shall include, but not
2693be limited to:
2694     a.  The insurer's proven ability to handle health insurance
2695coverage to small employer groups.
2696     b.  The efficiency and timeliness of the insurer's claim
2697processing procedures.
2698     c.  The insurer's ability to apply effective cost-
2699containment programs and procedures and to administer the
2700program in a cost-efficient manner.
2701     d.  The financial condition and stability of the insurer.
2702e.  The insurer's ability to develop an optional mutually
2703supported benefit plan.
2704
2705The office may use any financial information available to it
2706through its regulatory duties to make this evaluation.
2707     (f)  Insurer qualifications.--The insurer shall be a duly
2708authorized insurer or health maintenance organization.
2709     (g)  Duties of the insurer.--The insurer shall:
2710     1.  Develop and implement a program to publicize the
2711existence of the program, program eligibility requirements, and
2712procedures for enrollment and maintain public awareness of the
2713program.
2714     2.  Maintain employer awareness of the program.
2715     3.  Demonstrate the ability to use delivery of cost-
2716effective health care services.
2717     4.  Encourage, educate, advise, and administer the
2718effective use of health savings accounts by covered employees
2719and dependents.
2720     5.  Serve for a period specified in the contract between
2721the office and the insurer, subject to removal for cause and
2722subject to any terms, conditions, and limitations of the
2723contract between the office and the insurer as may be specified
2724in the request for proposal.
2725     (h)  Contract term.--The contract term shall not exceed 3
2726years. At least 6 months prior to the expiration of each
2727contract period, the office shall invite eligible entities,
2728including the current insurer, to submit bids to serve as the
2729insurer for a designated geographic area. Selection of the
2730insurer for the succeeding period shall be made at least 3
2731months prior to the end of the current period. If a protest is
2732filed and not resolved by the end of the contract period, the
2733contract with the existing administrator may be extended for a
2734period not to exceed 6 months. During the contract extension
2735period, the administrator shall be paid at a rate to be
2736negotiated by the office.
2737     (i)  Insurer reporting requirements.--On March 1 following
2738the close of each calendar year, the insurer shall determine net
2739written and earned premiums, the expense of administration, and
2740the paid and incurred losses for the year and report this
2741information to the office on a form prescribed by the office.
2742     (j)  Application requirements.--The insurer shall permit or
2743allow any licensed and duly appointed health insurance agent
2744residing in the designated region to submit applications for
2745coverage, and such agent shall be paid a fair commission if
2746coverage is written. The agent must be appointed to at least one
2747insurer.
2748     (k)  Benefits.--The benefits provided by the plan shall be
2749the same as the coverage required for small employers under
2750subsection (12). Upon the approval of the office, the insurer
2751may also establish an optional mutually supported benefit plan
2752which is an alternative plan developed within a defined
2753geographic region of this state or any other such alternative
2754plan which will carry out the intent of this subsection. Any
2755small employer carrier issuing new health benefit plans may
2756offer a benefit plan with coverages similar to, but not less
2757than, any alternative coverage plan developed pursuant to this
2758subsection.
2759     (l)  Annual reporting.--The office shall make an annual
2760report to the Governor, the President of the Senate, and the
2761Speaker of the House of Representatives. The report shall
2762summarize the activities of the program in the preceding
2763calendar year, including the net written and earned premiums,
2764program enrollment, the expense of administration, and the paid
2765and incurred losses. The report shall be submitted no later than
2766March 15 following the close of the prior calendar year.
2767     (16)(15)  APPLICABILITY OF OTHER STATE LAWS.--
2768     (a)  Except as expressly provided in this section, a law
2769requiring coverage for a specific health care service or
2770benefit, or a law requiring reimbursement, utilization, or
2771consideration of a specific category of licensed health care
2772practitioner, does not apply to a standard or basic health
2773benefit plan policy or contract or a limited benefit policy or
2774contract offered or delivered to a small employer unless that
2775law is made expressly applicable to such policies or contracts.
2776A law restricting or limiting deductibles, coinsurance,
2777copayments, or annual or lifetime maximum payments does not
2778apply to any health plan policy, including a standard or basic
2779health benefit plan policy or contract, offered or delivered to
2780a small employer unless such law is made expressly applicable to
2781such policy or contract. However, every small employer carrier
2782must offer to eligible small employers the standard benefit plan
2783and the basic benefit plan, as required by subsection (5), as
2784such plans have been approved by the office pursuant to
2785subsection (12).
2786     (b)  Except as provided in this section, a standard or
2787basic health benefit plan policy or contract or limited benefit
2788policy or contract offered to a small employer is not subject to
2789any provision of this code which:
2790     1.  Inhibits a small employer carrier from contracting with
2791providers or groups of providers with respect to health care
2792services or benefits;
2793     2.  Imposes any restriction on a small employer carrier's
2794ability to negotiate with providers regarding the level or
2795method of reimbursing care or services provided under a health
2796benefit plan; or
2797     3.  Requires a small employer carrier to either include a
2798specific provider or class of providers when contracting for
2799health care services or benefits or to exclude any class of
2800providers that is generally authorized by statute to provide
2801such care.
2802     (c)  Any second tier assessment paid by a carrier pursuant
2803to paragraph (11)(j) may be credited against assessments levied
2804against the carrier pursuant to s. 627.6494.
2805     (d)  Notwithstanding chapter 641, a health maintenance
2806organization is authorized to issue contracts providing benefits
2807equal to the standard health benefit plan, the basic health
2808benefit plan, and the limited benefit policy authorized by this
2809section.
2810     (17)(16)  RULEMAKING AUTHORITY.--The commission may adopt
2811rules to administer this section, including rules governing
2812compliance by small employer carriers and small employers.
2813     Section 25.  Section 627.6405, Florida Statutes, is created
2814to read:
2815     627.6405  Decreasing inappropriate utilization of emergency
2816care.--
2817     (1)  The Legislature finds and declares it to be of vital
2818importance that emergency services and care be provided by
2819hospitals and physicians to every person in need of such care,
2820but with the double-digit increases in health insurance
2821premiums, health care providers and insurers should encourage
2822patients and the insured to assume responsibility for their
2823treatment, including emergency care. The Legislature finds that
2824inappropriate utilization of emergency department services
2825increases the overall cost of providing health care and these
2826costs are ultimately borne by the hospital, the insured
2827patients, and, many times, by the taxpayers of this state.
2828Finally, the Legislature declares that the providers and
2829insurers must share the responsibility of providing alternative
2830treatment options to urgent care patients outside of the
2831emergency department. Therefore, it is the intent of the
2832Legislature to place the obligation for educating consumers and
2833creating mechanisms for delivery of care that will decrease the
2834overutilization of emergency service on health insurers and
2835providers.
2836     (2)  Health insurers shall provide on their websites
2837information regarding appropriate utilization of emergency care
2838services which shall include, but not be limited to, a list of
2839alternative urgent care contracted providers, the types of
2840services offered by these providers, and what to do in the event
2841of a true emergency.
2842     (3)  Health insurers shall develop community emergency
2843department diversion programs. Such programs may include, at the
2844discretion of the insurer, but not be limited to, enlisting
2845providers to be on call to insurers after hours, coordinating
2846care through local community resources, and providing incentives
2847to providers for case management.
2848     (4)  As a disincentive for insureds to inappropriately use
2849emergency department services for nonemergency care, health
2850insurers may require higher copayments for urgent care or
2851primary care provided in an emergency department and higher
2852copayments for use of out-of-network emergency departments.
2853Higher copayments may not be charged for the utilization of the
2854emergency department for emergency care. For the purposes of
2855this section, the term "emergency care" has the same meaning as
2856provided in s. 395.002, and shall include services provided to
2857rule out an emergency medical condition.
2858     Section 26.  Section 641.31097, Florida Statutes, is
2859created to read:
2860     641.31097  Decreasing inappropriate utilization of
2861emergency care.--
2862     (1)  The Legislature finds and declares it to be of vital
2863importance that emergency services and care be provided by
2864hospitals and physicians to every person in need of such care,
2865but with the double-digit increases in health insurance
2866premiums, health care providers and insurers should encourage
2867patients and the insured to assume responsibility for their
2868treatment, including emergency care. The Legislature finds that
2869inappropriate utilization of emergency department services
2870increases the overall cost of providing health care and these
2871costs are ultimately borne by the hospital, by the insured
2872patients, and, many times, by the taxpayers of this state.
2873Finally, the Legislature declares that the providers and
2874insurers must share the responsibility of providing alternative
2875treatment options to urgent care patients outside of the
2876emergency department. Therefore, it is the intent of the
2877Legislature to place the obligation for educating consumers and
2878creating mechanisms for delivery of care that will decrease the
2879overutilization of emergency service on health maintenance
2880organizations and providers.
2881     (2)  Health maintenance organizations shall provide on
2882their Internet websites information regarding appropriate
2883utilization of emergency care services, which shall include, but
2884not be limited to, a list of alternative urgent care contracted
2885providers, the types of services offered by these providers, and
2886what to do in the event of a true emergency.
2887     (3)  Health maintenance organizations shall develop
2888community emergency department diversion programs. Such programs
2889may include at the discretion of the health maintenance
2890organization, but not be limited to, enlisting providers to be
2891on call to subscribers after hours, coordinating care through
2892local community resources, and providing incentives to providers
2893for case management.
2894     (4)  As a disincentive for subscribers to inappropriately
2895use emergency department services for nonemergency care, health
2896maintenance organizations may require higher copayments for
2897urgent care or primary care provided in an emergency department
2898and higher copayments for use of out-of-network emergency
2899departments. Higher copayments may not be charged for the
2900utilization of the emergency department for emergency care. For
2901the purposes of this section, the term "emergency care" has the
2902same meaning as provided in s. 395.002 and shall include
2903services provided to rule out an emergency medical condition.
2904     Section 27.  Subsection (1) of section 627.9175, Florida
2905Statutes, is amended to read:
2906     627.9175  Reports of information on health and accident
2907insurance.--
2908     (1)  Each health insurer, prepaid limited health services
2909organization, and health maintenance organization shall submit,
2910no later than April 1 of each year, annually to the office
2911information concerning health and accident insurance coverage
2912and medical plans being marketed and currently in force in this
2913state. The required information shall be described by market
2914segment, to include, but not be limited to:
2915     (a)  Issuing, servicing company, and entity contact
2916information.
2917     (b)  Information on all health and accident insurance
2918policies and prepaid limited health service organizations and
2919health maintenance organization contracts in force and issued in
2920the previous year. Such information shall include, but not be
2921limited to, direct premiums earned, direct losses incurred,
2922number of policies, number of certificates, number of covered
2923lives, and the average number of days taken to pay claims. as to
2924policies of individual health insurance:
2925     (a)  A summary of typical benefits, exclusions, and
2926limitations for each type of individual policy form currently
2927being issued in the state. The summary shall include, as
2928appropriate:
2929     1.  The deductible amount;
2930     2.  The coinsurance percentage;
2931     3.  The out-of-pocket maximum;
2932     4.  Outpatient benefits;
2933     5.  Inpatient benefits; and
2934     6.  Any exclusions for preexisting conditions.
2935
2936The commission shall determine other appropriate benefits,
2937exclusions, and limitations to be reported for inclusion in the
2938consumer's guide published pursuant to this section.
2939     (b)  A schedule of rates for each type of individual policy
2940form reflecting typical variations by age, sex, region of the
2941state, or any other applicable factor which is in use and is
2942determined to be appropriate for inclusion by the commission.
2943
2944The commission may establish rules governing shall provide by
2945rule a uniform format for the submission of this information
2946described in this section, including the use of uniform formats
2947and electronic data transmission order to allow for meaningful
2948comparisons of premiums charged for comparable benefits. The
2949office shall provide this information to the department, which
2950shall publish annually a consumer's guide which summarizes and
2951compares the information required to be reported under this
2952subsection.
2953     Section 28.  Chapter 636, Florida Statutes, entitled
2954"Prepaid Limited Health Service Organizations," is retitled as
2955"Prepaid Limited Health Service Organizations and Discount
2956Medical Plan Organizations."
2957     Section 29.  Sections 636.002 through 636.067, Florida
2958Statutes, are designated as part I of chapter 636, Florida
2959Statutes, and entitled "Prepaid Limited Health Service
2960Organizations."
2961     Section 30.  Paragraph (c) of subsection (7) of section
2962636.003, Florida Statutes, is amended to read:
2963     636.003  Definitions.--As used in this act, the term:
2964     (7)  "Prepaid limited health service organization" means
2965any person, corporation, partnership, or any other entity which,
2966in return for a prepayment, undertakes to provide or arrange
2967for, or provide access to, the provision of a limited health
2968service to enrollees through an exclusive panel of providers.
2969Prepaid limited health service organization does not include:
2970     (c)  Any person who is licensed pursuant to part II as a
2971discount medical plan organization, in exchange for fees, dues,
2972charges or other consideration, provides access to a limited
2973health service provider without assuming any responsibility for
2974payment for the limited health service or any portion thereof.
2975     Section 31.  Effective January 1, 2005, part II of chapter
2976636, Florida Statutes, consisting of sections 636.202, 636.204,
2977636.206, 636.208, 636.210, 636.212, 636.214, 636.216, 636.218,
2978636.220, 636.222, 636.224, 636.226, 636.228, 636.230, 636.232,
2979636.234, 636.236, 636.238, 636.240, 636.242, and 636.244, is
2980created to read:
2981
PART II
2982
DISCOUNT MEDICAL PLAN ORGANIZATIONS
2983     636.202  Definitions.--As used in this part, the term:
2984     (1)  "Discount medical plan" means a business arrangement
2985or contract in which a person, in exchange for fees, dues,
2986charges, or other consideration, provides access for plan
2987members to providers of medical services and the right to
2988receive medical services from those providers at a discount. The
2989term "discount medical plan" does not include any product
2990regulated under chapter 627, chapter 641, or part I of chapter
2991636.
2992     (2)  "Discount medical plan organization" means an entity
2993which, in exchange for fees, dues, charges, or other
2994consideration, provides access for plan members to providers of
2995medical services and the right to receive medical services from
2996those providers at a discount. The term "discount medical plan"
2997does not include any product regulated under chapter 627,
2998chapter 641, or part I of chapter 636.
2999     (3)  "Marketer" means a person or entity which markets,
3000promotes, sells, or distributes a discount medical plan,
3001including a private label entity which places its name on and
3002markets or distributes a discount medical plan but does not
3003operate a discount medical plan.
3004     (4)  "Medical services" means any care, service, or
3005treatment of illness or dysfunction of, or injury to, the human
3006body, including, but not limited to, physician care, inpatient
3007care, hospital surgical services, emergency services, ambulance
3008services, dental care services, vision care services, mental
3009health services, substance abuse services, chiropractic
3010services, podiatric care services, laboratory services, and
3011medical equipment and supplies. The term does not include
3012pharmaceutical supplies or prescriptions.
3013     (5)  "Member" means any person who pays fees, dues,
3014charges, or other consideration for the right to receive the
3015purported benefits of a discount medical plan.
3016     (6)  "Provider" means any person or institution which is
3017contracted, directly or indirectly, with a discount medical plan
3018organization to provide medical services to members.
3019     (7)  "Provider network" means an entity which negotiates on
3020behalf of more than one provider with a discount medical plan
3021organization to provide medical services to members.
3022     636.204  License required.--
3023     (1)  Before doing business in this state as a discount
3024medical plan organization, an entity must be a corporation,
3025incorporated under the laws of this state or, if a foreign
3026corporation, authorized to transact business in this state, and
3027must possess a license as a discount medical plan organization
3028from the office.
3029     (2)  An application for a license to operate as a discount
3030medical plan organization must be filed with the office on a
3031form prescribed by the commission. Such application must be
3032sworn to by an officer or authorized representative of the
3033applicant and be accompanied by the following:
3034     (a)  A copy of the applicant's articles of incorporation,
3035including all amendments.
3036     (b)  A copy of the corporation's bylaws.
3037     (c)  A list of the names, addresses, official positions,
3038and biographical information of the individuals who are
3039responsible for conducting the applicant's affairs, including,
3040but not limited to, all members of the board of directors, board
3041of trustees, executive committee, or other governing board or
3042committee, the officers, contracted management company
3043personnel, and any person or entity owning or having the right
3044to acquire 10 percent or more of the voting securities of the
3045applicant. Such listing must fully disclose the extent and
3046nature of any contracts or arrangements between any individual
3047who is responsible for conducting the applicant's affairs and
3048the discount medical plan organization, including any possible
3049conflicts of interest.
3050     (d)  A complete biographical statement, on forms prescribed
3051by the commission, an independent investigation report, and a
3052set of fingerprints, as provided in chapter 624, with respect to
3053each individual identified under paragraph (c).
3054     (e)  A statement generally describing the applicant, its
3055facilities and personnel, and the medical services to be
3056offered.
3057     (f)  A copy of the form of all contracts made or to be made
3058between the applicant and any providers or provider networks
3059regarding the provision of medical services to members.
3060     (g)  A copy of the form of any contract made or arrangement
3061to be made between the applicant and any person listed in
3062paragraph (c).
3063     (h)  A copy of the form of any contract made or to be made
3064between the applicant and any person, corporation, partnership,
3065or other entity for the performance on the applicant's behalf of
3066any function, including, but not limited to, marketing,
3067administration, enrollment, investment management, and
3068subcontracting for the provision of health services to members.
3069     (i)  A copy of the applicant's most recent financial
3070statements audited by an independent certified public
3071accountant.
3072     (j)  A description of the proposed method of marketing.
3073     (k)  A description of the subscriber complaint procedures
3074to be established and maintained.
3075     (l)  The fee for issuance of a license.
3076     (m)  Such other information as the commission or office may
3077reasonably require to make the determinations required by this
3078part.
3079     (3)  The office shall issue a license which shall expire 1
3080year later, and each year on that date thereafter, and which the
3081office shall renew if the licensee pays the annual license fee
3082of $50 and if the office is satisfied that the licensee is in
3083compliance with this part.
3084     (4)  Prior to licensure by the office, each discount
3085medical plan organization must establish an Internet website so
3086as to conform to the requirements of s. 636.226.
3087     (5)  The license fee under subsection (2) is $50 per year
3088per licensee. All amounts collected shall be deposited into the
3089General Revenue Fund.
3090     (6)  Nothing in this part requires a provider who provides
3091discounts to his or her own patients to obtain and maintain a
3092license as a discount medical plan organization.
3093     636.206  Examinations and investigations.--
3094     (1)  The office may examine or investigate the business and
3095affairs of any discount medical plan organization. The office
3096may order any discount medical plan organization or applicant to
3097produce any records, books, files, advertising and solicitation
3098materials, or other information and may take statements under
3099oath to determine whether the discount medical plan organization
3100or applicant is in violation of the law or is acting contrary to
3101the public interest. The expenses incurred in conducting any
3102examination or investigation must be paid by the discount
3103medical plan organization or applicant. Examinations and
3104investigations must be conducted as provided in chapter 624, and
3105discount medical plan organizations are subject to all
3106applicable provisions of the insurance code.
3107     (2)  Failure by the discount medical plan organization to
3108pay the expenses incurred under subsection (1) is grounds for
3109denial or revocation.
3110     636.208  Fees.--A discount medical plan organization may
3111charge a reasonable one-time processing fee and a periodic
3112charge. If a discount medical plan charges for a time period in
3113excess of one month, the plan must, in the event of cancellation
3114of the membership by either party, make a pro rata reimbursement
3115of the fees to the member.
3116     636.210  Prohibited activities of a discount medical plan
3117organization.--
3118     (1)  A discount medical plan organization may not:
3119     (a)  Use in its advertisements, marketing material,
3120brochures, and discount cards the term "insurance" except as
3121otherwise provided in this part;
3122     (b)  Use in its advertisements, marketing material,
3123brochures, and discount cards the terms "health plan,"
3124"coverage," "copay," "copayments," "preexisting conditions,"
3125"guaranteed issue," "premium," "enrollment," "PPO," "preferred
3126provider organization," or other terms that could reasonably
3127mislead a person into believing the discount medical plan was
3128health insurance;
3129     (c)  Have restrictions on free access to plan providers,
3130including, but not limited to, waiting periods and notification
3131periods; or
3132     (d)  Pay providers any fees for medical services.
3133     (2)  A discount medical plan organization may not collect
3134or accept money from a member for payment to a provider for
3135specific medical services furnished or to be furnished to the
3136member unless the organization has an active certificate of
3137authority from the office to act as an administrator.
3138     636.212  Disclosures.--The following disclosures must be
3139made in writing to any prospective member and must be on the
3140first page of any advertisements, marketing materials, or
3141brochures relating to a discount medical plan. The disclosures
3142must be printed in not less than 12-point type or no smaller
3143than the largest type on the page if larger than 12-point type:
3144     (1)  That the plan is not a health insurance policy.
3145     (2)  That the plan provides discounts at certain health
3146care providers for medical services.
3147     (3)  That the plan does not make payments directly to the
3148providers of medical services.
3149     (4)  That the plan member is obligated to pay for all
3150health care services but will receive a discount from those
3151health care providers who have contracted with the discount plan
3152organization.
3153     (5)  The corporate name and the locations of the licensed
3154discount medical plan organization.
3155     636.214  Provider agreements.--
3156     (1)  All providers offering medical services to members
3157under a discount medical plan must provide such services
3158pursuant to a written agreement. The agreement may be entered
3159into directly by the provider or by a provider network to which
3160the provider belongs.
3161     (2)  A provider agreement must provide the following:
3162     (a)  A list of the services and products to be provided at
3163a discount.
3164     (b)  The amount or amounts of the discounts or,
3165alternatively, a fee schedule which reflects the provider's
3166discounted rates.
3167     (c)  That the provider will not charge members more than
3168the discounted rates.
3169     (3)  A provider agreement between a discount medical plan
3170organization and a provider network shall require that the
3171provider network have written agreements with its providers
3172which:
3173     (a)  Contain the terms described in subsection (2).
3174     (b)  Authorize the provider network to contract with the
3175discount medical plan organization on behalf of the provider.
3176     (c)  Require the network to maintain an up-to-date list of
3177its contracted providers and to provide that list on a monthly
3178basis to the discount medical plan organization.
3179     (4)  The discount medical plan organization shall maintain
3180a copy of each active provider agreement.
3181     636.216  Form filings.--
3182     (1)  All charges to members must be filed with the office
3183and any charge to members greater than $30 per month or $360 per
3184year must be approved by the office before the charges can be
3185used. The discount medical plan organization has the burden of
3186proof that the charges bear a reasonable relation to the
3187benefits received by the member.
3188     (2)  There must be a written agreement between the discount
3189medical plan organization and the member specifying the benefits
3190under the discount medical plan and complying with the
3191disclosure requirements of this part.
3192     (3)  All forms used, including the written agreement
3193pursuant to subsection (2), must first be filed with and
3194approved by the office. Every form filed shall be identified by
3195a unique form number placed in the lower left corner of each
3196form.
3197     (4)  If such filings are disapproved, the office shall
3198notify the discount medical plan organization and shall specify
3199in the notice the reasons for disapproval. The discount medical
3200plan organization has 21 days from the date of receipt of notice
3201to request a hearing before the office pursuant to chapter 120.
3202     636.218  Annual reports.--
3203     (1)  Each discount medical plan organization must file with
3204the office, within 3 months after the end of each fiscal year,
3205an annual report.
3206     (2)  Such reports must be on forms prescribed by the
3207commission and must include:
3208     (a)  Audited financial statements prepared in accordance
3209with generally accepted accounting principles certified by an
3210independent certified public accountant, including the
3211organization's balance sheet, income statement, and statement of
3212changes in cash flow for the preceding year.
3213     (b)  A list of the names and residence addresses of all
3214persons responsible for the conduct of the organization's
3215affairs, together with a disclosure of the extent and nature of
3216any contracts or arrangements between such persons and the
3217discount medical plan organization, including any possible
3218conflicts of interest.
3219     (c)  The number of discount medical plan members.
3220     (d)  Such other information relating to the performance of
3221the discount medical plan organization as is reasonably required
3222by the commission or office.
3223     (3)  Every discount medical plan organization which fails
3224to file an annual report in the form and within the time
3225required by this section shall forfeit up to $500 for each day
3226for the first 10 days during which the neglect continues and
3227shall forfeit up to $1,000 for each day after the first 10 days
3228during which the neglect continues; and, upon notice by the
3229office to that effect, the organization's authority to enroll
3230new members or to do business in this state ceases while such
3231default continues. The office shall deposit all sums collected
3232by the office under this section to the credit of the Insurance
3233Regulatory Trust Fund. The office may not collect more than
3234$50,000 for each report.
3235     636.220  Minimum capital requirements.?-
3236     (1)  Each discount medical plan organization must at all
3237times maintain a net worth of at least $150,000.
3238     (2)  The office may not issue a license unless the discount
3239medical plan organization has a net worth of at least $150,000.
3240     636.222  Suspension or revocation of license; suspension of
3241enrollment of new members; terms of suspension.--
3242     (1)  The office may suspend the authority of a discount
3243medical plan organization to enroll new members, revoke any
3244license issued to a discount medical plan organization, or order
3245compliance if the office finds that any of the following
3246conditions exist:
3247     (a)  The organization is not operating in compliance with
3248this part.
3249     (b)  The organization does not have the minimum net worth
3250as required by this part.
3251     (c)  The organization has advertised, merchandised, or
3252attempted to merchandise its services in such a manner as to
3253misrepresent its services or capacity for service or has engaged
3254in deceptive, misleading, or unfair practices with respect to
3255advertising or merchandising.
3256     (d)  The organization is not fulfilling its obligations as
3257a medical discount medical plan organization.
3258     (e)  The continued operation of the organization would be
3259hazardous to its members.
3260     (2)  If the office has cause to believe that grounds for
3261the suspension or revocation of a license exist, the office
3262shall notify the discount medical plan organization in writing
3263specifically stating the grounds for suspension or revocation
3264and shall pursue a hearing on the matter in accordance with the
3265provisions of chapter 120.
3266     (3)  When the license of a discount medical plan
3267organization is surrendered or revoked, such organization must
3268proceed, immediately following the effective date of the order
3269of revocation, to wind up its affairs transacted under the
3270license. The organization may not engage in any further
3271advertising, solicitation, collecting of fees, or renewal of
3272contracts.
3273     (4)  The office shall, in its order suspending the
3274authority of a discount medical plan organization to enroll new
3275members, specify the period during which the suspension is to be
3276in effect and the conditions, if any, which must be met by the
3277discount medical plan organization prior to reinstatement of its
3278license to enroll new members. The order of suspension is
3279subject to rescission or modification by further order of the
3280office prior to the expiration of the suspension period.
3281Reinstatement may not be made unless requested by the discount
3282medical plan organization; however, the office may not grant
3283reinstatement if it finds that the circumstances for which the
3284suspension occurred still exist or are likely to recur.
3285     636.224  Notice of change of name or address of discount
3286medical plan organization.--Each discount medical plan
3287organization must provide the office at least 30 days' advance
3288notice of any change in the discount medical plan organization's
3289name, address, principal business address, or mailing address.
3290     636.226  Provider name listing.?-Each discount medical plan
3291organization must maintain an up-to-date list of the names and
3292addresses of the providers with which it has contracted, on an
3293Internet website page, the address of which shall be prominently
3294displayed on all its advertisements, marketing materials,
3295brochures, and discount cards. This section applies to those
3296providers with whom the discount medical plan organization has
3297contracted directly, as well as those who are members of a
3298provider network with which the discount medical plan
3299organization has contracted.
3300     636.228  Marketing of discount medical plans.--
3301     (1)  All advertisements, marketing materials, brochures,
3302and discount cards used by marketers must be approved in writing
3303for such use by the discount medical plan organization.
3304     (2)  The discount medical plan organization shall have an
3305executed written agreement with a marketer prior to the
3306marketer's marketing, promoting, selling, or distributing the
3307discount medical plan and shall be responsible and financially
3308liable for any acts of its marketers that do not comply with the
3309provisions of this part.
3310     636.230  Bundling discount medical plans with other
3311insurance products.?-When a marketer or discount medical plan
3312organization sells a discount medical plan together with any
3313other product, the fees for each individual product must be
3314provided in writing to the member and itemized.
3315     636.232  Rules.--The commission may adopt rules to
3316administer this part, including rules for the licensing of
3317discount medical plan organizations; establishing standards for
3318evaluating forms, advertisements, marketing materials,
3319brochures, and discount cards; providing for the collection of
3320data; relating to disclosures to plan members; and defining
3321terms used in this part.
3322     636.234  Service of process on a discount medical plan
3323organization.-?Sections 624.422 and 624.423 apply to a discount
3324medical plan organization as if the discount medical plan
3325organization were an insurer.
3326     636.236  Security deposit.--
3327     (1)  A licensed discount medical plan organization must
3328deposit and maintain deposited in trust with the department
3329securities eligible for deposit under s. 625.52, having at all
3330times a value of not less than $35,000, for use by the office in
3331protecting plan members.
3332     (2)  No judgment creditor or other claimant of a discount
3333medical plan organization, other than the office or department,
3334shall have the right to levy upon any of the assets or
3335securities held in this state as a deposit under subsection (1).
3336     636.238  Penalties for violation of this part.--
3337     (1)  Except as provided in subsection (2), a person who
3338violates any provision of this part commits a misdemeanor of the
3339second degree, punishable as provided in s. 775.082 or s.
3340775.083.
3341     (2)  A person who operates as or aids and abets another
3342operating as a discount medical plan organization in violation
3343of s. 636.204(1) commits a felony punishable as provided for in
3344s. 624.401(4)(b), as if the unlicensed discount medical plan
3345organization were an unauthorized insurer, and the fees, dues,
3346charges, or other consideration collected from the members by
3347the unlicensed discount medical plan organization or marketer
3348were insurance premium.
3349     (3)  A person who collects fees for purported membership in
3350a discount medical plan but fails to provide the promised
3351benefits commits a theft, punishable as provided in s. 812.014.
3352     636.240  Injunctions.--
3353     (1)  In addition to the penalties and other enforcement
3354provisions of this part, the office may seek both temporary and
3355permanent injunctive relief when:
3356     (a)  A discount medical plan is being operated by any
3357person or entity that is not licensed pursuant to this part.
3358     (b)  Any person, entity, or discount medical plan
3359organization has engaged in any activity prohibited by this part
3360or any rule adopted pursuant to this part.
3361     (2)  The venue for any proceeding bought pursuant to this
3362section shall be in the Circuit Court of Leon County.
3363     (3)  The office's authority to seek injunctive relief is
3364not conditioned on having conducted any proceeding pursuant to
3365chapter 120.
3366     636.242  Civil remedies.--Any person damaged by the acts of
3367a person in violation of this part may bring a civil action
3368against the person committing the violation in the circuit court
3369of the county in which the alleged violator resides or has a
3370principal place of business or in the county in which the
3371alleged violation occurred. Upon an adverse adjudication, the
3372defendant is liable for damages, together with court costs and
3373reasonable attorney's fees incurred by the plaintiff. When so
3374awarded, court costs and attorney's fees must be included in the
3375judgment or decree rendered in the case. If it appears to the
3376court that the suit brought by the plaintiff is frivolous or
3377brought for purposes of harassment, the court may apply
3378sanctions in accordance with chapter 57.
3379     636.244  Unlicensed discount medical plan
3380organizations.--The provisions of ss. 626.901-626.912 apply to
3381The provisions of ss. 626.901-626.912 apply to the activities of
3382an unlicensed discount medical plan organization as if the
3383unlicensed discount medical plan organization were an
3384unauthorized insurer.
3385     Section 32.  Section 627.65626, Florida Statutes, is
3386created to read:
3387     627.65626  Insurance rebates for healthy lifestyles.--
3388     (1)  Any rate, rating schedule, or rating manual for a
3389health insurance policy filed with the office shall provide for
3390an appropriate rebate of premiums paid in the last calendar year
3391when the majority of members of a health plan have enrolled and
3392maintained participation in any health wellness, maintenance, or
3393improvement program offered by the employer. The employer must
3394provide evidence of demonstrative maintenance or improvement of
3395the enrollees' health status as determined by assessments of
3396agreed-upon health status indicators between the employer and
3397the health insurer, including, but not limited to, reduction in
3398weight, body mass index, and smoking cessation. Any rebate
3399provided by the health insurer is presumed to be appropriate
3400unless credible data demonstrates otherwise, but shall not
3401exceed 10 percent of paid premiums.
3402     (2)  The premium rebate authorized by this section shall be
3403effective for an insured on an annual basis, unless the number
3404of participating employees becomes less than the majority of the
3405employees eligible for participation in the wellness program.
3406     Section 33.  Section 627.6402, Florida Statutes, is created
3407to read:
3408     627.6402  Insurance rebates for healthy lifestyles.--
3409     (1)  Any rate, rating schedule, or rating manual for an
3410individual health insurance policy filed with the office shall
3411provide for an appropriate rebate of premiums paid in the last
3412calendar year when the individual covered by such plan is
3413enrolled in and maintains participation in any health wellness,
3414maintenance, or improvement program approved by the health plan.
3415The individual must provide evidence of demonstrative
3416maintenance or improvement of the individual's health status as
3417determined by assessments of agreed-upon health status
3418indicators between the individual and the health insurer,
3419including, but not limited to, reduction in weight, body mass
3420index, and smoking cessation. Any rebate provided by the health
3421insurer is presumed to be appropriate unless credible data
3422demonstrates otherwise, but shall not exceed 10 percent of paid
3423premiums.
3424     (2)  The premium rebate authorized by this section shall be
3425effective for an insured on an annual basis, unless the
3426individual fails to maintain or improve his or her health status
3427while participating in an approved wellness program, or credible
3428evidence demonstrates that the individual is not participating
3429in the approved wellness program.
3430     Section 34.  Subsection (38) of section 641.31, Florida
3431Statutes, is amended, and subsection (40) is added to said
3432section, to read:
3433     641.31  Health maintenance contracts.--
3434     (38)(a)  Notwithstanding any other provision of this part,
3435a health maintenance organization that meets the requirements of
3436paragraph (b) may, through a point-of-service rider to its
3437contract providing comprehensive health care services, include a
3438point-of-service benefit. Under such a rider, a subscriber or
3439other covered person of the health maintenance organization may
3440choose, at the time of covered service, a provider with whom the
3441health maintenance organization does not have a health
3442maintenance organization provider contract. The rider may not
3443require a referral from the health maintenance organization for
3444the point-of-service benefits.
3445     (b)  A health maintenance organization offering a point-of-
3446service rider under this subsection must have a valid
3447certificate of authority issued under the provisions of the
3448chapter, must have been licensed under this chapter for a
3449minimum of 3 years, and must at all times that it has riders in
3450effect maintain a minimum surplus of $5 million. A health
3451maintenance organization offering a point-of-service rider to
3452its contract providing comprehensive health care services may
3453offer the rider to employers who have employees living and
3454working outside the health maintenance organization's approved
3455geographic service area without having to obtain a health care
3456provider certificate, as long as the master group contract is
3457issued to an employer that maintains its primary place of
3458business within the health maintenance organization's approved
3459service area. Any member or subscriber that lives and works
3460outside the health maintenance organization's service area and
3461elects coverage under the health maintenance organization's
3462point-of-service rider must provide a statement to the health
3463maintenance organization that indicates the member or subscriber
3464understands the limitations of his or her policy and that only
3465those benefits under the point-of-service rider will be covered
3466when services are provided outside the service area.
3467     (c)  Premiums paid in for the point-of-service riders may
3468not exceed 15 percent of total premiums for all health plan
3469products sold by the health maintenance organization offering
3470the rider. If the premiums paid for point-of-service riders
3471exceed 15 percent, the health maintenance organization must
3472notify the office and, once this fact is known, must immediately
3473cease offering such a rider until it is in compliance with the
3474rider premium cap.
3475     (d)  Notwithstanding the limitations of deductibles and
3476copayment provisions in this part, a point-of-service rider may
3477require the subscriber to pay a reasonable copayment for each
3478visit for services provided by a noncontracted provider chosen
3479at the time of the service. The copayment by the subscriber may
3480either be a specific dollar amount or a percentage of the
3481reimbursable provider charges covered by the contract and must
3482be paid by the subscriber to the noncontracted provider upon
3483receipt of covered services. The point-of-service rider may
3484require that a reasonable annual deductible for the expenses
3485associated with the point-of-service rider be met and may
3486include a lifetime maximum benefit amount. The rider must
3487include the language required by s. 627.6044 and must comply
3488with copayment limits described in s. 627.6471. Section 641.3154
3489does not apply to a point-of-service rider authorized under this
3490subsection.
3491     (e)  The point-of-service rider must contain provisions
3492that comply with s. 627.6044.
3493     (f)(e)  The term "point of service" may not be used by a
3494health maintenance organization except with riders permitted
3495under this section or with forms approved by the office in which
3496a point-of-service product is offered with an indemnity carrier.
3497     (g)(f)  A point-of-service rider must be filed and approved
3498under ss. 627.410 and 627.411.
3499     (40)(a)  Any rate, rating schedule, or rating manual for a
3500health maintenance organization policy filed with the office
3501shall provide for an appropriate rebate of premiums paid in the
3502last calendar year when the individual covered by such plan is
3503enrolled in and maintains participation in any health wellness,
3504maintenance, or improvement program approved by the health plan.
3505The individual must provide evidence of demonstrative
3506maintenance or improvement of his or her health status as
3507determined by assessments of agreed-upon health status
3508indicators between the individual and the health insurer,
3509including, but not limited to, reduction in weight, body mass
3510index, and smoking cessation. Any rebate provided by the health
3511insurer is presumed to be appropriate unless credible data
3512demonstrates otherwise, but shall not exceed 10 percent of paid
3513premiums.
3514     (b)  The premium rebate authorized by this section shall be
3515effective for an insured on an annual basis, unless the
3516individual fails to maintain or improve his or her health status
3517while participating in an approved wellness program, or credible
3518evidence demonstrates that the individual is not participating
3519in the approved wellness program.
3520     Section 35.  Section 626.191, Florida Statutes, is amended
3521to read:
3522     626.191  Repeated applications.--The failure of an
3523applicant to secure a license upon an application shall not
3524preclude the applicant him or her from applying again as many
3525times as desired, but the department or office shall not give
3526consideration to or accept any further application by the same
3527individual for a similar license dated or filed within 30 days
3528subsequent to the date the department or office denied the last
3529application, except as provided in s. 626.281.
3530     Section 36.  Subsection (1) of section 626.201, Florida
3531Statutes, is amended to read:
3532     626.201  Investigation.--
3533     (1)  The department or office may propound any reasonable
3534interrogatories in addition to those contained in the
3535application, to any applicant for license or appointment, or on
3536any renewal, reinstatement, or continuation thereof, relating to
3537the applicant's his or her qualifications, residence,
3538prospective place of business, and any other matter which, in
3539the opinion of the department or office, is deemed necessary or
3540advisable for the protection of the public and to ascertain the
3541applicant's qualifications.
3542     Section 37.  Section 626.593, Florida Statutes, is created
3543to read:
3544     626.593  Insurance agent; written contract for
3545compensation.--
3546     (1)  No person licensed as an insurance agent may receive
3547any fee or commission or any other thing of value in addition to
3548the rates filed pursuant to chapter 627 for examining any group
3549health insurance or any group health benefit plan for the
3550purpose of giving or offering advice, counsel, recommendation,
3551or information in respect to terms, conditions, benefits,
3552coverage, or premium of any such policy or contract unless such
3553compensation is based upon a written contract signed by the
3554party to be charged and specifying or clearly defining the
3555amount or extent of such compensation and informing the party to
3556be charged that any commission received from an insurer will be
3557rebated to the party in accordance with subsection (3). In
3558addition, all compensation to be paid to the insurance agent
3559must be disclosed in the contract.
3560     (2)  A copy of every such contract shall be retained by the
3561licensee for not less than 3 years after such services have been
3562fully performed.
3563     (3)  Notwithstanding the provisions of s. 626.572, all
3564commissions received by an insurance agent from an insurer in
3565connection with the issuance of a policy, when a separate fee or
3566other consideration has been paid to the insurance agent by an
3567insured, shall be rebated to the insured or other party being
3568charged within 30 days after receipt of such commission by the
3569insurance agent.
3570     (4)  This section is subject to the unfair insurance trade
3571practices provisions of s. 626.9541(1)(g).
3572     Section 38.  Notwithstanding the amendment to s.
3573627.6699(5)(c), Florida Statutes, by this act, any right to an
3574open enrollment offer of health benefit coverage for groups of
3575fewer than two employees, pursuant to s. 627.6699(5)(c), Florida
3576Statutes, as it existed immediately before the effective date of
3577this act, shall remain in full force and effect until the
3578enactment of s. 627.64872, Florida Statutes, and the subsequent
3579date upon which such plan begins to accept new risks or members.
3580     Section 39.  Section 465.0244, Florida Statutes, is created
3581to read:
3582     465.0244  Information disclosure.--Every pharmacy shall
3583make available on its Internet website a link to the performance
3584outcome and financial data that is published by the Agency for
3585Health Care Administration pursuant to s. 408.05(3)(l) and shall
3586place in the area where customers receive filled prescriptions
3587notice that such information is available electronically and the
3588address of its Internet website.
3589     Section 40.  Section 627.6499, Florida Statutes, is amended
3590to read:
3591     627.6499  Reporting by insurers and third-party
3592administrators.--
3593     (1)  The office may require any insurer, third-party
3594administrator, or service company to report any information
3595reasonably required to assist the board in assessing insurers as
3596required by this act.
3597     (2)  Each health insurance issuer shall make available on
3598its Internet website a link to the performance outcome and
3599financial data that is published by the Agency for Health Care
3600Administration pursuant to s. 408.05(3)(l) and shall include in
3601every policy delivered or issued for delivery to any person in
3602the state or any materials provided as required by s. 627.64725
3603notice that such information is available electronically and the
3604address of its Internet website.
3605     Section 41.  Subsections (6) and (7) are added to section
3606641.54, Florida Statutes, to read:
3607     641.54  Information disclosure.--
3608     (6)  Each health maintenance organization shall make
3609available to its subscribers the estimated copay, coinsurance
3610percentage, or deductible, whichever is applicable, for any
3611covered services, the status of the subscriber's maximum annual
3612out-of-pocket payments for a covered individual or family, and
3613the status of the subscriber's maximum lifetime benefit. Such
3614estimate shall not preclude the actual copay, coinsurance
3615percentage, or deductible, whichever is applicable, from
3616exceeding the estimate.
3617     (7)  Each health maintenance organization shall make
3618available on its Internet website a link to the performance
3619outcome and financial data that is published by the Agency for
3620Health Care Administration pursuant to s. 408.05(3)(l) and shall
3621include in every policy delivered or issued for delivery to any
3622person in the state or any materials provided as required by s.
3623627.64725 notice that such information is available
3624electronically and the address of its Internet website.
3625     Section 42.  Section 408.02, Florida Statutes, is repealed.
3626     Section 43.  The sum of $250,000 is appropriated from the
3627Insurance Regulatory Trust Fund in the Department of Financial
3628Services to the Office of Insurance Regulation for the purpose
3629of implementing the provisions in this act relating to the Small
3630Employers Access Program.
3631     Section 44.  The sum of $250,000 is appropriated from the
3632Insurance Regulatory Trust Fund to enable the board of the
3633Florida Health Insurance Plan to conduct an actuarial study
3634required under s. 627.64872, Florida Statutes.
3635     Section 45.  The sum of $169,069 is appropriated from the
3636Insurance Regulatory Trust Fund in the Department of Financial
3637Services to the Office of Insurance Regulation, and three full-
3638time equivalent positions are authorized, for the purpose of
3639implementing the provisions in this act relating to the
3640regulation of Discount Medical Plan Organizations.
3641     Section 46.  The sum of $650,000 is appropriated from the
3642General Revenue Fund to the Agency for Health Care
3643Administration for the purposes of implementing the Florida
3644Patient Safety Corporation. The sum of $350,000 shall be used as
3645startup funds for the Florida Patient Safety Corporation and
3646$300,000 shall be used for the "near miss" project within the
3647Florida Patient Safety Corporation.
3648     Section 47.  The sum of $1,136,171 is appropriated from the
3649General Revenue Fund to the Agency for Health Care
3650Administration, and 11 full-time equivalent positions are
3651authorized, for the purposes of implementing the provisions of
3652this act relating to the reporting of performance and cost data
3653for hospitals, physicians, and pharmacies.
3654     Section 48.  Except as otherwise provided herein, this act
3655shall take effect July 1, 2004.


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