December 07, 2019
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Senate Bill 2910

Senate Bill sb2910c3

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    Florida Senate - 2004             CS for CS for CS for SB 2910

    By the Committees on Appropriations; Banking and Insurance;
    Health, Aging, and Long-Term Care; and Senator Peaden




    309-2683-04

  1                      A bill to be entitled

  2         An act relating to affordable health care;

  3         providing a popular name; providing purpose;

  4         amending s. 381.026, F.S.; requiring certain

  5         licensed facilities to provide public Internet

  6         access to certain financial information;

  7         amending s. 381.734, F.S.; including

  8         participation by health care providers, small

  9         businesses, and health insurers in the Healthy

10         Communities, Healthy People Program; requiring

11         the Department of Health to provide public

12         Internet access to certain public health

13         programs; requiring the department to monitor

14         and assess the effectiveness of such programs;

15         requiring a report; requiring the Office of

16         Program Policy and Government Accountability to

17         evaluate the effectiveness of such programs;

18         requiring a report; amending s. 395.003, F.S.;

19         prohibiting the Agency for Health Care

20         Administration from issuing licenses for

21         certain emergency departments located off the

22         primary premises of a hospital before July 1,

23         2005; requiring a study and report to the

24         Legislature; amending s. 395.1041, F.S.;

25         authorizing hospitals to develop certain

26         emergency room diversion programs; amending s.

27         395.301, F.S.; requiring certain licensed

28         facilities to provide prospective patients

29         certain estimates of charges for services;

30         requiring such facilities to provide patients

31         with certain bill verification information;

                                  1

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 1         providing for a fine for failure to provide

 2         such information; providing charge limitations;

 3         requiring such facilities to establish a

 4         patient question review and response

 5         methodology; providing requirements; requiring

 6         certain licensed facilities to provide public

 7         Internet access to certain financial

 8         information; providing an exception for

 9         specified rural hospitals; amending s. 408.061,

10         F.S.; requiring the Agency for Health Care

11         Administration to require health care

12         facilities, health care providers, and health

13         insurers to submit certain information;

14         providing requirements; requiring the agency to

15         adopt certain risk and severity adjustment

16         methodologies; requiring the agency to adopt

17         certain rules; requiring certain information to

18         be certified; amending s. 408.062, F.S.;

19         requiring the agency to conduct certain health

20         care costs and access research, analyses, and

21         studies; expanding the scope of such studies to

22         include collection of pharmacy retail price

23         data, use of emergency departments, physician

24         information, and Internet patient charge

25         information availability; requiring publication

26         of information collected on the Internet;

27         requiring a report; requiring the agency to

28         conduct additional data-based studies and make

29         recommendations to the Legislature; requiring

30         the agency to develop and implement a strategy

31         to adopt and use electronic health records;

                                  2

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 1         authorizing the agency to develop rules to

 2         protect electronic records confidentiality;

 3         requiring a report to the Governor and

 4         Legislature; amending s. 408.05, F.S.;

 5         requiring the agency to develop a plan to make

 6         performance outcome and financial data

 7         available to consumers for health care services

 8         comparison purposes; requiring submittal of the

 9         plan to the Governor and Legislature; requiring

10         the agency to update the plan; requiring the

11         agency to make the plan available

12         electronically; providing plan requirements;

13         amending s. 409.9066, F.S.; requiring the

14         agency to provide certain information relating

15         to the Medicare prescription discount program;

16         creating s. 465.0244, F.S.; requiring each

17         pharmacy to make available on its Internet

18         website a link to certain performance outcome

19         and financial data of the Agency for Health

20         Care Administration and a notice of the

21         availability of such information; amending s.

22         627.6499, F.S.; requiring each health insurer

23         to make available on its Internet website a

24         link to certain performance outcome and

25         financial data of the Agency for Health Care

26         Administration and a notice in policies of the

27         availability of such information; amending s.

28         641.54, F.S.; requiring health maintenance

29         organizations to make certain insurance

30         financial information available to subscribers;

31         requiring health maintenance organizations to

                                  3

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 1         make available on its Internet website a link

 2         to certain performance outcome and financial

 3         data of the Agency for Health Care

 4         Administration and a notice in policies of the

 5         availability of such information; amending s.

 6         408.7056, F.S.; renaming the Statewide Provider

 7         and Subscriber Assistance Program as the

 8         Subscriber Assistance Program; revising

 9         provisions to conform; expanding certain

10         records availability provisions; revising

11         membership provisions relating to a subscriber

12         grievance hearing panel; providing hearing

13         procedures; amending s. 641.3154, F.S., to

14         conform to the renaming of the Subscriber

15         Assistance Program; amending s. 641.511, F.S.,

16         to conform to the renaming of the Subscriber

17         Assistance Program; adopting and incorporating

18         by reference the Employee Retirement Income

19         Security Act of 1974, as implemented by federal

20         regulations; amending s. 641.58, F.S., to

21         conform to the renaming of the Subscriber

22         Assistance Program; amending s. 408.909, F.S.;

23         expanding a definition of "health flex plan

24         entity" to include public-private partnerships;

25         making a pilot health flex plan program apply

26         permanently statewide; providing additional

27         program requirements; creating s. 381.0271,

28         F.S.; providing definitions; creating the

29         Florida Patient Safety Corporation, which shall

30         be registered, incorporated, organized, and

31         operated in compliance with ch. 617, F.S.;

                                  4

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 1         authorizing the corporation to create

 2         not-for-profit subsidiaries; specifying that

 3         the corporation is not an agency within the

 4         meaning of s. 20.03(11), F.S.; requiring the

 5         corporation to be subject to public meetings

 6         and records requirements; specifying that the

 7         corporation is not subject to the provisions of

 8         ch. 297, F.S., relating to procurement of

 9         personal property and services; providing a

10         purpose for the corporation; establishing the

11         membership of the board of directors of the

12         corporation; requiring the formation of certain

13         advisory committees for the corporation;

14         requiring the Agency for Health Care

15         Administration to provide assistance in

16         establishing the corporation; specifying the

17         powers and duties of the corporation; requiring

18         annual reports; requiring the Office of Program

19         Policy Analysis and Government Accountability,

20         in consultation with the Agency for Health Care

21         Administration and the Department of Health, to

22         develop performance measures for the

23         corporation; requiring a performance audit;

24         requiring a report to the Governor and the

25         Legislature; requiring the Patient Safety

26         Center at the Florida State University College

27         of Medicine to study the return on investment

28         by hospitals from implementing computerized

29         physician order entry and other information

30         technologies related to patient safety;

31         providing requirements for the study; requiring

                                  5

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 1         a report to the Governor and the Legislature;

 2         amending s. 395.1012, F.S.; providing

 3         additional duties of the patient safety

 4         committee at hospitals and other licensed

 5         facilities; requiring such facilities to adopt

 6         a plan to reduce medication errors and adverse

 7         drug events, including the use of computerized

 8         physician order entry and other information

 9         technologies; amending s. 409.91255, F.S.;

10         expanding assistance to certain health centers

11         to include community emergency room diversion

12         programs and urgent care services; amending s.

13         627.410, F.S.; requiring insurers to file

14         certain rates with the Office of Insurance

15         Regulation; creating s. 627.6405, F.S.; making

16         legislative findings related to inappropriate

17         utilization of emergency room care; requiring

18         health insurers to take certain actions and

19         authorizing higher copayments for certain uses

20         of emergency departments; creating s.

21         627.64872, F.S.; providing legislative intent;

22         creating the Florida Health Insurance Plan for

23         certain purposes; providing definitions;

24         providing requirements for operation of the

25         plan; providing for a board of directors;

26         providing for appointment of members; providing

27         for terms; specifying service without

28         compensation; providing for travel and per diem

29         expenses; requiring a plan of operation;

30         providing requirements; providing for powers of

31         the plan; requiring reports to the Governor and

                                  6

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 1         Legislature; providing certain immunity from

 2         liability for plan obligations; authorizing the

 3         board to provide for indemnification of certain

 4         costs; requiring an annually audited financial

 5         statement; providing for eligibility for

 6         coverage under the plan; providing criteria;

 7         requirements, and limitations; specifying

 8         certain activity as an unfair trade practice;

 9         providing for a plan administrator; providing

10         criteria; providing requirements; providing

11         term limits for the plan administrator;

12         providing duties; providing for paying the

13         administrator; providing for funding mechanisms

14         of the plan; providing for premium rates for

15         plan coverage; providing rate limitations;

16         specifying benefits under the plan; providing

17         criteria, requirements, and limitations;

18         providing for nonduplication of benefits;

19         providing for annual and maximum lifetime

20         benefits; providing for tax exempt status;

21         providing for abolition of the Florida

22         Comprehensive Health Association upon

23         implementation of the plan; providing for

24         enrollment in the plan of persons enrolled in

25         the association; requiring insurers to pay

26         certain assessments to the board for certain

27         purposes; providing criteria, requirements, and

28         limitations for such assessments; repealing ss.

29         627.6488, 627.6489, 627.649, 627.6492,

30         627.6494, 627.6496, and 627.6498, F.S.,

31         relating to the Florida Comprehensive Health

                                  7

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 1         Association, upon implementation of the plan;

 2         amending s. 627.662, F.S.; providing for

 3         application of certain claim payment

 4         methodologies and actions related to

 5         inappropriate use of emergency care to certain

 6         types of insurance; amending s. 627.6699, F.S.;

 7         revising provisions requiring small employer

 8         carriers to offer certain health benefit plans;

 9         preserving a right to open enrollment for

10         certain small groups; requiring small employer

11         carriers to file and provide coverage under

12         certain high deductible plans; including high

13         deductible plans under certain required plan

14         provisions; providing a delayed effective date

15         for certain filing requirements; creating the

16         Small Employers Access Program; providing

17         legislative intent; providing definitions;

18         providing participation eligibility

19         requirements and criteria; requiring the Office

20         of Insurance Regulation to administer the

21         program by selecting an insurer through

22         competitive bidding; providing requirements;

23         specifying insurer qualifications; providing

24         duties of the insurer; providing a contract

25         term; providing insurer reporting requirements;

26         providing application requirements; providing

27         for benefits under the program; requiring the

28         office to annually report to the Governor and

29         Legislature; providing for decreases in

30         inappropriate use of emergency care; providing

31         legislative intent; requiring health insurers

                                  8

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 1         to provide certain information electronically

 2         and develop community emergency department

 3         diversion programs; amending s. 627.9175, F.S.;

 4         requiring certain health insurers to annually

 5         report certain coverage information to the

 6         office; providing requirements; deleting

 7         certain reporting requirements; creating part I

 8         of ch. 636, F.S., relating to prepaid limited

 9         health services organization; amending s.

10         636.002, F.S.; providing a short title;

11         amending s. 636.003, F.S.; revising the

12         definition of the term "prepaid limited health

13         services organization"; creating part II of ch.

14         636, F.S., relating to discount medical plan

15         organization; providing a short title;

16         providing definitions; requiring that a person

17         be licensed before conducting business in this

18         state as a discount medical plan organizations;

19         providing for an application to receive a

20         license; providing for the contents of the

21         application; requiring each discount medical

22         plan organization to create an Internet

23         website; authorizing the Office of Insurance

24         Regulation to investigate or examine a discount

25         medical plan organization under certain

26         conditions; specifying the permitted and

27         prohibited activities of a discount medical

28         plan organization; directing each discount

29         medical plan organization to disclose certain

30         specified information to members and

31         prospective members; providing for contracts

                                  9

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 1         and agreements with providers and networks of

 2         providers; detailing the required contents of

 3         the contract or agreement; requiring each

 4         discount medical plan organization to file its

 5         proposed rates with the office; directing each

 6         discount medical plan organization to file an

 7         annual report with the office; specifying the

 8         contents of the report; providing for fines

 9         when a discount medical plan organization is

10         delinquent in filing the annual report;

11         requiring minimum capitalization; providing the

12         circumstances and procedures when the office

13         proposes to suspend or revoke the license of a

14         discount medical plan organization; directing

15         each discount medical plan organization to

16         maintain an up-to-date list of the names and

17         addresses of the providers with whom it has a

18         contract to deliver medical services; directing

19         that the list be posted on the organization's

20         website; providing for marketing plans;

21         authorizing the office to adopt rules;

22         providing for service of process; providing for

23         a security deposit by each discount medical

24         plan organization; providing criminal penalties

25         for violations of the act; authorizing the

26         office to seek temporary and permanent

27         injunctive relief against a discount medical

28         plan organization under certain conditions;

29         providing civil remedies for any person injured

30         by another acting in violation of the act;

31         providing venue for a civil action; creating

                                  10

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 1         ss. 627.65626 and 627.6402, F.S.; providing for

 2         insurance rebates for healthy lifestyles;

 3         providing for rebate of certain premiums for

 4         participation in health wellness, maintenance,

 5         or improvement programs under certain

 6         circumstances; providing requirements; amending

 7         s. 641.31, F.S.; authorizing health maintenance

 8         organizations offering certain point-of-service

 9         riders to offer such riders to certain

10         employers for certain employees; providing

11         requirements and limitations; providing for

12         application of certain claim payment

13         methodologies to certain types of insurance;

14         providing for rebate of certain premiums for

15         participation in health wellness, maintenance,

16         or improvement programs under certain

17         circumstances; providing requirements;

18         preserving certain rights to enrollment in

19         certain health benefit coverage for certain

20         groups under certain circumstances; repealing

21         s. 408.02, F.S., relating to the development,

22         endorsement, implementation, and evaluation of

23         patient management practice parameters by the

24         Agency for Health Care Administration; amending

25         s. 766.309, F.S.; granting the administrative

26         law judge exclusive jurisdiction to make

27         factual determinations regarding certain notice

28         requirements in medical negligence proceedings;

29         authorizing the Agency for Health Care

30         Administration to adopt rules; providing

31         legislative intent; requiring the Auditor

                                  11

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 1         General to conduct a study of nursing home

 2         finances; specifying the issues to be studied;

 3         directing the Auditor General to report its

 4         findings to the Governor, the President of the

 5         Senate, and the Speaker of the House of

 6         Representatives by a specified date; requiring

 7         the Agency for Health Care Administration to

 8         conduct a survey of all nursing home operators;

 9         detailing the contents of the data survey;

10         directing the agency to report its findings to

11         the Governor, the President of the Senate, and

12         the Speaker of the House of Representatives by

13         a specified date; providing appropriations;

14         providing effective dates.

15  

16         WHEREAS, according to the Kaiser Family Foundation,

17  eight out of ten uninsured Americans are workers or dependents

18  of workers and nearly eight out of ten uninsured Americans

19  have family incomes above the poverty level, and

20         WHEREAS, fifty-five percent of those who do not have

21  insurance state that the reason they do not have insurance is

22  lack of affordability, and

23         WHEREAS, average health insurance premium increases for

24  the last 2 years have been in the range of 10 to 20 percent

25  for Florida's employers, and

26         WHEREAS, an increasing number of employers are opting

27  to cease providing insurance coverage to their employees due

28  to the high cost, and

29         WHEREAS, an increasing number of employers who continue

30  providing coverage are forced to shift more premium cost to

31  

                                  12

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 1  their employees, thus diminishing the value of employee wage

 2  increases, and

 3         WHEREAS, according to studies, the rate of avoidable

 4  hospitalization is 50 to 70 percent lower for the insured

 5  versus the uninsured, and

 6         WHEREAS, according to Florida Cancer Registry data, the

 7  uninsured have a 70 percent greater chance of a late

 8  diagnosis, thus decreasing the chances of a positive health

 9  outcome, and

10         WHEREAS, according to the Agency for Health Care

11  Administration's 2002 financial data, uncompensated care in

12  Florida's hospitals is growing at the rate of 12 to 13 percent

13  per year, and, at $4.3 billion in 2001, this cost, when

14  shifted to Floridians who remain insured, is not sustainable,

15  and

16         WHEREAS, the Florida Legislature, through the creation

17  of Health Flex, has already identified the need for lower cost

18  alternatives, and

19         WHEREAS, it is of vital importance and in the best

20  interests of the people of this state that the issue of

21  available, affordable health care insurance be addressed in a

22  cohesive and meaningful manner, and

23         WHEREAS, there is general recognition that the issues

24  surrounding the problem of access to affordable health

25  insurance are complicated and multifaceted, NOW, THEREFORE,

26  

27  Be It Enacted by the Legislature of the State of Florida:

28  

29         Section 1.  This act may be referred to by the popular

30  name "The 2004 Affordable Health Care for Floridians Act."

31  

                                  13

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 1         Section 2.  The purpose of this act is to address the

 2  underlying cause of the double-digit increases in health

 3  insurance premiums by mitigating the overall growth in health

 4  care costs.

 5         Section 3.  Paragraph (c) of subsection (4) of section

 6  381.026, Florida Statutes, is amended to read:

 7         381.026  Florida Patient's Bill of Rights and

 8  Responsibilities.--

 9         (4)  RIGHTS OF PATIENTS.--Each health care facility or

10  provider shall observe the following standards:

11         (c)  Financial information and disclosure.--

12         1.  A patient has the right to be given, upon request,

13  by the responsible provider, his or her designee, or a

14  representative of the health care facility full information

15  and necessary counseling on the availability of known

16  financial resources for the patient's health care.

17         2.  A health care provider or a health care facility

18  shall, upon request, disclose to each patient who is eligible

19  for Medicare, in advance of treatment, whether the health care

20  provider or the health care facility in which the patient is

21  receiving medical services accepts assignment under Medicare

22  reimbursement as payment in full for medical services and

23  treatment rendered in the health care provider's office or

24  health care facility.

25         3.  A health care provider or a health care facility

26  shall, upon request, furnish a patient, prior to provision of

27  medical services, a reasonable estimate of charges for such

28  services.  Such reasonable estimate shall not preclude the

29  health care provider or health care facility from exceeding

30  the estimate or making additional charges based on changes in

31  the patient's condition or treatment needs.

                                  14

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 1         4.  Each licensed facility not operated by the state

 2  shall make available to the public on its Internet website or

 3  by other electronic means a description of and a link to the

 4  performance outcome and financial data that is published by

 5  the agency pursuant to s. 408.05(3)(l). The facility shall

 6  place a notice in the reception areas that such information is

 7  available electronically and the website address. The licensed

 8  facility may indicate that the pricing information is based on

 9  a compilation of charges for the average patient and that each

10  patient's bill may vary from the average depending upon the

11  severity of illness and individual resources consumed. The

12  licensed facility may also indicate that the price of service

13  is negotiable for eligible patients based upon the patient's

14  ability to pay.

15         5.4.  A patient has the right to receive a copy of an

16  itemized bill upon request.  A patient has a right to be given

17  an explanation of charges upon request.

18         Section 4.  Subsection (1) and paragraph (g) of

19  subsection (3) of section 381.734, Florida Statutes, are

20  amended, and subsections (4), (5), and (6) are added to that

21  section, to read:

22         381.734  Healthy Communities, Healthy People Program.--

23         (1)  The department shall develop and implement the

24  Healthy Communities, Healthy People Program, a comprehensive

25  and community-based health promotion and wellness program. The

26  program shall be designed to reduce major behavioral risk

27  factors associated with chronic diseases, including those

28  chronic diseases identified in chapter 385, by enhancing the

29  knowledge, skills, motivation, and opportunities for

30  individuals, organizations, health care providers, small

31  

                                  15

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 1  businesses, health insurers, and communities to develop and

 2  maintain healthy lifestyles.

 3         (3)  The program shall include:

 4         (g)  The establishment of a comprehensive program to

 5  inform the public, health care professionals, health insurers,

 6  and communities about the prevalence of chronic diseases in

 7  the state; known and potential risks, including social and

 8  behavioral risks; and behavior changes that would reduce

 9  risks.

10         (4)  The department shall make available on its

11  Internet website, no later than October 1, 2004, and in a

12  hard-copy format upon request, a listing of age-specific,

13  disease-specific, and community-specific health promotion,

14  preventive care, and wellness programs offered and established

15  under the Healthy Communities, Healthy People Program. The

16  website shall also provide residents with information to

17  identify behavior risk factors that lead to diseases that are

18  preventable by maintaining a healthy lifestyle. The website

19  shall allow consumers to select by county or region

20  disease-specific statistical information.

21         (5)  The department shall monitor and assess the

22  effectiveness of such programs. The department shall submit a

23  status report based on this monitoring and assessment to the

24  Governor, the President of the Senate, the Speaker of the

25  House of Representatives, and the substantive committees of

26  each house of the Legislature, with the first annual report

27  due January 31, 2005.

28         (6)  The Office of Program Policy and Government

29  Accountability shall evaluate and report to the Governor, the

30  President of the Senate, and the Speaker of the House of

31  Representatives, by March 1, 2005, on the effectiveness of the

                                  16

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 1  department's monitoring and assessment of the program's

 2  effectiveness.

 3         Section 5.  Subsection (1) of section 395.003, Florida

 4  Statutes, is amended to read:

 5         395.003  Licensure; issuance, renewal, denial,

 6  modification, suspension, and revocation.--

 7         (1)(a)  No person shall establish, conduct, or maintain

 8  a hospital, ambulatory surgical center, or mobile surgical

 9  facility in this state without first obtaining a license under

10  this part.

11         (b)1.  It is unlawful for any person to use or

12  advertise to the public, in any way or by any medium

13  whatsoever, any facility as a "hospital," "ambulatory surgical

14  center," or "mobile surgical facility" unless such facility

15  has first secured a license under the provisions of this part.

16         2.  Nothing in this part applies to veterinary

17  hospitals or to commercial business establishments using the

18  word "hospital," "ambulatory surgical center," or "mobile

19  surgical facility" as a part of a trade name if no treatment

20  of human beings is performed on the premises of such

21  establishments.

22         3.  The agency may not issue any license for an

23  emergency department for a medical facility located away from

24  the primary premises of a licensed hospital before July 1,

25  2005. The agency shall conduct a study of existing facilities

26  licensed as offsite emergency departments in this state and

27  other states, which includes a review of issues related to

28  access to care and quality of care. The study shall be

29  submitted to the Governor and the Legislature by February 1,

30  2005.

31  

                                  17

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 1         Section 6.  Subsection (7) is added to section

 2  395.1041, Florida Statutes, to read:

 3         395.1041  Access to emergency services and care.--

 4         (7)  EMERGENCY ROOM DIVERSION PROGRAMS.--Hospitals may

 5  develop emergency room diversion programs, including, but not

 6  limited to, an "Emergency Hotline" which allows patients to

 7  help determine if emergency department services are

 8  appropriate or if other health care settings may be more

 9  appropriate for care, and a "Fast Track" program allowing

10  nonemergency patients to be treated at an alternative site.

11  Alternative sites may include health care programs funded with

12  local tax revenue and federally funded community health

13  centers, county health departments, or other nonhospital

14  providers of health care services. The program may include

15  provisions for followup care and case management.

16         Section 7.  Subsections (1), (2), and (3) of section

17  395.301, Florida Statutes, are amended, and subsections (7),

18  (8), (9), (10), and (11) are added to that section, to read:

19         395.301  Itemized patient bill; form and content

20  prescribed by the agency.--

21         (1)  A licensed facility not operated by the state

22  shall notify each patient during admission and at discharge of

23  his or her right to receive an itemized bill upon request.

24  Within 7 days following the patient's discharge or release

25  from a licensed facility not operated by the state, or within

26  7 days after the earliest date at which the loss or expense

27  from the service may be determined, the licensed facility

28  providing the service shall, upon request, submit to the

29  patient, or to the patient's survivor or legal guardian as may

30  be appropriate, an itemized statement detailing in language

31  comprehensible to an ordinary layperson the specific nature of

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 1  charges or expenses incurred by the patient, which in the

 2  initial billing shall contain a statement of specific services

 3  received and expenses incurred for such items of service,

 4  enumerating in detail the constituent components of the

 5  services received within each department of the licensed

 6  facility and including unit price data on rates charged by the

 7  licensed facility, as prescribed by the agency.

 8         (2)(a)  Each such statement submitted pursuant to this

 9  section:

10         1.(a)  May not include charges of hospital-based

11  physicians if billed separately.

12         2.(b)  May not include any generalized category of

13  expenses such as "other" or "miscellaneous" or similar

14  categories.

15         3.(c)  Shall list drugs by brand or generic name and

16  not refer to drug code numbers when referring to drugs of any

17  sort.

18         4.(d)  Shall specifically identify therapy treatment as

19  to the date, type, and length of treatment when therapy

20  treatment is a part of the statement.

21         (b)  Any person receiving a statement pursuant to this

22  section shall be fully and accurately informed as to each

23  charge and service provided by the institution preparing the

24  statement.

25         (3)  On each such itemized statement submitted pursuant

26  to subsection (1) there shall appear the words "A FOR-PROFIT

27  (or NOT-FOR-PROFIT or PUBLIC) HOSPITAL (or AMBULATORY SURGICAL

28  CENTER) LICENSED BY THE STATE OF FLORIDA" or substantially

29  similar words sufficient to identify clearly and plainly the

30  ownership status of the licensed facility.  Each itemized

31  statement must prominently display the phone number of the

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 1  medical facility's patient liaison who is responsible for

 2  expediting the resolution of any billing dispute between the

 3  patient, or his or her representative, and the billing

 4  department.

 5         (7)  Each licensed facility not operated by the state

 6  shall provide, prior to provision of any nonemergency medical

 7  services, a written good faith estimate of reasonably

 8  anticipated charges for the facility to treat the patient's

 9  condition upon written request of a prospective patient. The

10  estimate shall be provided to the prospective patient within 7

11  business days of the receipt of the request. The estimate may

12  be the average charges for that diagnosis related group or the

13  average charges for that procedure. Upon request, the facility

14  shall notify the patient of any revision to the good faith

15  estimate. Such estimate shall not preclude the actual charges

16  from exceeding the estimate. The facility shall place a notice

17  in reception areas that such information is available. Failure

18  to provide the estimate within the provisions established

19  pursuant to this section shall result in a fine of $500 for

20  each instance of the facility's failure to provide the

21  requested information.

22         (8)  A licensed facility shall make available to a

23  patient all records necessary for verification of the accuracy

24  of the patient's bill within 30 business days after the

25  request for such records. The verification information must be

26  made available in the facility's offices. Such records shall

27  be available to the patient prior to and after payment of the

28  bill or claim. The facility may not charge the patient for

29  making such verification records available; however, the

30  facility may charge its usual fee for providing copies of

31  records as specified in s. 395.3025.

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 1         (9)  Each facility shall establish a method for

 2  reviewing and responding to questions from patients concerning

 3  the patient's itemized bill. Such response shall be provided

 4  within 30 days after the date a question is received. If the

 5  patient is not satisfied with the response, the facility must

 6  provide the patient with the address of the agency to which

 7  the issue may be sent for review.

 8         (10)  Each licensed facility shall make available on

 9  its Internet website a link to the performance outcome and

10  financial data that is published by the Agency for Health Care

11  Administration pursuant to s. 408.05(3)(l). The facility shall

12  place a notice in the reception area that the information is

13  availability electronically and the website address.

14         (11)  Each rural hospital as defined in s. 395.602

15  which has fewer than 50 beds is exempt from subsection (10).

16  The agency shall evaluate the most cost-efficient method for

17  collecting and reporting data for these qualifying rural

18  hospitals and shall, by December 1, 2005, submit a report to

19  the Governor, the President of the Senate, and the Speaker of

20  the House of Representatives.

21         Section 8.  Subsection (1) of section 408.061, Florida

22  Statutes, is amended to read:

23         408.061  Data collection; uniform systems of financial

24  reporting; information relating to physician charges;

25  confidential information; immunity.--

26         (1)  The agency shall may require the submission by

27  health care facilities, health care providers, and health

28  insurers of data necessary to carry out the agency's duties.

29  Specifications for data to be collected under this section

30  shall be developed by the agency with the assistance of

31  technical advisory panels including representatives of

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 1  affected entities, consumers, purchasers, and such other

 2  interested parties as may be determined by the agency.

 3         (a)  Data to be submitted by health care facilities,

 4  including the facilities as defined in chapter 395, shall may

 5  include, but are not limited to: case-mix data, patient

 6  admission and or discharge data, hospital emergency department

 7  data shall include the number of patients treated in the

 8  emergency department of a licensed hospital reported by

 9  patient acuity level, data on hospital-acquired infections as

10  specified by rule, data on complications as specified by rule,

11  data on readmissions as specified by rule, with patient and

12  provider-specific identifiers included, actual charge data by

13  diagnostic groups, financial data, accounting data, operating

14  expenses, expenses incurred for rendering services to patients

15  who cannot or do not pay, interest charges, depreciation

16  expenses based on the expected useful life of the property and

17  equipment involved, and demographic data. The agency shall

18  adopt nationally recognized risk adjustment methodologies or

19  software consistent with the standards of the Agency for

20  Healthcare Research and Quality for all data submitted as

21  required by this section. Data may be obtained from documents

22  such as, but not limited to: leases, contracts, debt

23  instruments, itemized patient bills, medical record abstracts,

24  and related diagnostic information. Reported data elements

25  shall be reported electronically in accordance with Rule

26  59E-7.012, Florida Administrative Code. Data submitted shall

27  be certified by the chief executive officer or an appropriate

28  and duly authorized representative or employee of the licensed

29  facility that the information is true and accurate.

30         (b)  Data to be submitted by health care providers may

31  include, but are not limited to: Medicare and Medicaid

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 1  participation, types of services offered to patients, amount

 2  of revenue and expenses of the health care provider, and such

 3  other data which are reasonably necessary to study utilization

 4  patterns. Data submitted shall be certified as true and

 5  accurate by the health care provider or by an appropriate and

 6  duly authorized representative or employee of the health care

 7  provider.

 8         (c)  Data to be submitted by health insurers may

 9  include, but are not limited to: claims, premium,

10  administration, and financial information. Data submitted

11  shall be certified by the appropriate and duly authorized

12  representative, or employee of the insurer that the

13  information submitted is true and accurate.

14         (d)  Data required to be submitted by health care

15  facilities, health care providers, or health insurers shall

16  not include specific provider contract reimbursement

17  information. However, such specific provider reimbursement

18  data shall be reasonably available for onsite inspection by

19  the agency as is necessary to carry out the agency's

20  regulatory duties. Any such data obtained by the agency as a

21  result of onsite inspections may not be used by the state for

22  purposes of direct provider contracting and are confidential

23  and exempt from the provisions of s. 119.07(1) and s. 24(a),

24  Art. I of the State Constitution.

25         (e)  A requirement to submit data shall be adopted by

26  rule if the submission of data is being required of all

27  members of any type of health care facility, health care

28  provider, or health insurer. Rules are not required, however,

29  for the submission of data for a special study mandated by the

30  Legislature or when information is being requested for a

31  

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 1  single health care facility, health care provider, or health

 2  insurer.

 3         Section 9.  Subsections (1) and (4) of section 408.062,

 4  Florida Statutes, are amended, and subsection (5) is added to

 5  that section, to read:

 6         408.062  Research, analyses, studies, and reports.--

 7         (1)  The agency shall have the authority to conduct

 8  research, analyses, and studies relating to health care costs

 9  and access to and quality of health care services as access

10  and quality are affected by changes in health care costs. Such

11  research, analyses, and studies shall include, but not be

12  limited to, research and analysis relating to:

13         (a)  The financial status of any health care facility

14  or facilities subject to the provisions of this chapter.

15         (b)  The impact of uncompensated charity care on health

16  care facilities and health care providers.

17         (c)  The state's role in assisting to fund indigent

18  care.

19         (d)  In conjunction with the Office of Insurance

20  Regulation, the availability and affordability of health

21  insurance for small businesses.

22         (e)  Total health care expenditures in the state

23  according to the sources of payment and the type of

24  expenditure.

25         (f)  The quality of health services, using techniques

26  such as small area analysis, severity adjustments, and

27  risk-adjusted mortality rates.

28         (g)  The development of physician information payment

29  systems which are capable of providing data for health care

30  consumers taking into account the amount of resources

31  consumed, including at licensed facilities as defined in

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 1  chapter 395, and the outcomes produced in the delivery of

 2  care.

 3         (h)  The collection of a statistically valid sample of

 4  data on the retail prices charged by pharmacies for the 50

 5  most frequently prescribed medicines from any pharmacy

 6  licensed by this state as a special study authorized by the

 7  Legislature to be performed by the agency quarterly. If the

 8  drug is available generically, price data shall be reported

 9  for the generic drug and price data of a brand-named drug for

10  which the generic drug is the equivalent shall be reported.

11  The agency shall make available on its Internet website for

12  each pharmacy, no later than October 1, 2005, drug prices for

13  a 30-day supply at a standard dose. The data collected shall

14  be reported for each drug by pharmacy and by metropolitan

15  statistical area or region and updated quarterly. The impact

16  of subacute admissions on hospital revenues and expenses for

17  purposes of calculating adjusted admissions as defined in s.

18  408.07.

19         (i)  The use of emergency department services by

20  patient acuity level and the implication of increasing

21  hospital cost by providing nonurgent care in emergency

22  departments. The agency shall submit an annual report based on

23  this monitoring and assessment to the Governor, the President

24  of the Senate, and the Speaker of the House of

25  Representatives, and the substantive legislative committees

26  with the first report due January 1, 2006.

27         (j)  Making available on its Internet website no later

28  than October 1, 2004, and in a hard-copy format upon request,

29  patient charge, volumes, length of stay, and performance

30  outcome indicators collected from health care facilities

31  pursuant to s. 408.061(1)(a) for not less than 50 inpatient

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 1  and 50 outpatient procedures provided in inpatient and

 2  outpatient facilities as determined by the agency. In making

 3  the determination of specific medical conditions, surgeries,

 4  and procedures to include, the agency shall consider such

 5  factors as volume, severity of the illness, urgency of

 6  admission, individual and societal costs, and whether the

 7  condition is acute or chronic. Performance outcome indicators

 8  shall re risk adjusted or severity adjusted, as applicable,

 9  using nationally recognized risk adjustment methodologies or

10  software consistent with the standards of the Agency for

11  Healthcare Research and Quality and as selected by the agency.

12  The website shall also provide an interactive search that

13  allows consumers to view and compare the information for

14  specific facilities, a map that allows consumers to select a

15  county or region, definitions of all of the data, descriptions

16  of each procedure, and an explanation about why the data may

17  differ from facility to facility. Such public data shall be

18  updated quarterly. The agency shall submit an annual status

19  report on the collection of data and publication of

20  performance outcome indicators to the Governor, the Speaker of

21  the House of Representatives, the President of the Senate, and

22  the substantive legislative committees with the first status

23  report due January 1, 2005.

24         (4)(a)  The agency shall may conduct data-based studies

25  and evaluations and make recommendations to the Legislature

26  and the Governor concerning exemptions, the effectiveness of

27  limitations of referrals, restrictions on investment interests

28  and compensation arrangements, and the effectiveness of public

29  disclosure. Such analysis shall may include, but need not be

30  limited to, utilization of services, cost of care, quality of

31  care, and access to care. The agency may require the

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 1  submission of data necessary to carry out this duty, which may

 2  include, but need not be limited to, data concerning

 3  ownership, Medicare and Medicaid, charity care, types of

 4  services offered to patients, revenues and expenses,

 5  patient-encounter data, and other data reasonably necessary to

 6  study utilization patterns and the impact of health care

 7  provider ownership interests in health-care-related entities

 8  on the cost, quality, and accessibility of health care.

 9         (b)  The agency may collect such data from any health

10  facility or licensed health care provider as a special study.

11         (5)  The agency shall develop and implement a strategy

12  for the adoption and use of electronic health records. The

13  agency may develop rules to facilitate the functionality and

14  protect the confidentiality of electronic health records. The

15  agency shall report to the Governor, the President of the

16  Senate, and the Speaker of the House of Representatives on

17  legislative recommendations to protect the confidentiality of

18  electronic health records.

19         Section 10.  Paragraph (l) is added to subsection (3)

20  of section 408.05, Florida Statutes, and paragraph (a) of

21  subsection (8) of that section is amended, to read:

22         408.05  State Center for Health Statistics.--

23         (3)  COMPREHENSIVE HEALTH INFORMATION SYSTEM.--In order

24  to produce comparable and uniform health information and

25  statistics, the agency shall perform the following functions:

26         (l)  Develop, in conjunction with the State

27  Comprehensive Health Information System Advisory Council, and

28  implement a long-range plan for making available performance

29  outcome and financial data that will allow consumers to

30  compare health care services. The performance outcomes and

31  financial data the agency must make available shall include,

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 1  but is not limited to, pharmaceuticals, physicians, health

 2  care facilities, and health plans and managed care entities.

 3  The agency shall submit the initial plan to the Governor, the

 4  President of the Senate, and the Speaker of the House of

 5  Representatives by March 1, 2005, and shall update the plan

 6  and report on the status of its implementation annually

 7  thereafter. The agency shall also make the plan and status

 8  report available to the public on its Internet website. As

 9  part of the plan, the agency shall identify the process and

10  timeframes for implementation, any barriers to implementation,

11  and recommendations of changes in the law that may be enacted

12  by the Legislature to eliminate the barriers. As preliminary

13  elements of the plan, the agency shall:

14         1.  Make available performance outcome and patient

15  charge data collected from health care facilities pursuant to

16  s. 408.061(1)(a) and (2). The agency shall determine which

17  conditions and procedures, performance outcomes, and patient

18  charge data to disclose based upon input from the council.

19  When determining which conditions and procedures are to be

20  disclosed, the council and the agency shall consider variation

21  in costs, variation in outcomes, and magnitude of variations

22  and other relevant information. When determining which

23  performance outcomes to disclose, the agency: 

24         a.  Shall consider such factors as volume of cases;

25  average patient charges; average length of stay; complication

26  rates; mortality rates; and infection rates, among others,

27  which shall he adjusted for case mix and severity, if

28  applicable.

29         b.  May consider such additional measures that are

30  adopted by the Centers for Medicare and Medicaid Studies,

31  National Quality Forum, the Joint Commission on Accreditation

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 1  of Healthcare Organizations, the Agency for Healthcare

 2  Research and Quality, or a similar national entity that

 3  establishes standards to measure the performance of health

 4  care providers, or by other states.

 5  

 6  When determining which patient charge data to disclose, the

 7  agency shall consider such measures as average charge, average

 8  net revenue per adjusted patient day, average cost per

 9  adjusted patient day, and average cost per admission, among

10  others.

11         2.  Make available performance measures, benefit

12  design, and premium cost data from health plans licensed

13  pursuant to chapter 627 or chapter 641. The agency shall

14  determine which performance outcome and member and subscriber

15  cost data to disclose, based upon input from the council. When

16  determining which data to disclose, the agency shall consider

17  information that may be required by either individual or group

18  purchasers to assess the value of the product, which may

19  include membership satisfaction, quality of care, current

20  enrollment or membership, coverage areas, accreditation

21  status, premium costs, plan costs, premium increases, range of

22  benefits, copayments and deductibles, accuracy and speed of

23  claims payment, credentials of physicians, number of

24  providers, names of network providers, and hospitals in the

25  network. Health plans shall make available to the agency any

26  such data or information that is not currently reported to the

27  agency or the office.

28         3.  Determine the method and format for public

29  disclosure of data reported pursuant to this paragraph. The

30  agency shall make its determination based upon input from the

31  Comprehensive Health Information System Advisory Council. At a

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 1  minimum, the data shall be made available on the agency's

 2  Internet website in a manner that allows consumers to conduct

 3  an interactive search that allows them to view and compare the

 4  information for specific providers. The website must include

 5  such additional information as is determined necessary to

 6  ensure that the website enhances informed decision-making

 7  among consumers and health care purchasers, which shall

 8  include, at a minimum, appropriate guidance on how to use the

 9  data and an explanation of why the data may vary from provider

10  to provider. The data specified in subparagraph 1. shall be

11  released no later than March 1, 2005. The data specified in

12  subparagraph 2. shall be released no later than March 1, 2006.

13         (8)  STATE COMPREHENSIVE HEALTH INFORMATION SYSTEM

14  ADVISORY COUNCIL.--

15         (a)  There is established in the agency the State

16  Comprehensive Health Information System Advisory Council to

17  assist the center in reviewing the comprehensive health

18  information system and to recommend improvements for such

19  system. The council shall consist of the following members:

20         1.  An employee of the Executive Office of the

21  Governor, to be appointed by the Governor.

22         2.  An employee of the Office of Insurance Regulation

23   Department of Financial Services, to be appointed by the

24  Chief Financial Officer.

25         3.  An employee of the Department of Education, to be

26  appointed by the Commissioner of Education.

27         4.  Ten persons, to be appointed by the Secretary of

28  Health Care Administration, representing other state and local

29  agencies, state universities, the Florida Association of

30  Business/Health Coalitions, local health councils,

31  

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 1  professional health-care-related associations, consumers, and

 2  purchasers.

 3         Section 11.  Subsection (3) of section 409.9066,

 4  Florida Statutes, is amended to read:

 5         409.9066  Medicare prescription discount program.--

 6         (3)  The Agency for Health Care Administration shall

 7  publish, on a free website available to the public, the most

 8  recent average wholesale prices for the 200 drugs most

 9  frequently dispensed to the elderly and, to the extent

10  possible, shall provide a mechanism that consumers may use to

11  calculate the retail price and the price that should be paid

12  after the discount required in subsection (1) is applied. The

13  agency shall provide retail information by geographic area and

14  retail information by provider within geographical areas.

15         Section 12.  Section 465.0244, Florida Statutes, is

16  created to read:

17         465.0244  Information disclosure.--Every pharmacy shall

18  make available on its Internet website a link to the financial

19  data that is published by the Agency for Health Care

20  Administration pursuant to ss. 408.05(3)(l) and 409.9066 and

21  shall place in the area where customers receive filled

22  prescriptions notice that such information is available

23  electronically and the address of its Internet website.

24         Section 13.  Section 627.6499, Florida Statutes, is

25  amended to read:

26         627.6499  Reporting by insurers and third-party

27  administrators.--

28         (1)  The office may require any insurer, third-party

29  administrator, or service company to report any information

30  reasonably required to assist the board in assessing insurers

31  as required by this act.

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 1         (2)  Each health insurance issuer shall make available

 2  on its Internet website a link to the performance outcome and

 3  financial data that is published by the Agency for Health Care

 4  Administration pursuant to s. 408.05(3)(l) and shall include

 5  in every policy delivered or issued for delivery to any person

 6  in the state or any materials provided as required by s.

 7  627.64725 notice that such information is available

 8  electronically and the address of its Internet website.

 9         Section 14.  Subsections (6) and (7) are added to

10  section 641.54, Florida Statutes, to read:

11         641.54  Information disclosure.--

12         (6)  Each health maintenance organization shall make

13  available to its subscribers the estimated co-pay, coinsurance

14  percentage, or deductible, whichever is applicable, for any

15  covered services, the status of the subscriber's maximum

16  annual out-of-pocket payments for a covered individual or

17  family, and the status of the subscriber's maximum lifetime

18  benefit. Such estimate shall not preclude the actual co-pay,

19  coinsurance percentage, or deductible, whichever is

20  applicable, from exceeding the estimate.

21         (7)  Each health maintenance organization shall make

22  available on its Internet website a link to the performance

23  outcome and financial data that is published by the Agency for

24  Health Care Administration pursuant to s. 408.05(3)(l) and

25  shall include in every policy delivered or issued for delivery

26  to any person in the state or any materials provided as

27  required by s. 627.64725 notice that such information is

28  available electronically and the address of its Internet

29  website.

30         Section 15.  Section 408.7056, Florida Statutes, is

31  amended to read:

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 1         408.7056  Statewide Provider and Subscriber Assistance

 2  Program.--

 3         (1)  As used in this section, the term:

 4         (a)  "Agency" means the Agency for Health Care

 5  Administration.

 6         (b)  "Department" means the Department of Financial

 7  Services.

 8         (c)  "Grievance procedure" means an established set of

 9  rules that specify a process for appeal of an organizational

10  decision.

11         (d)  "Health care provider" or "provider" means a

12  state-licensed or state-authorized facility, a facility

13  principally supported by a local government or by funds from a

14  charitable organization that holds a current exemption from

15  federal income tax under s. 501(c)(3) of the Internal Revenue

16  Code, a licensed practitioner, a county health department

17  established under part I of chapter 154, a prescribed

18  pediatric extended care center defined in s. 400.902, a

19  federally supported primary care program such as a migrant

20  health center or a community health center authorized under s.

21  329 or s. 330 of the United States Public Health Services Act

22  that delivers health care services to individuals, or a

23  community facility that receives funds from the state under

24  the Community Alcohol, Drug Abuse, and Mental Health Services

25  Act and provides mental health services to individuals.

26         (e)  "Managed care entity" means a health maintenance

27  organization or a prepaid health clinic certified under

28  chapter 641, a prepaid health plan authorized under s.

29  409.912, or an exclusive provider organization certified under

30  s. 627.6472.

31  

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 1         (f)  "Office" means the Office of Insurance Regulation

 2  of the Financial Services Commission.

 3         (g)  "Panel" means a statewide provider and subscriber

 4  assistance panel selected as provided in subsection (11).

 5         (2)  The agency shall adopt and implement a program to

 6  provide assistance to subscribers and providers, including

 7  those whose grievances are not resolved by the managed care

 8  entity to the satisfaction of the subscriber or provider. The

 9  program shall consist of one or more panels that meet as often

10  as necessary to timely review, consider, and hear grievances

11  and recommend to the agency or the office any actions that

12  should be taken concerning individual cases heard by the

13  panel. The panel shall hear every grievance filed by

14  subscribers and providers on behalf of subscribers, unless the

15  grievance:

16         (a)  Relates to a managed care entity's refusal to

17  accept a provider into its network of providers;

18         (b)  Is part of an internal grievance in a Medicare

19  managed care entity or a reconsideration appeal through the

20  Medicare appeals process which does not involve a quality of

21  care issue;

22         (c)  Is related to a health plan not regulated by the

23  state such as an administrative services organization,

24  third-party administrator, or federal employee health benefit

25  program;

26         (d)  Is related to appeals by in-plan suppliers and

27  providers, unless related to quality of care provided by the

28  plan;

29         (e)  Is part of a Medicaid fair hearing pursued under

30  42 C.F.R. ss. 431.220 et seq.;

31  

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 1         (f)  Is the basis for an action pending in state or

 2  federal court;

 3         (g)  Is related to an appeal by nonparticipating

 4  providers, unless related to the quality of care provided to a

 5  subscriber by the managed care entity and the provider is

 6  involved in the care provided to the subscriber;

 7         (h)  Was filed before the subscriber or provider

 8  completed the entire internal grievance procedure of the

 9  managed care entity, the managed care entity has complied with

10  its timeframes for completing the internal grievance

11  procedure, and the circumstances described in subsection (6)

12  do not apply;

13         (i)  Has been resolved to the satisfaction of the

14  subscriber or provider who filed the grievance, unless the

15  managed care entity's initial action is egregious or may be

16  indicative of a pattern of inappropriate behavior;

17         (j)  Is limited to seeking damages for pain and

18  suffering, lost wages, or other incidental expenses, including

19  accrued interest on unpaid balances, court costs, and

20  transportation costs associated with a grievance procedure;

21         (k)  Is limited to issues involving conduct of a health

22  care provider or facility, staff member, or employee of a

23  managed care entity which constitute grounds for disciplinary

24  action by the appropriate professional licensing board and is

25  not indicative of a pattern of inappropriate behavior, and the

26  agency, office, or department has reported these grievances to

27  the appropriate professional licensing board or to the health

28  facility regulation section of the agency for possible

29  investigation; or

30  

31  

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 1         (l)  Is withdrawn by the subscriber or provider.

 2  Failure of the subscriber or the provider to attend the

 3  hearing shall be considered a withdrawal of the grievance.

 4         (3)  The agency shall review all grievances within 60

 5  days after receipt and make a determination whether the

 6  grievance shall be heard. Once the agency notifies the panel,

 7  the subscriber or provider, and the managed care entity that a

 8  grievance will be heard by the panel, the panel shall hear the

 9  grievance either in the network area or by teleconference no

10  later than 120 days after the date the grievance was filed.

11  The agency shall notify the parties, in writing, by facsimile

12  transmission, or by phone, of the time and place of the

13  hearing. The panel may take testimony under oath, request

14  certified copies of documents, and take similar actions to

15  collect information and documentation that will assist the

16  panel in making findings of fact and a recommendation. The

17  panel shall issue a written recommendation, supported by

18  findings of fact, to the provider or subscriber, to the

19  managed care entity, and to the agency or the office no later

20  than 15 working days after hearing the grievance. If at the

21  hearing the panel requests additional documentation or

22  additional records, the time for issuing a recommendation is

23  tolled until the information or documentation requested has

24  been provided to the panel. The proceedings of the panel are

25  not subject to chapter 120.

26         (4)  If, upon receiving a proper patient authorization

27  along with a properly filed grievance, the agency requests

28  medical records from a health care provider or managed care

29  entity, the health care provider or managed care entity that

30  has custody of the records has 10 days to provide the records

31  to the agency. Records include medical records, communication

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 1  logs associated with the grievance both to and from the

 2  subscriber, contracts, and any other contents of the internal

 3  grievance file associated with the complaint filed with the

 4  Subscriber Assistance Program. Failure to provide requested

 5  medical records may result in the imposition of a fine of up

 6  to $500. Each day that records are not produced is considered

 7  a separate violation.

 8         (5)  Grievances that the agency determines pose an

 9  immediate and serious threat to a subscriber's health must be

10  given priority over other grievances. The panel may meet at

11  the call of the chair to hear the grievances as quickly as

12  possible but no later than 45 days after the date the

13  grievance is filed, unless the panel receives a waiver of the

14  time requirement from the subscriber. The panel shall issue a

15  written recommendation, supported by findings of fact, to the

16  office or the agency within 10 days after hearing the

17  expedited grievance.

18         (6)  When the agency determines that the life of a

19  subscriber is in imminent and emergent jeopardy, the chair of

20  the panel may convene an emergency hearing, within 24 hours

21  after notification to the managed care entity and to the

22  subscriber, to hear the grievance. The grievance must be heard

23  notwithstanding that the subscriber has not completed the

24  internal grievance procedure of the managed care entity. The

25  panel shall, upon hearing the grievance, issue a written

26  emergency recommendation, supported by findings of fact, to

27  the managed care entity, to the subscriber, and to the agency

28  or the office for the purpose of deferring the imminent and

29  emergent jeopardy to the subscriber's life. Within 24 hours

30  after receipt of the panel's emergency recommendation, the

31  

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 1  agency or office may issue an emergency order to the managed

 2  care entity. An emergency order remains in force until:

 3         (a)  The grievance has been resolved by the managed

 4  care entity;

 5         (b)  Medical intervention is no longer necessary; or

 6         (c)  The panel has conducted a full hearing under

 7  subsection (3) and issued a recommendation to the agency or

 8  the office, and the agency or office has issued a final order.

 9         (7)  After hearing a grievance, the panel shall make a

10  recommendation to the agency or the office which may include

11  specific actions the managed care entity must take to comply

12  with state laws or rules regulating managed care entities.

13         (8)  A managed care entity, subscriber, or provider

14  that is affected by a panel recommendation may within 10 days

15  after receipt of the panel's recommendation, or 72 hours after

16  receipt of a recommendation in an expedited grievance, furnish

17  to the agency or office written evidence in opposition to the

18  recommendation or findings of fact of the panel.

19         (9)  No later than 30 days after the issuance of the

20  panel's recommendation and, for an expedited grievance, no

21  later than 10 days after the issuance of the panel's

22  recommendation, the agency or the office may adopt the panel's

23  recommendation or findings of fact in a proposed order or an

24  emergency order, as provided in chapter 120, which it shall

25  issue to the managed care entity. The agency or office may

26  issue a proposed order or an emergency order, as provided in

27  chapter 120, imposing fines or sanctions, including those

28  contained in ss. 641.25 and 641.52. The agency or the office

29  may reject all or part of the panel's recommendation. All

30  fines collected under this subsection must be deposited into

31  the Health Care Trust Fund.

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 1         (10)  In determining any fine or sanction to be

 2  imposed, the agency and the office may consider the following

 3  factors:

 4         (a)  The severity of the noncompliance, including the

 5  probability that death or serious harm to the health or safety

 6  of the subscriber will result or has resulted, the severity of

 7  the actual or potential harm, and the extent to which

 8  provisions of chapter 641 were violated.

 9         (b)  Actions taken by the managed care entity to

10  resolve or remedy any quality-of-care grievance.

11         (c)  Any previous incidents of noncompliance by the

12  managed care entity.

13         (d)  Any other relevant factors the agency or office

14  considers appropriate in a particular grievance.

15         (11)(a)  The panel shall consist of the Insurance

16  Consumer Advocate, or designee thereof, established by s.

17  627.0613; at least two members employed by the agency and at

18  least two members employed by the department, chosen by their

19  respective agencies; a consumer appointed by the Governor; a

20  physician appointed by the Governor, as a standing member;

21  and, if necessary, physicians who have expertise relevant to

22  the case to be heard, on a rotating basis. The agency may

23  contract with a medical director, and a primary care

24  physician, or both, who shall provide additional technical

25  expertise to the panel but shall not be voting members of the

26  panel. The medical director shall be selected from a health

27  maintenance organization with a current certificate of

28  authority to operate in Florida.

29         (b)  A majority of those panel members required under

30  paragraph (a) shall constitute a quorum for any meeting or

31  hearing of the panel. A grievance may not be heard or voted

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 1  upon at any panel meeting or hearing unless a quorum is

 2  present, except that a minority of the panel may adjourn a

 3  meeting or hearing until a quorum is present. A panel convened

 4  for the purpose of hearing a subscriber's grievance in

 5  accordance with subsections (2) and (3) shall not consist of

 6  more than 11 members.

 7         (12)  Every managed care entity shall submit a

 8  quarterly report to the agency, the office, and the department

 9  listing the number and the nature of all subscribers' and

10  providers' grievances which have not been resolved to the

11  satisfaction of the subscriber or provider after the

12  subscriber or provider follows the entire internal grievance

13  procedure of the managed care entity. The agency shall notify

14  all subscribers and providers included in the quarterly

15  reports of their right to file an unresolved grievance with

16  the panel.

17         (13)  A proposed order issued by the agency or office

18  which only requires the managed care entity to take a specific

19  action under subsection (7) is subject to a summary hearing in

20  accordance with s. 120.574, unless all of the parties agree

21  otherwise. If the managed care entity does not prevail at the

22  hearing, the managed care entity must pay reasonable costs and

23  attorney's fees of the agency or the office incurred in that

24  proceeding.

25         (14)(a)  Any information that identifies a subscriber

26  which is held by the panel, agency, or department pursuant to

27  this section is confidential and exempt from the provisions of

28  s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

29  However, at the request of a subscriber or managed care entity

30  involved in a grievance procedure, the panel, agency, or

31  department shall release information identifying the

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 1  subscriber involved in the grievance procedure to the

 2  requesting subscriber or managed care entity.

 3         (b)  Meetings of the panel shall be open to the public

 4  unless the provider or subscriber whose grievance will be

 5  heard requests a closed meeting or the agency or the

 6  department determines that information which discloses the

 7  subscriber's medical treatment or history or information

 8  relating to internal risk management programs as defined in s.

 9  641.55(5)(c), (6), and (8) may be revealed at the panel

10  meeting, in which case that portion of the meeting during

11  which a subscriber's medical treatment or history or internal

12  risk management program information is discussed shall be

13  exempt from the provisions of s. 286.011 and s. 24(b), Art. I

14  of the State Constitution. All closed meetings shall be

15  recorded by a certified court reporter.

16         Section 16.  Paragraph (c) of subsection (4) of section

17  641.3154, Florida Statutes, is amended to read:

18         641.3154  Organization liability; provider billing

19  prohibited.--

20         (4)  A provider or any representative of a provider,

21  regardless of whether the provider is under contract with the

22  health maintenance organization, may not collect or attempt to

23  collect money from, maintain any action at law against, or

24  report to a credit agency a subscriber of an organization for

25  payment of services for which the organization is liable, if

26  the provider in good faith knows or should know that the

27  organization is liable. This prohibition applies during the

28  pendency of any claim for payment made by the provider to the

29  organization for payment of the services and any legal

30  proceedings or dispute resolution process to determine whether

31  the organization is liable for the services if the provider is

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 1  informed that such proceedings are taking place. It is

 2  presumed that a provider does not know and should not know

 3  that an organization is liable unless:

 4         (c)  The office or agency makes a final determination

 5  that the organization is required to pay for such services

 6  subsequent to a recommendation made by the Statewide Provider

 7  and Subscriber Assistance Panel pursuant to s. 408.7056; or

 8         Section 17.  Subsection (1), paragraphs (b) and (e) of

 9  subsection (3), paragraph (d) of subsection (4), subsection

10  (5), paragraph (g) of subsection (6), and subsections (9),

11  (10), and (11) of section 641.511, Florida Statutes, are

12  amended to read:

13         641.511  Subscriber grievance reporting and resolution

14  requirements.--

15         (1)  Every organization must have a grievance procedure

16  available to its subscribers for the purpose of addressing

17  complaints and grievances. Every organization must notify its

18  subscribers that a subscriber must submit a grievance within 1

19  year after the date of occurrence of the action that initiated

20  the grievance, and may submit the grievance for review to the

21  Statewide Provider and Subscriber Assistance Program panel as

22  provided in s. 408.7056 after receiving a final disposition of

23  the grievance through the organization's grievance process. An

24  organization shall maintain records of all grievances and

25  shall report annually to the agency the total number of

26  grievances handled, a categorization of the cases underlying

27  the grievances, and the final disposition of the grievances.

28         (3)  Each organization's grievance procedure, as

29  required under subsection (1), must include, at a minimum:

30         (b)  The names of the appropriate employees or a list

31  of grievance departments that are responsible for implementing

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 1  the organization's grievance procedure. The list must include

 2  the address and the toll-free telephone number of each

 3  grievance department, the address of the agency and its

 4  toll-free telephone hotline number, and the address of the

 5  Statewide Provider and Subscriber Assistance Program and its

 6  toll-free telephone number.

 7         (e)  A notice that a subscriber may voluntarily pursue

 8  binding arbitration in accordance with the terms of the

 9  contract if offered by the organization, after completing the

10  organization's grievance procedure and as an alternative to

11  the Statewide Provider and Subscriber Assistance Program. Such

12  notice shall include an explanation that the subscriber may

13  incur some costs if the subscriber pursues binding

14  arbitration, depending upon the terms of the subscriber's

15  contract.

16         (4)

17         (d)  In any case when the review process does not

18  resolve a difference of opinion between the organization and

19  the subscriber or the provider acting on behalf of the

20  subscriber, the subscriber or the provider acting on behalf of

21  the subscriber may submit a written grievance to the Statewide

22  Provider and Subscriber Assistance Program.

23         (5)  Except as provided in subsection (6), the

24  organization shall resolve a grievance within 60 days after

25  receipt of the grievance, or within a maximum of 90 days if

26  the grievance involves the collection of information outside

27  the service area. These time limitations are tolled if the

28  organization has notified the subscriber, in writing, that

29  additional information is required for proper review of the

30  grievance and that such time limitations are tolled until such

31  information is provided. After the organization receives the

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 1  requested information, the time allowed for completion of the

 2  grievance process resumes. The Employee Retirement Income

 3  Security Act of 1974, as implemented by 29 C.F.R. 2560.503-1,

 4  is adopted and incorporated by reference as applicable to all

 5  organizations that administer small and large group health

 6  plans that are subject to 29 C.F.R. 2560.503-1. The claims

 7  procedures of the regulations of the Employee Retirement

 8  Income Security Act of 1974 as implemented by 29 C.F.R.

 9  2560.503-1 shall be the minimum standards for grievance

10  processes for claims for benefits for small and large group

11  health plans that are subject to 29 C.F.R. 2560.503-1.

12         (6)

13         (g)  In any case when the expedited review process does

14  not resolve a difference of opinion between the organization

15  and the subscriber or the provider acting on behalf of the

16  subscriber, the subscriber or the provider acting on behalf of

17  the subscriber may submit a written grievance to the Statewide

18  Provider and Subscriber Assistance Program.

19         (9)(a)  The agency shall advise subscribers with

20  grievances to follow their organization's formal grievance

21  process for resolution prior to review by the Statewide

22  Provider and Subscriber Assistance Program. The subscriber

23  may, however, submit a copy of the grievance to the agency at

24  any time during the process.

25         (b)  Requiring completion of the organization's

26  grievance process before the Statewide Provider and Subscriber

27  Assistance Program panel's review does not preclude the agency

28  from investigating any complaint or grievance before the

29  organization makes its final determination.

30         (10)  Each organization must notify the subscriber in a

31  final decision letter that the subscriber may request review

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 1  of the organization's decision concerning the grievance by the

 2  Statewide Provider and Subscriber Assistance Program, as

 3  provided in s. 408.7056, if the grievance is not resolved to

 4  the satisfaction of the subscriber. The final decision letter

 5  must inform the subscriber that the request for review must be

 6  made within 365 days after receipt of the final decision

 7  letter, must explain how to initiate such a review, and must

 8  include the addresses and toll-free telephone numbers of the

 9  agency and the Statewide Provider and Subscriber Assistance

10  Program.

11         (11)  Each organization, as part of its contract with

12  any provider, must require the provider to post a consumer

13  assistance notice prominently displayed in the reception area

14  of the provider and clearly noticeable by all patients. The

15  consumer assistance notice must state the addresses and

16  toll-free telephone numbers of the Agency for Health Care

17  Administration, the Statewide Provider and Subscriber

18  Assistance Program, and the Department of Financial Services.

19  The consumer assistance notice must also clearly state that

20  the address and toll-free telephone number of the

21  organization's grievance department shall be provided upon

22  request. The agency may adopt rules to implement this section.

23         Section 18.  Subsection (4) of section 641.58, Florida

24  Statutes, is amended to read:

25         641.58  Regulatory assessment; levy and amount; use of

26  funds; tax returns; penalty for failure to pay.--

27         (4)  The moneys received and deposited into the Health

28  Care Trust Fund shall be used to defray the expenses of the

29  agency in the discharge of its administrative and regulatory

30  powers and duties under this part, including conducting an

31  annual survey of the satisfaction of members of health

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 1  maintenance organizations; contracting with physician

 2  consultants for the Statewide Provider and Subscriber

 3  Assistance Panel; maintaining offices and necessary supplies,

 4  essential equipment, and other materials, salaries and

 5  expenses of required personnel; and discharging the

 6  administrative and regulatory powers and duties imposed under

 7  this part.

 8         Section 19.  Paragraph (f) of subsection (2) and

 9  subsections (3) and (9) of section 408.909, Florida Statutes,

10  are amended to read:

11         408.909  Health flex plans.--

12         (2)  DEFINITIONS.--As used in this section, the term:

13         (f)  "Health flex plan entity" means a health insurer,

14  health maintenance organization,

15  health-care-provider-sponsored organization, local government,

16  health care district, or other public or private

17  community-based organization, or public-private partnership

18  that develops and implements an approved health flex plan and

19  is responsible for administering the health flex plan and

20  paying all claims for health flex plan coverage by enrollees

21  of the health flex plan.

22         (3)  PILOT PROGRAM.--The agency and the office shall

23  each approve or disapprove health flex plans that provide

24  health care coverage for eligible participants who reside in

25  the three areas of the state that have the highest number of

26  uninsured persons, as identified in the Florida Health

27  Insurance Study conducted by the agency and in Indian River

28  County . A health flex plan may limit or exclude benefits

29  otherwise required by law for insurers offering coverage in

30  this state, may cap the total amount of claims paid per year

31  per enrollee, may limit the number of enrollees, or may take

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 1  any combination of those actions. A health flex plan offering

 2  may include the option of a catastrophic plan supplementing

 3  the health flex plan.

 4         (a)  The agency shall develop guidelines for the review

 5  of applications for health flex plans and shall disapprove or

 6  withdraw approval of plans that do not meet or no longer meet

 7  minimum standards for quality of care and access to care. The

 8  agency shall ensure that the health flex plans follow

 9  standardized grievance procedures similar to those required of

10  health maintenance organizations.

11         (b)  The office shall develop guidelines for the review

12  of health flex plan applications and provide regulatory

13  oversight of health flex plan advertisement and marketing

14  procedures. The office shall disapprove or shall withdraw

15  approval of plans that:

16         1.  Contain any ambiguous, inconsistent, or misleading

17  provisions or any exceptions or conditions that deceptively

18  affect or limit the benefits purported to be assumed in the

19  general coverage provided by the health flex plan;

20         2.  Provide benefits that are unreasonable in relation

21  to the premium charged or contain provisions that are unfair

22  or inequitable or contrary to the public policy of this state,

23  that encourage misrepresentation, or that result in unfair

24  discrimination in sales practices; or

25         3.  Cannot demonstrate that the health flex plan is

26  financially sound and that the applicant is able to underwrite

27  or finance the health care coverage provided.

28         (c)  The agency and the Financial Services Commission

29  may adopt rules as needed to administer this section.

30         (9)  PROGRAM EVALUATION.--The agency and the office

31  shall evaluate the pilot program and its effect on the

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 1  entities that seek approval as health flex plans, on the

 2  number of enrollees, and on the scope of the health care

 3  coverage offered under a health flex plan; shall provide an

 4  assessment of the health flex plans and their potential

 5  applicability in other settings; shall use health flex plans

 6  to gather more information to evaluate low-income consumer

 7  driven benefit packages; and shall, by January 1, 2005 2004,

 8  jointly submit a report to the Governor, the President of the

 9  Senate, and the Speaker of the House of Representatives.

10         Section 20.  Effective upon this act becoming a law,

11  section 381.0271, Florida Statutes, is created to read:

12         381.0271  Florida Patient Safety Corporation.--

13         (1)  DEFINITIONS.--As used in this section, the term:

14         (a)  "Adverse incident" has the same meanings as

15  provided in ss. 395.0197, 458.351, and 459.026.

16         (b)  "Corporation" means the Florida Patient Safety

17  Corporation created in this section.

18         (c)  "Patient safety data" has the same meaning as

19  provided in s. 766.1016.

20         (2)  CREATION.--

21         (a)  There is created a not-for-profit corporation to

22  be known as the Florida Patient Safety Corporation, which

23  shall be registered, incorporated, organized, and operated in

24  compliance with chapter 617. Upon the prior approval of the

25  board of directors, the corporation may create not-for-profit

26  corporate subsidiaries, organized under the provisions of

27  chapter 617, as necessary to fulfill the mission of the

28  corporation.

29         (b)  The corporation or any authorized and approved

30  subsidiary is not an agency within the meaning of s.

31  20.03(11).

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 1         (c)  The corporation and its authorized and approved

 2  subsidiaries are subject to the public meetings and records

 3  requirements of s. 24, Art I of the State Constitution,

 4  chapter 119, and s. 286.011.

 5         (d)  The corporation and its authorized and approved

 6  subsidiaries are not subject to the provisions of chapter 287.

 7         (e)  The corporation is a patient safety organization

 8  for purposes of s. 766.1016.

 9         (3)  PURPOSE.--

10         (a)  The purpose of the Florida Patient Safety

11  Corporation is to serve as a learning organization dedicated

12  to assisting health care providers in the state to improve the

13  quality and safety of health care rendered and to reduce harm

14  to patients. The corporation shall promote the development of

15  a culture of patient safety in the health care system in the

16  state. The corporation may not regulate health care providers

17  in this state.

18         (b)  In the fulfillment of its purpose, the corporation

19  shall work with a consortium of patient safety centers and

20  other patient safety programs within the universities in this

21  state.

22         (4)  BOARD OF DIRECTORS; MEMBERSHIP.--The corporation

23  shall be governed by a board of directors. The board of

24  directors shall consist of:

25         (a)  The chairperson of the Council of Medical School

26  Deans.

27         (b)  The person responsible for patient safety issues

28  for the authorized health insurer with the largest market

29  share as measured by premiums written in the state for the

30  most recent calendar year, appointed by such insurer.

31  

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 1         (c)  A representative of the authorized medical

 2  malpractice insurer with the largest market share as measured

 3  by premiums written in the state for the most recent calendar

 4  year, appointed by such insurer.

 5         (d)  The president of the Florida Health Care

 6  Coalition.

 7         (e)  A representative of a hospital in the state that

 8  is implementing innovative patient safety initiatives,

 9  appointed by the Florida Hospital Association.

10         (f)  A physician with expertise in patient safety,

11  appointed by the Florida Medical Association.

12         (g)  A physician with expertise in patient safety,

13  appointed by the Florida Osteopathic Medical Association.

14         (h)  A nurse with expertise in patient safety,

15  appointed by the Florida Nurses Association.

16         (i)  An institutional pharmacist, appointed by the

17  Florida Society of Health System Pharmacists, Inc.

18         (j)  A representative of Florida AARP, appointed by the

19  state director of the Florida AARP.

20         (k)  An independent consultant on health care

21  information systems, appointed jointly by the Central Florida

22  Chapter and the South Florida Chapter of the Healthcare

23  Information and Management Systems Society.

24         (l)  A physician with expertise in patient safety,

25  appointed by the Florida Podiatric Medical Association.

26         (m)  A physician with expertise in patient safety,

27  appointed by the Florida Chiropractic Association.

28         (n)  A dentist with expertise in patient safety,

29  appointed bt the Florida Dental Association.

30  

31  

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 1         (5)  ADVISORY COMMITTEES.--In addition to any

 2  committees that the corporation may establish, the corporation

 3  shall establish the following advisory committees:

 4         (a)  A scientific research advisory committee that

 5  includes, at a minimum, a representative from each patient

 6  safety center or other patient safety program in the

 7  universities of this state who is a physician licensed under

 8  chapter 458 or chapter 459, with experience in patient safety

 9  and evidence-based medicine. The duties of the scientific

10  research advisory committee shall include, but not be limited

11  to, the analysis of existing data and research to improve

12  patient safety and encourage evidence-based medicine.

13         (b)  A technology advisory committee that includes, at

14  a minimum, a representative of a hospital that has implemented

15  a computerized physician order entry system and a health care

16  provider that has implemented an electronic medical records

17  system. The duties of the technology advisory committee shall

18  include, but not be limited to, fostering development and use

19  of new patient safety technologies, including electronic

20  medical records.

21         (c)  A health care provider advisory committee that

22  includes, at a minimum, representatives of hospitals,

23  ambulatory surgical centers, physicians, nurses, and

24  pharmacists licensed in this state and a representative of the

25  Veterans Integrated Service Network 8 VA Patient Safety

26  Center. The duties of the health care provider advisory

27  committee shall include, but not be limited to, promotion of a

28  culture of patient safety that reduces errors.

29         (d)  A health care consumer advisory committee that

30  includes, at a minimum, representatives of businesses that

31  provide health insurance coverage to their employees, consumer

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 1  advocacy groups, and representatives of patient organizations.

 2  The duties of the health care consumer advisory committee

 3  shall include, but not be limited to, identification of

 4  incentives to encourage patient safety and the efficiency and

 5  quality of care.

 6         (e)  A state agency advisory committee that includes,

 7  at a minimum, a representative from each state agency that has

 8  regulatory responsibilities related to patient safety. The

 9  duties of the state agency advisory committee shall include,

10  but not be limited to, fostering coordination of patient

11  safety activities among state agencies.

12         (f)  A litigation alternatives advisory committee that

13  includes, at a minimum, representatives of attorneys who

14  represent plaintiffs and defendants in medical malpractice

15  cases, a representative of each law school in the state,

16  physicians, and health care facilities. The duties of the

17  litigation alternatives advisory committee shall include, but

18  not be limited to, identification of alternative systems to

19  compensate for injuries.

20         (g)  An education advisory committee that includes, at

21  a minimum, the associate dean for education, or the equivalent

22  position, as a representative from each school of medicine,

23  nursing, public health, or allied health to provide advice on

24  the development, implementation, and measurement of core

25  competencies for patient safety to be considered for

26  incorporation in the educational programs of the universities

27  and colleges of this state.

28         (6)  ORGANIZATION; MEETINGS.--

29         (a)  The Agency for Health Care Administration shall

30  assist the corporation in its organizational activities

31  required under chapter 617, including, but not limited to:

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 1         1.  Eliciting appointments for the initial board of

 2  directors.

 3         2.  Convening the first meeting of the board of

 4  directors and assisting with other meetings of the board of

 5  directors, upon the request of the board of directors, during

 6  the first year of operation of the corporation.

 7         3.  Drafting articles of incorporation for the board of

 8  directors and, upon the request of the board of directors,

 9  delivering articles of incorporation to the Department of

10  State for filing.

11         4.  Drafting proposed bylaws for the corporation.

12         5.  Paying fees related to incorporation.

13         6.  Providing office space and administrative support,

14  at the request of the board of directors, but not beyond July

15  1, 2005.

16         (b)  The board of directors must conduct its first

17  meeting no later than August 1, 2004, and shall meet

18  thereafter as frequently as necessary to carry out the duties

19  of the corporation.

20         (7)  POWERS AND DUTIES.--In addition to the powers and

21  duties prescribed in chapter 617 and the articles and bylaws

22  adopted under that chapter, the corporation shall directly or

23  through contract:

24         (a)  Secure staff necessary to properly administer the

25  corporation.

26         (b)  Collect, analyze, and evaluate patient safety

27  data, quality and patient safety indicators, medical

28  malpractice closed claims, and adverse incidents reported to

29  the Agency for Health Care Administration and the Department

30  of Health for the purpose of recommending changes in practices

31  and procedures which may be implemented by health care

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 1  practitioners and health care facilities to improve the

 2  quality of health care and to prevent future adverse

 3  incidents. Notwithstanding any other law, the Agency for

 4  Health Care Administration and the Department of Health shall

 5  make available to the corporation any adverse incident report

 6  submitted under s. 395.0197, s. 458.351, or s. 459.026. To the

 7  extent that adverse incident reports submitted under s.

 8  395.0197 are confidential and exempt from disclosure, the

 9  confidential and exempt status of such reports must be

10  maintained by the corporation.

11         (c)  Maintain an active library of best practices

12  relating to patient safety and patient safety literature,

13  along with the emerging evidence supporting the retention or

14  modification of such practices, and make this information

15  available to health care practitioners, health care

16  facilities, and the public.

17         (d)  Assess the patient safety culture at volunteering

18  hospitals and recommend methods to improve the working

19  environment related to patient safety at these hospitals.

20         (e)  Inventory the information technology capabilities

21  related to patient safety of health care facilities and health

22  care practitioners and recommend a plan for expediting

23  implementation of safety technologies statewide.

24         (f)  Facilitate the development of core competencies

25  relevant to patient safety which can be made available to be

26  considered for incorporation into the undergraduate and

27  graduate curriculums in schools of medicine, nursing, and

28  allied health in this state.

29         (g)  Facilitate continuing professional education

30  regarding patient safety for practicing health care

31  practitioners.

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 1         (h)  Study and facilitate the testing of alternative

 2  systems of encouraging the implementation of effective risk

 3  management strategies and clinical best practices, and of

 4  compensating injured patients as a means of reducing and

 5  preventing medical errors and promoting patient safety.

 6         (i)  Develop programs to educate the public about the

 7  role of health care consumers in promoting patient safety.

 8         (j)  Provide interagency coordination of patient safety

 9  efforts in this state.

10         (k)  Conduct other activities identified by the board

11  of directors to promote patient safety in this state.

12         (8)  ANNUAL REPORT.--By December 1, 2004, the

13  corporation shall prepare a report on the start-up activities

14  of the corporation and any proposals for legislative action

15  needed to enable the corporation to fulfill its purposes under

16  this section. By December 1 of each year thereafter, the

17  corporation shall prepare a report for the preceding fiscal

18  year. The report, at a minimum, must include:

19         (a)  A description of the activities of the corporation

20  under this section.

21         (b)  Progress made in improving patient safety and

22  reducing medical errors.

23         (c)  A compliance and financial audit of the accounts

24  and records of the corporation at the end of the preceding

25  fiscal year conducted by an independent certified public

26  accountant.

27         (d)  An assessment of the ability of the corporation to

28  fulfill the duties specified in subsection (7) and the

29  appropriateness of those duties for the corporation.

30         (e)  Recommendations for legislative action needed to

31  improve patient safety in this state.

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 1  

 2  The corporation shall submit the report to the Governor, the

 3  President of the Senate, and the Speaker of the House of

 4  Representatives.

 5         (9)  PERFORMANCE EXPECTATIONS.--The Office of Program

 6  Policy Analysis and Government Accountability, in consultation

 7  with the Agency for Health Care Administration, the Department

 8  of Health, and the corporation, shall develop performance

 9  standards by which to measure the success of the corporation

10  in organizing to fulfill and beginning to implement the

11  purposes and duties established in this section. The Office of

12  Program Policy Analysis and Government Accountability shall

13  conduct a performance audit of the corporation during 2006,

14  using the performance standards, and shall submit a report to

15  the Governor, the President of the Senate, and the Speaker of

16  the House of Representatives by January 1, 2007.

17         Section 21.  The Patient Safety Center at the Florida

18  State University College of Medicine, in collaboration with

19  researchers at other state universities, shall conduct a study

20  to analyze the return on investment that hospitals in this

21  state could realize from implementing computerized physician

22  order entry and other information technologies related to

23  patient safety. For the purposes of this analysis, the return

24  on investment shall include both financial results and

25  benefits relating to quality of care and patient safety. The

26  study must include a representative sample of large and small

27  hospitals, located in urban and rural areas, in the north,

28  central, and southern regions of the state. By February 1,

29  2005, the Patient Safety Center at the Florida State

30  University College of Medicine must submit a report to the

31  

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 1  Governor, the President of the Senate, and the Speaker of the

 2  House of Representatives concerning the results of the study.

 3         Section 22.  Section 395.1012, Florida Statutes, is

 4  amended to read:

 5         395.1012  Patient safety.--

 6         (1)  Each licensed facility must adopt a patient safety

 7  plan. A plan adopted to implement the requirements of 42

 8  C.F.R. part 482.21 shall be deemed to comply with this

 9  requirement.

10         (2)  Each licensed facility shall appoint a patient

11  safety officer and a patient safety committee, which shall

12  include at least one person who is neither employed by nor

13  practicing in the facility, for the purpose of promoting the

14  health and safety of patients, reviewing and evaluating the

15  quality of patient safety measures used by the facility,

16  recommending improvements in the patient safety measures used

17  by the facility, and assisting in the implementation of the

18  facility patient safety plan.

19         (3)  Each licensed facility shall adopt a plan to

20  reduce medication errors and adverse drug events, which must

21  consider the use of computerized physician order entry and

22  other information technologies related to patient safety.

23         Section 23.  Subsection (3) of section 409.91255,

24  Florida Statutes, is amended to read:

25         409.91255  Federally qualified health center access

26  program.--

27         (3)  ASSISTANCE TO FEDERALLY QUALIFIED HEALTH

28  CENTERS.--The Department of Health shall develop a program for

29  the expansion of federally qualified health centers for the

30  purpose of providing comprehensive primary and preventive

31  health care and urgent care services, including services that

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 1  may reduce the morbidity, mortality, and cost of care among

 2  the uninsured population of the state. The program shall

 3  provide for distribution of financial assistance to federally

 4  qualified health centers that apply and demonstrate a need for

 5  such assistance in order to sustain or expand the delivery of

 6  primary and preventive health care services. In selecting

 7  centers to receive this financial assistance, the program:

 8         (a)  Shall give preference to communities that have few

 9  or no community-based primary care services or in which the

10  current services are unable to meet the community's needs.

11         (b)  Shall require that primary care services be

12  provided to the medically indigent using a sliding fee

13  schedule based on income.

14         (c)  Shall allow innovative and creative uses of

15  federal, state, and local health care resources.

16         (d)  Shall require that the funds provided be used to

17  pay for operating costs of a projected expansion in patient

18  caseloads or services or for capital improvement projects.

19  Capital improvement projects may include renovations to

20  existing facilities or construction of new facilities,

21  provided that an expansion in patient caseloads or services to

22  a new patient population will occur as a result of the capital

23  expenditures. The department shall include in its standard

24  contract document a requirement that any state funds provided

25  for the purchase of or improvements to real property are

26  contingent upon the contractor granting to the state a

27  security interest in the property at least to the amount of

28  the state funds provided for at least 5 years from the date of

29  purchase or the completion of the improvements or as further

30  required by law. The contract must include a provision that,

31  as a condition of receipt of state funding for this purpose,

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 1  the contractor agrees that, if it disposes of the property

 2  before the department's interest is vacated, the contractor

 3  will refund the proportionate share of the state's initial

 4  investment, as adjusted by depreciation.

 5         (e)  May require in-kind support from other sources.

 6         (f)  May encourage coordination among federally

 7  qualified health centers, other private-sector providers, and

 8  publicly supported programs.

 9         (g)  Shall allow the development of community emergency

10  room diversion programs in conjunction with local resources,

11  providing extended hours of operation to urgent care patients.

12  Diversion programs shall include case management for emergency

13  room followup care.

14         Section 24.  Paragraph (a) of subsection (6) of section

15  627.410, Florida Statutes, is amended to read:

16         627.410  Filing, approval of forms.--

17         (6)(a)  An insurer shall not deliver or issue for

18  delivery or renew in this state any health insurance policy

19  form until it has filed with the office a copy of every

20  applicable rating manual, rating schedule, change in rating

21  manual, and change in rating schedule; if rating manuals and

22  rating schedules are not applicable, the insurer must file

23  with the office order applicable premium rates and any change

24  in applicable premium rates. This paragraph does not apply to

25  group health insurance policies, effectuated and delivered in

26  this state, insuring groups of 51 or more persons, except for

27  Medicare supplement insurance, long-term care insurance, and

28  any coverage under which the increase in claim costs over the

29  lifetime of the contract due to advancing age or duration is

30  prefunded in the premium.

31  

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 1         Section 25.  Section 627.6405, Florida Statutes, is

 2  created to read:

 3         627.6405  Decrease in inappropriate utilization of

 4  emergency care.--

 5         (1)  The Legislature finds and declares it to be of

 6  vital importance that emergency services and care be provided

 7  by hospitals and physicians to every person in need of such

 8  care, but with the double-digit increases in health insurance

 9  premiums, health care providers and insurers should encourage

10  patients and the insured to assume responsibility for their

11  treatment, including emergency care. The Legislature finds

12  that inappropriate utilization of emergency department

13  services increases the overall cost of providing health care

14  and these costs are ultimately borne by the hospital, the

15  insured patients, and, many times, by the taxpayers of this

16  state. Finally, the Legislature declares that the providers

17  and insurers must share the responsibility of providing

18  alternative treatment options to urgent care patients outside

19  of the emergency department. Therefore, it is the intent of

20  the Legislature to place the obligation for educating

21  consumers and creating mechanisms for delivery of care that

22  will decrease the overutilization of emergency service on

23  health insurers and providers.

24         (2)  Health insurers shall provide on their websites

25  information regarding appropriate utilization of emergency

26  care services which shall include, but not be limited to, a

27  list of alternative urgent care contracted providers, the

28  types of services offered by these providers, and what to do

29  in the event of a true emergency.

30         (3)  Health insurers shall develop community emergency

31  department diversion programs. Such programs may include, at

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 1  the discretion of the insurer, but are not limited to,

 2  enlisting providers to be on call to insurers after hours,

 3  coordinating care through local community resources, and

 4  incentives to providers for case management.

 5         (4)  As a disincentive for insureds to inappropriately

 6  use emergency department services, health insurers may require

 7  higher copayments for nonemergency use of emergency

 8  departments and higher copayments for use of out-of-network

 9  emergency departments. For the purposes of this section, the

10  term "emergency care" has the same meaning as provided in s.

11  395.002, and shall include services provided to rule out an

12  emergency medical condition.

13         Section 26.  Effective upon this act becoming a law,

14  section 627.64872, Florida Statutes, is created to read:

15         627.64872  Florida Health Insurance Plan.--

16         (1)  LEGISLATIVE INTENT; FLORIDA HEALTH INSURANCE

17  PLAN.--

18         (a)  The Legislature recognizes that to secure a more

19  stable and orderly health insurance market, the establishment

20  of a plan to assume risks deemed uninsurable by the private

21  marketplace is required.

22         (b)  The Florida Health Insurance Plan is created to

23  make coverage available to individuals who have no other

24  option for similar coverage, at a premium that is commensurate

25  with the risk and benefits provided, and with benefit designs

26  that are reasonable in relation to the general market. While

27  plan operations may include supplementary funding, the plan

28  shall fundamentally operate on sound actuarial principles,

29  using basic insurance management techniques to ensure that the

30  plan is run in an economical, cost-efficient, and sound

31  

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 1  manner, conserving plan resources to serve the maximum number

 2  of people possible in a sustainable fashion.

 3         (2)  DEFINITIONS.--As used in this section:

 4         (a)  "Board" means the board of directors of the plan.

 5         (b)  "Commission" means the Financial Services

 6  Commission.

 7         (c)  "Dependent" means a resident spouse or resident

 8  unmarried child under the age of 19 years, a child who is a

 9  student under the age of 25 years and who is financially

10  dependent upon the parent, or a child of any age who is

11  disabled and dependent upon the parent.

12         (d)  "Director" means the director of the Office of

13  Insurance Regulation.

14         (e)  "Health insurance" means any hospital or medical

15  expense incurred policy pursuant to this chapter or health

16  maintenance organization subscriber contract pursuant to

17  chapter 641. The term does not include short term, accident,

18  dental-only, vision-only, fixed indemnity, limited benefit,

19  credit, or disability income insurance; coverage for onsite

20  medical clinics; insurance coverage specified in federal

21  regulations issued pursuant to Pub. L. No. 104-191, under

22  which benefits for medical care are secondary or incidental to

23  other insurance benefits; benefits for long-term care, nursing

24  home care, home health care, community-based care, or any

25  combination thereof, or other similar, limited benefits

26  specified in federal regulations issued pursuant to Pub. L.

27  No. 104-191; benefits provided under a separate policy,

28  certificate, or contract of insurance where there is no

29  coordination between the provision of the benefits and any

30  exclusion of benefits under any group health plan maintained

31  by the same plan sponsor, and the benefits are paid with

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 1  respect to an event without regard to whether benefits are

 2  provided with respect to such an event under any group health

 3  plan maintained by the same plan sponsor, such as for coverage

 4  only for a specified disease or illness; hospital indemnity or

 5  other fixed indemnity insurance; coverage offered as a

 6  separate policy, certificate, or contract of insurance, such

 7  as Medicare supplemental health insurance as defined under s.

 8  1882(g)(1) of the Social Security Act; coverage supplemental

 9  to the coverage provided under Chapter 55 of Title 10, United

10  States Code (Civilian Health and Medical Program of the

11  Uniformed Services (CHAMPUS)); similar supplemental coverage

12  provided to coverage under a group health plan; coverage

13  issued as a supplement to liability insurance; insurance

14  arising out of a workers' compensation or similar law;

15  automobile medical-payment insurance; or insurance under which

16  benefits are payable with or without regard to fault and which

17  is statutorily required to be contained in any liability

18  insurance policy or equivalent self-insurance.

19         (f)  "Implementation" means the effective date after

20  the first meeting of the board when legal authority and

21  administrative ability exist for the board to subsume the

22  transfer of all statutory powers, duties, functions, assets,

23  records, personnel, and property of the Florida Comprehensive

24  Health Association as specified in s. 627.6488.

25         (g)  "Insurer" means any entity that provides health

26  insurance in this state. For purposes of this section, insurer

27  includes an insurance company with a valid certificate in

28  accordance with chapter 624, a health maintenance organization

29  with a valid certificate of authority in accordance with part

30  I or part III of chapter 641, a prepaid health clinic

31  authorized to transact business in this state pursuant to part

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 1  II of chapter 641, multiple employer welfare arrangements

 2  authorized to transact business in this state pursuant to ss.

 3  624.436-624.45, or a fraternal benefit society providing

 4  health benefits to its members as authorized pursuant to

 5  chapter 632.

 6         (h)  "Medicare" means coverage under both Parts A and B

 7  of Title XVIII of the Social Security Act, 42 USC 1395 et

 8  seq., as amended.

 9         (i)  "Medicaid" means coverage under Title XIX of the

10  Social Security Act.

11         (j)  "Office" means the Office of Insurance Regulation

12  of the Financial Services Commission.

13         (k)  "Participating insurer" means any insurer

14  providing health insurance to citizens of this state.

15         (l)  "Provider" means any physician, hospital, or other

16  institution, organization, or person that furnishes health

17  care services and is licensed or otherwise authorized to

18  practice in the state.

19         (m)  "Plan" means the Florida Health Insurance Plan

20  created in subsection (1).

21         (n)  "Plan of operation" means the articles, bylaws,

22  and operating rules and procedures adopted by the board

23  pursuant to this section.

24         (o)  "Resident" means an individual who has been

25  legally domiciled in this state for a period of at least 6

26  months.

27         (3)  BOARD OF DIRECTORS.--

28         (a)  The plan shall operate subject to the supervision

29  and control of the board. The board shall consist of the

30  director or his or her designated representative, who shall

31  serve as a member of the board and shall be its chair, and an

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 1  additional eight members, five of whom shall be appointed by

 2  the Governor, at least three of whom shall be individuals not

 3  representative of insurers or health care providers, one of

 4  whom shall be appointed by the Chief Financial Officer, one of

 5  whom shall be appointed by the President of the Senate, and

 6  one of whom shall be appointed by the Speaker of the House of

 7  Representatives.

 8         (b)  The Director of the Office of Insurance

 9  Regulation's term on the board shall be determined by

10  continued employment in the position. The remaining initial

11  board members shall serve for a period of time as follows: two

12  members appointed by the Governor and the members appointed by

13  the President of the Senate and the Speaker of the House of

14  Representatives shall serve 2-year terms; and three members

15  appointed by the Governor and the state's Chief Financial

16  Officer shall serve 4-year terms. Subsequent board members

17  shall serve for 3-year terms. A board member's term shall

18  continue until his or her successor is appointed.

19         (c)  Vacancies on the board shall be filled by the

20  appointing authority, the authority being the Governor, the

21  President of the Senate, the Speaker of the House of

22  Representatives, or the Chief Financial Officer. Board members

23  may be removed by the appointing authority for cause.

24         (d)  The director, or his or her representative, is

25  responsible for any organizational requirements necessary for

26  the initial meeting of the board which shall take place no

27  later than September 1, 2004.

28         (e)  Members shall not be compensated in their capacity

29  as board members but shall be reimbursed for reasonable

30  expenses incurred in the necessary performance of their duties

31  in accordance with s. 112.061.

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 1         (f)  The board shall submit to the commission a plan of

 2  operation for the plan and any amendments thereto necessary or

 3  suitable to ensure the fair, reasonable, and equitable

 4  administration of the plan. The plan of operation shall ensure

 5  that the plan qualifies to apply for any available funding

 6  from the Federal Government that adds to the financial

 7  viability of the plan. The plan of operation shall become

 8  effective upon approval in writing by the commission

 9  consistent with the date on which the coverage under this

10  section must be made available. If the board fails to submit a

11  suitable plan of operation within 1 year after the appointment

12  of the board of directors, or at any time thereafter fails to

13  submit suitable amendments to the plan of operation, the

14  commission shall adopt such rules as are necessary or

15  advisable to effectuate the provisions of this section. Such

16  rules shall continue in force until modified by the office or

17  superseded by a plan of operation submitted by the board and

18  approved by the commission.

19         (g)  The board shall take no action to implement the

20  plan, other than the administration of coverage of individuals

21  enrolled in the Florida Comprehensive Health Association, as

22  specified in subsection (20) and the completion of the

23  actuarial study authorized in subsection (6), until funds are

24  appropriated for start-up costs and any projected deficits.

25         (4)  PLAN OF OPERATION.--The plan of operation shall:

26         (a)  Establish procedures for operation of the plan.

27         (b)  Establish procedures for selecting an

28  administrator in accordance with subsection (11).

29         (c)  Establish procedures to create a fund, under

30  management of the board, for administrative expenses.

31  

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 1         (d)  Establish procedures for the handling, accounting,

 2  and auditing of assets, moneys, and claims of the plan and the

 3  plan administrator.

 4         (e)  Develop and implement a program to publicize the

 5  existence of the plan, plan eligibility requirements, and

 6  procedures for enrollment and maintain public awareness of the

 7  plan.

 8         (f)  Establish procedures under which applicants and

 9  participants may have grievances reviewed by a grievance

10  committee appointed by the board. The grievances shall be

11  reported to the board after completion of the review, with the

12  committee's recommendation for grievance resolution. The board

13  shall retain all written grievances regarding the plan for at

14  least 3 years.

15         (g)  Provide for other matters as may be necessary and

16  proper for the execution of the board's powers, duties, and

17  obligations under this section.

18         (5)  POWERS OF THE PLAN.--The plan shall have the

19  general powers and authority granted under the laws of this

20  state to health insurers and, in addition thereto, the

21  specific authority to:

22         (a)  Enter into such contracts as are necessary or

23  proper to carry out the provisions and purposes of this

24  section, including the authority, with the approval of the

25  commission, to enter into contracts with similar plans of

26  other states for the joint performance of common

27  administrative functions, or with persons or other

28  organizations for the performance of administrative functions.

29         (b)  Take any legal actions necessary or proper to

30  recover or collect assessments due the plan.

31         (c)  Take such legal action as is necessary to:

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 1         1.  Avoid payment of improper claims against the plan

 2  or the coverage provided by or through the plan;

 3         2.  Recover any amounts erroneously or improperly paid

 4  by the plan;

 5         3.  Recover any amounts paid by the plan as a result of

 6  mistake of fact or law; or

 7         4.  Recover other amounts due the plan.

 8         (d)  Establish, and modify as appropriate, rates, rate

 9  schedules, rate adjustments, expense allowances, agents'

10  commissions, claims reserve formulas, and any other actuarial

11  functions appropriate to the operation of the plan. Rates and

12  rate schedules may be adjusted for appropriate factors such as

13  age, sex, and geographic variation in claim cost and shall

14  take into consideration appropriate factors in accordance with

15  established actuarial and underwriting practices. For purposes

16  of this paragraph, usual and customary agent's commissions

17  shall be paid for the initial placement of coverage with the

18  plan and for one renewal only.

19         (e)  Issue policies of insurance in accordance with the

20  requirements of this section.

21         (f)  Appoint appropriate legal, actuarial, investment,

22  and other committees as necessary to provide technical

23  assistance in the operation of the plan and develop and

24  educate its policyholders regarding health savings accounts,

25  policy and contract design, and any other function within the

26  authority of the plan.

27         (g)  Borrow money to effectuate the purposes of the

28  plan. Any notes or other evidence of indebtedness of the plan

29  not in default shall be legal investments for insurers and may

30  be carried as admitted assets.

31         (h)  Employ and fix the compensation of employees.

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 1         (i)  Prepare and distribute certificate of eligibility

 2  forms and enrollment instruction forms to insurance producers

 3  and to the general public.

 4         (j)  Provide for reinsurance of risks incurred by the

 5  plan.

 6         (k)  Provide for and employ cost-containment measures

 7  and requirements, including, but not limited to, preadmission

 8  screening, second surgical opinion, concurrent utilization

 9  review, and individual case management for the purpose of

10  making the plan more cost-effective.

11         (l)  Design, use, contract, or otherwise arrange for

12  the delivery of cost-effective health care services,

13  including, but not limited to, establishing or contracting

14  with preferred provider organizations, health maintenance

15  organizations, and other limited network provider

16  arrangements.

17         (m)  Adopt such bylaws, policies, and procedures as may

18  be necessary or convenient for the implementation of this

19  section and the operation of the plan.

20         (n)  Subsume the transfer of statutory powers, duties,

21  functions, assets, records, personnel, and property of the

22  Florida Comprehensive Health Association as specified in ss.

23  627.6488, 627.6489, 627.649, 627.6492, 627.6496, 627.6498, and

24  627.6499, unless otherwise specified by law.

25         (6)(a)  Interim report.--No later than December 1,

26  2004, the board shall submit to the Governor, the President of

27  the Senate, and the Speaker of the House of Representatives an

28  actuarial study to determine, including, but not limited to:

29         1.  The impact the creation of this plan will have on

30  the small group insurance market, specifically on the premiums

31  paid by insureds. This shall include an estimate of the total

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 1  anticipated aggregate savings for all small employers in the

 2  state.

 3         2.  The number of individuals the pool could reasonably

 4  cover at various funding levels.

 5         3.  A recommendation as to the best source of funding

 6  for the anticipated deficits of the pool.

 7         4.  The effect on the individual and small group market

 8  by including in the Florida Health Insurance Plan persons

 9  eligible for coverage under s. 627.6487, as well as the cost

10  of including these individuals.

11         (b)  Annual report.--No later than December 1, 2005,

12  and annually thereafter, the board shall submit to the

13  Governor, the President of the Senate, the Speaker of the

14  House of Representatives, and the substantive legislative

15  committees of the Legislature a report which includes an

16  independent actuarial study to determine, including, but not

17  be limited to:

18         1.  The impact the creation of the plan has on the

19  small group and individual insurance market, specifically on

20  the premiums paid by insureds. This shall include an estimate

21  of the total anticipated aggregate savings for all small

22  employers in the state.

23         2.  The actual number of individuals covered at the

24  current funding and benefit level, the projected number of

25  individuals that may seek coverage in the forthcoming fiscal

26  year, and the projected funding needed to cover anticipated

27  increase or decrease in plan participation.

28         3.  A recommendation as to the best source of funding

29  for the anticipated deficits of the pool.

30         4.  A summarization of the activities of the plan in

31  the preceding calendar year, including the net written and

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 1  earned premiums, plan enrollment, the expense of

 2  administration, and the paid and incurred losses.

 3         5.  A review of the operation of the plan as to whether

 4  the plan has met the intent of this section.

 5         (7)  LIABILITY OF THE PLAN.--Neither the board nor its

 6  employees shall be liable for any obligations of the plan. No

 7  member or employee of the board shall be liable, and no cause

 8  of action of any nature may arise against a member or employee

 9  of the board, for any act or omission related to the

10  performance of any powers and duties under this section,

11  unless such act or omission constitutes willful or wanton

12  misconduct. The board may provide in its bylaws or rules for

13  indemnification of, and legal representation for, its members

14  and employees.

15         (8)  AUDITED FINANCIAL STATEMENT.--No later than June 1

16  following the close of each calendar year, the plan shall

17  submit to the Governor an audited financial statement prepared

18  in accordance with statutory accounting principles as adopted

19  by the National Association of Insurance Commissioners.

20         (9)  ELIGIBILITY.--

21         (a)  Any individual person who is and continues to be a

22  resident of this state shall be eligible for coverage under

23  the plan if:

24         1.  Evidence is provided that the person received

25  notices of rejection or refusal to issue substantially similar

26  insurance for health reasons from two or more health insurers.

27  A rejection or refusal by an insurer offering only stoploss,

28  excess of loss, or reinsurance coverage with respect to the

29  applicant shall not be sufficient evidence under this

30  paragraph; or

31  

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 1         2.  The person is enrolled in the Florida Comprehensive

 2  Health Association as of the date the plan is implemented.

 3         (b)  Each resident dependent of a person who is

 4  eligible for coverage under the plan shall also be eligible

 5  for such coverage.

 6         (c)  A person shall not be eligible for coverage under

 7  the plan if:

 8         1.  The person has or obtains health insurance coverage

 9  substantially similar to or more comprehensive than a plan

10  policy, or would be eligible to obtain such coverage, unless a

11  person may maintain other coverage for the period of time the

12  person is satisfying any preexisting condition waiting period

13  under a plan policy or may main tain plan coverage for the

14  period of time the person is satisfying a preexisting

15  condition waiting period under another health insurance policy

16  intended to replace the plan policy;

17         2.  The person is determined to be eligible for health

18  care benefits under Medicaid, Medicare, the state's children's

19  health insurance program, or any other federal, state, or

20  local government program that provides health benefits;

21         3.  The person voluntarily terminated plan coverage

22  unless 12 months have elapsed since such termination;

23         4.  The person is an inmate or resident of a public

24  institution; or

25         5.  The person's premiums are paid for or reimbursed

26  under any government-sponsored program or by any government

27  agency or health care provider.

28         (d)  Coverage shall cease:

29         1.  On the date a person is no longer a resident of

30  this state;

31         2.  On the date a person requests coverage to end;

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 1         3.  Upon the death of the covered person;

 2         4.  On the date state law requires cancellation or

 3  nonrenewal of the policy;

 4         5.  At the option of the plan, 30 days after the plan

 5  makes any inquiry concerning the person's eligibility or place

 6  of residence to which the person does not reply; or

 7         6.  Upon failure of the insured to pay for continued

 8  coverage.

 9         (e)  Except under the circumstances described in this

10  subsection, coverage of a person who ceased to meet the

11  eligibility requirements of this subsection shall be

12  terminated at the end of the policy period for which the

13  necessary premiums have been paid.

14         (10)  UNFAIR REFERRAL TO PLAN.--It is an unfair trade

15  practice for the purposes of part IX of chapter 626 or s.

16  641.3901 for an insurer, health maintenance organization

17  insurance agent, insurance broker, or third-party

18  administrator to refer an individual employee to the plan, or

19  arrange for an individual employee to apply to the plan, for

20  the purpose of separating that employee from group health

21  insurance coverage provided in connection with the employee's

22  employment.

23         (11)  PLAN ADMINISTRATOR.--The board shall select

24  through a competitive bidding process a plan administrator to

25  administer the plan. The board shall evaluate bids submitted

26  based on criteria established by the board, which shall

27  include:

28         (a)  The plan administrator's proven ability to handle

29  health insurance coverage to individuals.

30         (b)  The efficiency and timeliness of the plan

31  administrator's claim processing procedures.

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 1         (c)  An estimate of total charges for administering the

 2  plan.

 3         (d)  The plan administrator's ability to apply

 4  effective cost-containment programs and procedures and to

 5  administer the plan in a cost-efficient manner.

 6         (e)  The financial condition and stability of the plan

 7  administrator.

 8  

 9  The administrator shall be an insurer, a health maintenance

10  organization, or a third-party administrator, or another

11  organization duly authorized to provide insurance pursuant to

12  the Florida Insurance Code.

13         (12)  ADMINISTRATOR TERM LIMITS.--The plan

14  administrator shall serve for a period specified in the

15  contract between the plan and the plan administrator subject

16  to removal for cause and subject to any terms, conditions, and

17  limitations of the contract between the plan and the plan

18  administrator. At least 1 year prior to the expiration of each

19  period of service by a plan administrator, the board shall

20  invite eligible entities, including the current plan

21  administrator, to submit bids to serve as the plan

22  administrator. Selection of the plan administrator for each

23  succeeding period shall be made at least 6 months prior to the

24  end of the current period.

25         (13)  DUTIES OF THE PLAN ADMINISTRATOR.--

26         (a)  The plan administrator shall perform such

27  functions relating to the plan as may be assigned to it,

28  including, but not limited to:

29         1.  Determination of eligibility.

30         2.  Payment of claims.

31  

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 1         3.  Establishment of a premium billing procedure for

 2  collection of premiums from persons covered under the plan.

 3         4.  Other necessary functions to ensure timely payment

 4  of benefits to covered persons under the plan.

 5         (b)  The plan administrator shall submit regular

 6  reports to the board regarding the operation of the plan. The

 7  frequency, content, and form of the reports shall be specified

 8  in the contract between the board and the plan administrator.

 9         (c)  On March 1 following the close of each calendar

10  year, the plan administrator shall determine net written and

11  earned premiums, the expense of administration, and the paid

12  and incurred losses for the year and report this information

13  to the board and the Governor on a form prescribed by the

14  Governor.

15         (14)  PAYMENT OF THE PLAN ADMINISTRATOR.--The plan

16  administrator shall be paid as provided in the contract

17  between the plan and the plan administrator.

18         (15)  FUNDING OF THE PLAN.--

19         (a)  Premiums.--

20         1.  The plan shall establish premium rates for plan

21  coverage as provided in this section. Separate schedules of

22  premium rates based on age, sex, and geographical location may

23  apply for individual risks. Premium rates and schedules shall

24  be submitted to the office for approval prior to use.

25         2.  Initial rates for plan coverage shall be limited to

26  200 percent of rates established as applicable for individual

27  standard risks as specified in s. 627.6675(3)(c). Subject to

28  the limits provided in this paragraph, subsequent rates shall

29  be established to provide fully for the expected costs of

30  claims, including recovery of prior losses, expenses of

31  operation, investment income of claim reserves, and any other

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 1  cost factors subject to the limitations described herein, but

 2  in no event shall premiums exceed the 200-percent rate

 3  limitation provided in this section. Notwithstanding the

 4  200-percent rate limitation, sliding scale premium surcharges

 5  based upon the insured's income may apply to all enrollees,

 6  provided that such premiums do not exceed 300 percent of the

 7  standard risk rate.

 8         (b)  Sources of additional revenue.--Any deficit

 9  incurred by the plan shall be primarily funded through amounts

10  appropriated by the Legislature from general revenue sources,

11  including, but not limited to, a portion of the annual growth

12  in existing net insurance premium taxes. The board shall

13  operate the plan in such a manner that the estimated cost of

14  providing health insurance during any fiscal year will not

15  exceed total income the plan expects to receive from policy

16  premiums and funds appropriated by the Legislature, including

17  any interest on investments. After determining the amount of

18  funds appropriated to the board for a fiscal year, the board

19  shall estimate the number of new policies it believes the plan

20  has the financial capacity to insure during that year so that

21  costs do not exceed income. The board shall take steps

22  necessary to ensure that plan enrollment does not exceed the

23  number of residents it has estimated it has the financial

24  capacity to insure.

25         (16)  BENEFITS.--

26         (a)  The benefits provided shall be the same as the

27  standard and basic plans for small employers as outlined in s.

28  627.6699. The board shall also establish an option of

29  alternative coverage such as catastrophic coverage that

30  includes a minimum level of primary care coverage and a high

31  

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 1  deductible plan that meets the federal requirements of a

 2  health savings account.

 3         (b)  In establishing the plan coverage, the board shall

 4  take into consideration the levels of health insurance

 5  provided in the state and such medical economic factors as may

 6  be deemed appropriate and adopt benefit levels, deductibles,

 7  copayments, coinsurance factors, exclusions, and limitations

 8  determined to be generally reflective of and commensurate with

 9  health insurance provided through a representative number of

10  large employers in the state.

11         (c)  The board may adjust any deductibles and

12  coinsurance factors annually according to the medical

13  component of the Consumer Price Index.

14         (d)1.  Plan coverage shall exclude charges or expenses

15  incurred during the first 6 months following the effective

16  date of coverage for any condition for which medical advice,

17  care, or treatment was recommended or received for such

18  condition during the 6-month period immediately preceding the

19  effective date of coverage.

20         2.  Such preexisting condition exclusions shall be

21  waived to the extent that similar exclusions, if any, have

22  been satisfied under any prior health insurance coverage which

23  was involuntarily terminated, provided application for pool

24  coverage is made not later than 63 days following such

25  involuntary termination. In such case, coverage under the plan

26  shall be effective from the date on which such prior coverage

27  was terminated and the applicant is not eligible for

28  continuation or conversion rights that would provide coverage

29  substantially similar to plan coverage.

30         (17)  NONDUPLICATION OF BENEFITS.--

31  

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 1         (a)  The plan shall be payor of last resort of benefits

 2  whenever any other benefit or source of third-party payment is

 3  available. Benefits otherwise payable under plan coverage

 4  shall be reduced by all amounts paid or payable through any

 5  other health insurance, by all hospital and medical expense

 6  benefits paid or payable under any workers' compensation

 7  coverage, automobile medical payment, or liability insurance,

 8  whether provided on the basis of fault or nonfault, and by any

 9  hospital or medical benefits paid or payable under or provided

10  pursuant to any state or federal law or program.

11         (b)  The plan shall have a cause of action against an

12  eligible person for the recovery of the amount of benefits

13  paid that are not for covered expenses. Benefits due from the

14  plan may be reduced or refused as a setoff against any amount

15  recoverable under this paragraph.

16         (18)  ANNUAL AND MAXIMUM BENEFITS.--Maximum benefits

17  under the plan shall be determined by the board.

18         (19)  TAXATION.--The plan is exempt from any tax

19  imposed by this state. The plan shall apply for federal tax

20  exemption status.

21         (20)  COMBINING MEMBERSHIP OF THE FLORIDA COMPREHENSIVE

22  HEALTH ASSOCIATION.--

23         (a)1.  Upon implementation of the Florida Health

24  Insurance Plan, the Florida Comprehensive Health Association,

25  as specified in s. 627.6488 is abolished as a separate

26  nonprofit entity and shall be subsumed under the Board of

27  Directors of the Florida Health Insurance Plan. All

28  individuals actively enrolled in the Florida Comprehensive

29  Health Association shall be enrolled in th plan subject to its

30  rules and requirements, except as otherwise specified in this

31  section. Maximum lifetime benefits paid to an individual in

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 1  the plan may not exceed the amount established under

 2  subsection (16), and benefits previously paid for any

 3  individual by the Florida Comprehensive Health Association

 4  shall be used in the determination of the total lifetime

 5  benefits paid under the plan.

 6         2.  All persons enrolled in the Florida Comprehensive

 7  Health Association upon implementation of the Florida Health

 8  Insurance Plan are eligible only for the benefits authorized

 9  under subsection (16). Persons identified by this section

10  shall convert to the benefits authorized under subsection (16)

11  no later than January 1, 2005.

12         3.  Except as otherwise provided in this section, the

13  Florida Comprehensive Health Association shall operate under

14  the existing plan of operation without modification until the

15  adoption of the new plan of operation for the Florida Health

16  Insurance Plan.

17         (b)1.  As a condition of doing business in this state,

18  an insurer shall pay an assessment to the board in the amount

19  prescribed by this paragraph. For operating losses incurred on

20  or after July 1, 2004, by persons previously enrolled in the

21  Florida Comprehensive Health Association, each insurer shall

22  annually be assessed by the board in the following calendar

23  year a portion of such incurred operating losses of the plan.

24  Such portion shall be determined by multiplying such operating

25  losses by a fraction, the numerator of which equals the

26  insurer's earned premium pertaining to direct writings of

27  health insurance in the state during the calendar year

28  proceeding that for which the assessment is levied, and the

29  denominator of which equals the total of all such premiums

30  earned by participating insurers in the state during such

31  calendar year.

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 1         2.  The total of all assessments under this paragraph

 2  upon a participating insurer shall not exceed 1 percent of

 3  such insurer's health insurance premium earned in this state

 4  during the calendar year preceding the year for which the

 5  assessments were levied.

 6         3.  All rights, title, and interest in the assessment

 7  funds collected under this paragraph shall vest in this state.

 8  However, all of such funds and interest earned shall be used

 9  by the plan to pay claims and administrative expenses.

10         (c)  If assessments and other receipts by the plan,

11  board, or plan administrator exceed the actual losses and

12  administrative expenses of the plan, the excess shall be held

13  in interest and used by the board to offset future losses. As

14  used in this subsection, the term "future losses" includes

15  reserves for claims incurred but not reported.

16         (d)  Each insurer's assessment shall be determined

17  annually by the board or plan administrator based on annual

18  statements and other reports deemed necessary by the board or

19  plan administrator and filed with the board or plan

20  administrator by the insurer. Any deficit incurred under the

21  plan by persons previously enrolled in the Florida

22  Comprehensive Health Association shall be recouped by the

23  assessments against participating insurers by the board or

24  plan administrator in the manner provided in paragraph (b),

25  and the insurers may recover the assessment in the normal

26  course of their respective businesses without time limitation.

27         (e)  If a person enrolled in the Florida Comprehensive

28  Health Association as of July 1, 2004, loses eligibility for

29  participation in the plan, such person shall not be included

30  in the calculation of incurred operational losses as described

31  

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 1  in paragraph (b) if the person later regains eligibility for

 2  participation in the plan.

 3         (f)  After all persons enrolled in the Florida

 4  Comprehensive Health Association as of July 1, 2004, are no

 5  longer eligible for participation in the plan, the plan,

 6  board, or plan administrator shall no longer be allowed to

 7  assess insurers in this state for incurred losses as described

 8  in paragraph (b).

 9         Section 27.  Upon implementation, as defined in section

10  627.64872(2), Florida Statutes, and provided in section

11  627.64872(20), Florida Statutes, of the Florida Health Benefit

12  Plan created under section 627.64872, Florida Statutes,

13  sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494,

14  627.6496, and 627.6498, Florida Statutes, are repealed.

15         Section 28.  Subsections (12) and (13) are added to

16  section 627.662, Florida Statutes, to read:

17         627.662  Other provisions applicable.--The following

18  provisions apply to group health insurance, blanket health

19  insurance, and franchise health insurance:

20         (12)  Section 627.6044, relating to the use of specific

21  methodology for payment of claims.

22         (13)  Section 627.6405, relating to inappropriate

23  utilization of emergency care.

24         Section 29.  Paragraphs (c) and (d) of subsection (5),

25  subsection (6), and subsection (12) of section 627.6699,

26  Florida Statutes, are amended, subsections (15) and (16) of

27  that section are renumbered as subsections (16) and (17),

28  respectively, present subsection (15) of that section is

29  amended, and new subsections (15) and (18) are added to that

30  section, to read:

31         627.6699  Employee Health Care Access Act.--

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 1         (5)  AVAILABILITY OF COVERAGE.--

 2         (c)  Every small employer carrier must, as a condition

 3  of transacting business in this state:

 4         1.  Offer and issue all small employer health benefit

 5  plans on a guaranteed-issue basis to every eligible small

 6  employer, with 2 to 50 eligible employees, that elects to be

 7  covered under such plan, agrees to make the required premium

 8  payments, and satisfies the other provisions of the plan. A

 9  rider for additional or increased benefits may be medically

10  underwritten and may only be added to the standard health

11  benefit plan. The increased rate charged for the additional or

12  increased benefit must be rated in accordance with this

13  section.

14         2.  In the absence of enrollment availability in the

15  Florida Health Insurance Plan, offer and issue basic and

16  standard small employer health benefit plans on a

17  guaranteed-issue basis, during a 31-day open enrollment period

18  of August 1 through August 31 of each year, to every eligible

19  small employer, with fewer than two eligible employees, which

20  small employer is not formed primarily for the purpose of

21  buying health insurance and which elects to be covered under

22  such plan, agrees to make the required premium payments, and

23  satisfies the other provisions of the plan. Coverage provided

24  under this subparagraph shall begin on October 1 of the same

25  year as the date of enrollment, unless the small employer

26  carrier and the small employer agree to a different date. A

27  rider for additional or increased benefits may be medically

28  underwritten and may only be added to the standard health

29  benefit plan. The increased rate charged for the additional or

30  increased benefit must be rated in accordance with this

31  section. For purposes of this subparagraph, a person, his or

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 1  her spouse, and his or her dependent children constitute a

 2  single eligible employee if that person and spouse are

 3  employed by the same small employer and either that person or

 4  his or her spouse has a normal work week of less than 25

 5  hours. Any right to an open enrollment of health benefit

 6  coverage for groups of fewer than two employees, pursuant to

 7  this section, shall remain in full force and effect in the

 8  absence of the availability of new enrollment into the Florida

 9  Health Insurance Plan.

10         3.  This paragraph does not limit a carrier's ability

11  to offer other health benefit plans to small employers if the

12  standard and basic health benefit plans are offered and

13  rejected.

14         (d)  A small employer carrier must file with the

15  office, in a format and manner prescribed by the committee, a

16  standard health care plan, a high deductible plan that meets

17  the federal requirements of a health savings account plan or a

18  health reimbursement arrangement, and a basic health care plan

19  to be used by the carrier. The provisions of this section

20  which require the filing of a high deductible plan shall take

21  effect September 1, 2004.

22         (6)  RESTRICTIONS RELATING TO PREMIUM RATES.--

23         (a)  The commission may, by rule, establish regulations

24  to administer this section and to assure that rating practices

25  used by small employer carriers are consistent with the

26  purpose of this section, including assuring that differences

27  in rates charged for health benefit plans by small employer

28  carriers are reasonable and reflect objective differences in

29  plan design, not including differences due to the nature of

30  the groups assumed to select particular health benefit plans.

31  

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 1         (b)  For all small employer health benefit plans that

 2  are subject to this section and are issued by small employer

 3  carriers on or after January 1, 1994, premium rates for health

 4  benefit plans subject to this section are subject to the

 5  following:

 6         1.  Small employer carriers must use a modified

 7  community rating methodology in which the premium for each

 8  small employer must be determined solely on the basis of the

 9  eligible employee's and eligible dependent's gender, age,

10  family composition, tobacco use, or geographic area as

11  determined under paragraph (5)(j) and in which the premium may

12  be adjusted as permitted by this paragraph.

13         2.  Rating factors related to age, gender, family

14  composition, tobacco use, or geographic location may be

15  developed by each carrier to reflect the carrier's experience.

16  The factors used by carriers are subject to office review and

17  approval.

18         3.  Small employer carriers may not modify the rate for

19  a small employer for 12 months from the initial issue date or

20  renewal date, unless the composition of the group changes or

21  benefits are changed. However, a small employer carrier may

22  modify the rate one time prior to 12 months after the initial

23  issue date for a small employer who enrolls under a previously

24  issued group policy that has a common anniversary date for all

25  employers covered under the policy if:

26         a.  The carrier discloses to the employer in a clear

27  and conspicuous manner the date of the first renewal and the

28  fact that the premium may increase on or after that date.

29         b.  The insurer demonstrates to the office that

30  efficiencies in administration are achieved and reflected in

31  the rates charged to small employers covered under the policy.

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 1         4.  A carrier may issue a group health insurance policy

 2  to a small employer health alliance or other group association

 3  with rates that reflect a premium credit for expense savings

 4  attributable to administrative activities being performed by

 5  the alliance or group association if such expense savings are

 6  specifically documented in the insurer's rate filing and are

 7  approved by the office.  Any such credit may not be based on

 8  different morbidity assumptions or on any other factor related

 9  to the health status or claims experience of any person

10  covered under the policy. Nothing in this subparagraph exempts

11  an alliance or group association from licensure for any

12  activities that require licensure under the insurance code. A

13  carrier issuing a group health insurance policy to a small

14  employer health alliance or other group association shall

15  allow any properly licensed and appointed agent of that

16  carrier to market and sell the small employer health alliance

17  or other group association policy. Such agent shall be paid

18  the usual and customary commission paid to any agent selling

19  the policy.

20         5.  Any adjustments in rates for claims experience,

21  health status, or duration of coverage may not be charged to

22  individual employees or dependents. For a small employer's

23  policy, such adjustments may not result in a rate for the

24  small employer which deviates more than 15 percent from the

25  carrier's approved rate. Any such adjustment must be applied

26  uniformly to the rates charged for all employees and

27  dependents of the small employer. A small employer carrier may

28  make an adjustment to a small employer's renewal premium, not

29  to exceed 10 percent annually, due to the claims experience,

30  health status, or duration of coverage of the employees or

31  dependents of the small employer. Semiannually, small group

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 1  carriers shall report information on forms adopted by rule by

 2  the commission, to enable the office to monitor the

 3  relationship of aggregate adjusted premiums actually charged

 4  policyholders by each carrier to the premiums that would have

 5  been charged by application of the carrier's approved modified

 6  community rates. If the aggregate resulting from the

 7  application of such adjustment exceeds the premium that would

 8  have been charged by application of the approved modified

 9  community rate by 4 5 percent for the current reporting

10  period, the carrier shall limit the application of such

11  adjustments only to minus adjustments beginning not more than

12  60 days after the report is sent to the office. For any

13  subsequent reporting period, if the total aggregate adjusted

14  premium actually charged does not exceed the premium that

15  would have been charged by application of the approved

16  modified community rate by 4 5 percent, the carrier may apply

17  both plus and minus adjustments. A small employer carrier may

18  provide a credit to a small employer's premium based on

19  administrative and acquisition expense differences resulting

20  from the size of the group. Group size administrative and

21  acquisition expense factors may be developed by each carrier

22  to reflect the carrier's experience and are subject to office

23  review and approval.

24         6.  A small employer carrier rating methodology may

25  include separate rating categories for one dependent child,

26  for two dependent children, and for three or more dependent

27  children for family coverage of employees having a spouse and

28  dependent children or employees having dependent children

29  only. A small employer carrier may have fewer, but not

30  greater, numbers of categories for dependent children than

31  those specified in this subparagraph.

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 1         7.  Small employer carriers may not use a composite

 2  rating methodology to rate a small employer with fewer than 10

 3  employees. For the purposes of this subparagraph, a "composite

 4  rating methodology" means a rating methodology that averages

 5  the impact of the rating factors for age and gender in the

 6  premiums charged to all of the employees of a small employer.

 7         8.a.  A carrier may separate the experience of small

 8  employer groups with fewer less than 2 eligible employees from

 9  the experience of small employer groups with 2-50 eligible

10  employees for purposes of determining an alternative modified

11  community rating.

12         b.  If a carrier separates the experience of small

13  employer groups as provided in sub-subparagraph a., the rate

14  to be charged to small employer groups of fewer less than 2

15  eligible employees may not exceed 150 percent of the rate

16  determined for small employer groups of 2-50 eligible

17  employees. However, the carrier may charge excess losses of

18  the experience pool consisting of small employer groups with

19  fewer less than 2 eligible employees to the experience pool

20  consisting of small employer groups with 2-50 eligible

21  employees so that all losses are allocated and the 150-percent

22  rate limit on the experience pool consisting of small employer

23  groups with fewer less than 2 eligible employees is

24  maintained. Notwithstanding s. 627.411(1), the rate to be

25  charged to a small employer group of fewer than 2 eligible

26  employees, insured as of July 1, 2002, may be up to 125

27  percent of the rate determined for small employer groups of

28  2-50 eligible employees for the first annual renewal and 150

29  percent for subsequent annual renewals.

30         (c)  For all small employer health benefit plans that

31  are subject to this section, that are issued by small employer

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 1  carriers before January 1, 1994, and that are renewed on or

 2  after January 1, 1995, renewal rates must be based on the same

 3  modified community rating standard applied to new business.

 4         (d)  Notwithstanding s. 627.401(2), this section and

 5  ss. 627.410 and 627.411 apply to any health benefit plan

 6  provided by a small employer carrier that is an insurer, and

 7  this section and s. 641.31 apply to any health benefit

 8  provided by a small employer carrier that is a health

 9  maintenance organization, that provides coverage to one or

10  more employees of a small employer regardless of where the

11  policy, certificate, or contract is issued or delivered, if

12  the health benefit plan covers employees or their covered

13  dependents who are residents of this state.

14         (12)  STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED

15  HEALTH BENEFIT PLANS.--

16         (a)1.  The Chief Financial Officer shall appoint a

17  health benefit plan committee composed of four representatives

18  of carriers which shall include at least two representatives

19  of HMOs, at least one of which is a staff model HMO, two

20  representatives of agents, four representatives of small

21  employers, and one employee of a small employer. The carrier

22  members shall be selected from a list of individuals

23  recommended by the board. The Chief Financial Officer may

24  require the board to submit additional recommendations of

25  individuals for appointment.

26         2.  The plans shall comply with all of the requirements

27  of this subsection.

28         3.  The plans must be filed with and approved by the

29  office prior to issuance or delivery by any small employer

30  carrier.

31  

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 1         4.  After approval of the revised health benefit plans,

 2  if the office determines that modifications to a plan might be

 3  appropriate, the Chief Financial Officer shall appoint a new

 4  health benefit plan committee in the manner provided in

 5  subparagraph 1. to submit recommended modifications to the

 6  office for approval.

 7         (b)1.  Each small employer carrier issuing new health

 8  benefit plans shall offer to any small employer, upon request,

 9  a standard health benefit plan, and a basic health benefit

10  plan, and a high deductible plan that meets the requirements

11  of a health savings account plan or health reimbursement

12  account as defined by federal law, that meet meets the

13  criteria set forth in this section.

14         2.  For purposes of this subsection, the terms

15  "standard health benefit plan," and "basic health benefit

16  plan," and "high deductible plan" mean policies or contracts

17  that a small employer carrier offers to eligible small

18  employers that contain:

19         a.  An exclusion for services that are not medically

20  necessary or that are not covered preventive health services;

21  and

22         b.  A procedure for preauthorization by the small

23  employer carrier, or its designees.

24         3.  A small employer carrier may include the following

25  managed care provisions in the policy or contract to control

26  costs:

27         a.  A preferred provider arrangement or exclusive

28  provider organization or any combination thereof, in which a

29  small employer carrier enters into a written agreement with

30  the provider to provide services at specified levels of

31  reimbursement or to provide reimbursement to specified

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 1  providers. Any such written agreement between a provider and a

 2  small employer carrier must contain a provision under which

 3  the parties agree that the insured individual or covered

 4  member has no obligation to make payment for any medical

 5  service rendered by the provider which is determined not to be

 6  medically necessary. A carrier may use preferred provider

 7  arrangements or exclusive provider arrangements to the same

 8  extent as allowed in group products that are not issued to

 9  small employers.

10         b.  A procedure for utilization review by the small

11  employer carrier or its designees.

12  

13  This subparagraph does not prohibit a small employer carrier

14  from including in its policy or contract additional managed

15  care and cost containment provisions, subject to the approval

16  of the office, which have potential for controlling costs in a

17  manner that does not result in inequitable treatment of

18  insureds or subscribers. The carrier may use such provisions

19  to the same extent as authorized for group products that are

20  not issued to small employers.

21         4.  The standard health benefit plan shall include:

22         a.  Coverage for inpatient hospitalization;

23         b.  Coverage for outpatient services;

24         c.  Coverage for newborn children pursuant to s.

25  627.6575;

26         d.  Coverage for child care supervision services

27  pursuant to s. 627.6579;

28         e.  Coverage for adopted children upon placement in the

29  residence pursuant to s. 627.6578;

30         f.  Coverage for mammograms pursuant to s. 627.6613;

31  

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 1         g.  Coverage for handicapped children pursuant to s.

 2  627.6615;

 3         h.  Emergency or urgent care out of the geographic

 4  service area; and

 5         i.  Coverage for services provided by a hospice

 6  licensed under s. 400.602 in cases where such coverage would

 7  be the most appropriate and the most cost-effective method for

 8  treating a covered illness.

 9         5.  The standard health benefit plan and the basic

10  health benefit plan may include a schedule of benefit

11  limitations for specified services and procedures. If the

12  committee develops such a schedule of benefits limitation for

13  the standard health benefit plan or the basic health benefit

14  plan, a small employer carrier offering the plan must offer

15  the employer an option for increasing the benefit schedule

16  amounts by 4 percent annually.

17         6.  The basic health benefit plan shall include all of

18  the benefits specified in subparagraph 4.; however, the basic

19  health benefit plan shall place additional restrictions on the

20  benefits and utilization and may also impose additional cost

21  containment measures.

22         7.  Sections 627.419(2), (3), and (4), 627.6574,

23  627.6612, 627.66121, 627.66122, 627.6616, 627.6618, 627.668,

24  and 627.66911 apply to the standard health benefit plan and to

25  the basic health benefit plan. However, notwithstanding said

26  provisions, the plans may specify limits on the number of

27  authorized treatments, if such limits are reasonable and do

28  not discriminate against any type of provider.

29         8.  The high deductible plan associated with a health

30  savings account or a health reimbursement arrangement shall

31  include all the benefits specified in subparagraph 4.

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 1         9.8.  Each small employer carrier that provides for

 2  inpatient and outpatient services by allopathic hospitals may

 3  provide as an option of the insured similar inpatient and

 4  outpatient services by hospitals accredited by the American

 5  Osteopathic Association when such services are available and

 6  the osteopathic hospital agrees to provide the service.

 7         (c)  If a small employer rejects, in writing, the

 8  standard health benefit plan, and the basic health benefit

 9  plan, and the high deductible health savings account plan or a

10  health reimbursement arrangement, the small employer carrier

11  may offer the small employer a limited benefit policy or

12  contract.

13         (d)1.  Upon offering coverage under a standard health

14  benefit plan, a basic health benefit plan, or a limited

15  benefit policy or contract for any small employer, the small

16  employer carrier shall provide such employer group with a

17  written statement that contains, at a minimum:

18         a.  An explanation of those mandated benefits and

19  providers that are not covered by the policy or contract;

20         b.  An explanation of the managed care and cost control

21  features of the policy or contract, along with all appropriate

22  mailing addresses and telephone numbers to be used by insureds

23  in seeking information or authorization; and

24         c.  An explanation of the primary and preventive care

25  features of the policy or contract.

26  

27  Such disclosure statement must be presented in a clear and

28  understandable form and format and must be separate from the

29  policy or certificate or evidence of coverage provided to the

30  employer group.

31  

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 1         2.  Before a small employer carrier issues a standard

 2  health benefit plan, a basic health benefit plan, or a limited

 3  benefit policy or contract, it must obtain from the

 4  prospective policyholder a signed written statement in which

 5  the prospective policyholder:

 6         a.  Certifies as to eligibility for coverage under the

 7  standard health benefit plan, basic health benefit plan, or

 8  limited benefit policy or contract;

 9         b.  Acknowledges the limited nature of the coverage and

10  an understanding of the managed care and cost control features

11  of the policy or contract;

12         c.  Acknowledges that if misrepresentations are made

13  regarding eligibility for coverage under a standard health

14  benefit plan, a basic health benefit plan, or a limited

15  benefit policy or contract, the person making such

16  misrepresentations forfeits coverage provided by the policy or

17  contract; and

18         d.  If a limited plan is requested, acknowledges that

19  the prospective policyholder had been offered, at the time of

20  application for the insurance policy or contract, the

21  opportunity to purchase any health benefit plan offered by the

22  carrier and that the prospective policyholder had rejected

23  that coverage.

24  

25  A copy of such written statement shall be provided to the

26  prospective policyholder no later than at the time of delivery

27  of the policy or contract, and the original of such written

28  statement shall be retained in the files of the small employer

29  carrier for the period of time that the policy or contract

30  remains in effect or for 5 years, whichever period is longer.

31  

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 1         3.  Any material statement made by an applicant for

 2  coverage under a health benefit plan which falsely certifies

 3  as to the applicant's eligibility for coverage serves as the

 4  basis for terminating coverage under the policy or contract.

 5         4.  Each marketing communication that is intended to be

 6  used in the marketing of a health benefit plan in this state

 7  must be submitted for review by the office prior to use and

 8  must contain the disclosures stated in this subsection.

 9         (e)  A small employer carrier may not use any policy,

10  contract, form, or rate under this section, including

11  applications, enrollment forms, policies, contracts,

12  certificates, evidences of coverage, riders, amendments,

13  endorsements, and disclosure forms, until the insurer has

14  filed it with the office and the office has approved it under

15  ss. 627.410 and 627.411 and this section.

16         (15)  SMALL EMPLOYERS ACCESS PROGRAM.--

17         (a)  Popular name.--This subsection may be referred to

18  by the popular name "The Small Employers Access Program."

19         (b)  Intent.--The Legislature finds that increased

20  access to health care coverage for small employers with up to

21  25 employees could improve employees' health and reduce the

22  incidence and costs of illness and disabilities among

23  residents in this state. Many employers do not offer health

24  care benefits to their employees citing the increased cost of

25  this benefit. It is the intent of the Legislature to create

26  the Small Business Health Plan to provide small employers the

27  option and ability to provide health care benefits to their

28  employees at an affordable cost through the creation of

29  purchasing pools for employers with up to 25 employees, and

30  rural hospital employers and nursing home employers regardless

31  of the number of employees.

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 1         (c)  Definitions.--For purposes of this subsection, the

 2  term:

 3         1.  "Fair commission" means a commission structure

 4  determined by the insurers and reflected in the insurers' rate

 5  filings made pursuant to this subsection.

 6         2.  "Insurer" means any entity that provides health

 7  insurance in this state. For purposes of this subsection,

 8  insurer includes an insurance company holding a certificate of

 9  authority pursuant to chapter 624 or a health maintenance

10  organization holding a certificate of authority pursuant to

11  chapter 641, which qualifies to provide coverage to small

12  employer groups pursuant to this section.

13         3.  "Mutually supported benefit plan" means an optional

14  alternative coverage plan developed within a defined

15  geographic region which may include, but is not limited to, a

16  minimum level of primary care coverage in which the percentage

17  of the premium is distributed among the employer, the

18  employee, and community-generated revenue either alone or in

19  conjunction with federal matching funds.

20         4.  "Office" means the Office of Insurance Regulation

21  of the Department of Financial Services.

22         5.  "Participating insurer" means any insurer providing

23  health insurance to small employers that has been selected by

24  the office in accordance with this subsection for its

25  designated region.

26         6.  "Program" means the Small Employer Access Program

27  as created by this subsection.

28         (d)  Eligibility.--

29         1.  Any small employer group of up to 25 employees.

30  

31  

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 1         2.  Any municipality, county, school district, or

 2  hospital located in a rural community as defined in s.

 3  288.0636(2)(b).

 4         3.  Nursing home employers may participate.

 5         4.  Each dependent of a person eligible for coverage is

 6  also eligible to participate.

 7         5.  Any small employer that is actively engaged in

 8  business, has its principal place of business in this state,

 9  employed up to 25 eligible employees on business days during

10  the preceding calendar year, and employs at least 2 employees

11  on the first day of the plan year may participate.

12  

13  Coverage for a small employer group that ceases to meet the

14  eligibility requirements of this section may be terminated at

15  the end of the policy period for which the necessary premiums

16  have been paid.

17         (e)  Administration.--

18         1.  The office shall by competitive bid, in accordance

19  with current state law, select an insurer to provide coverage

20  through the program to eligible small employers within an

21  established geographical area of this state. The office may

22  develop exclusive regions for the program similar to those

23  used by the Healthy Kids Corporation. However the office is

24  not precluded from developing, in conjunction with insurers,

25  regions different from those used by the Healthy Kids

26  Corporation if the office deems that such a region will carry

27  out the intentions of this subsection.

28         2.  The office shall evaluate bids submitted based upon

29  criteria established by the office, which shall include, but

30  not be limited to:

31  

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 1         a.  The insurer's proven ability to handle health

 2  insurance coverage to small employer groups.

 3         b.  The efficiency and timeliness of the insurer's

 4  claim processing procedures.

 5         c.  The insurer's ability to apply effective

 6  cost-containment programs and procedures and to administer the

 7  program in a cost-efficient manner.

 8         d.  The financial condition and stability of the

 9  insurer.

10         e.  The insurer's ability to develop an optional

11  mutually supported benefit plan.

12  

13  The office may use any financial information available to it

14  through its regulatory duties to make this evaluation.

15         (f)  Insurer qualifications.--The insurer shall be a

16  duly authorized insurer or health maintenance organization.

17         (g)  Duties of the insurer.--The insurer shall:

18         1.  Develop and implement a program to publicize the

19  existence of the program, program eligibility requirements,

20  and procedures for enrollment and maintain public awareness of

21  the program.

22         2.  Maintain employer awareness of the program.

23         3.  Demonstrate the ability to use delivery of

24  cost-effective health care services.

25         4.  Encourage, educate, advise, and administer the

26  effective use of health savings accounts by covered employees

27  and dependents.

28         5.  Serve for a period specified in the contract

29  between the office and the insurer, subject to removal for

30  cause and subject to any terms, conditions, and limitations of

31  

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 1  the contract between the office and the insurer as may be

 2  specified in the request for proposal.

 3         (h)  Contract term.--The contract term shall not exceed

 4  3 years. At least 6 months prior to the expiration of each

 5  contract period, the office shall invite eligible entities,

 6  including the current insurer, to submit bids to serve as the

 7  insurer for a designated geographic area. Selection of the

 8  insurer for the succeeding period shall be made at least 3

 9  months prior to the end of the current period. If a protest is

10  filed and not resolved by the end of the contract period, the

11  contract with the existing administrator may be extended for a

12  period not to exceed 6 months. During the contract extension

13  period, the administrator shall be paid at a rate to be

14  negotiated by the office.

15         (i)  Insurer reporting requirements.--On March 1

16  following the close of each calendar year, the insurer shall

17  determine net written and earned premiums, the expense of

18  administration, and the paid and incurred losses for the year

19  and report this information to the office on a form prescribed

20  by the office.

21         (j)  Application requirements.--The insurer shall

22  permit or allow any licensed and duly appointed health

23  insurance agent residing in the designated region to submit

24  applications for coverage, and such agent shall be paid a fair

25  commission if coverage is written. The agent must be appointed

26  to at least one insurer.

27         (k)  Benefits.--The benefits provided by the plan shall

28  be the same as the coverage required for small employers under

29  subsection (12). Upon the approval of the office, the insurer

30  may also establish an optional mutually supported benefit plan

31  which is an alternative plan developed within a defined

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 1  geographic region of this state or any other such alternative

 2  plan which will carry out the intent of this subsection. Any

 3  small employer carrier issuing new health benefit plans may

 4  offer a benefit plan with coverages similar to, but not less

 5  than, any alternative coverage plan developed pursuant to this

 6  subsection.

 7         (l)  Annual reporting.--The office shall make an annual

 8  report to the Governor, the President of the Senate, and the

 9  Speaker of the House of Representatives. The report shall

10  summarize the activities of the program in the preceding

11  calendar year, including the net written and earned premiums,

12  program enrollment, the expense of administration, and the

13  paid and incurred losses. The report shall be submitted no

14  later than March 15 following the close of the prior calendar

15  year.

16         (16)(15)  APPLICABILITY OF OTHER STATE LAWS.--

17         (a)  Except as expressly provided in this section, a

18  law requiring coverage for a specific health care service or

19  benefit, or a law requiring reimbursement, utilization, or

20  consideration of a specific category of licensed health care

21  practitioner, does not apply to a standard or basic health

22  benefit plan policy or contract or a limited benefit policy or

23  contract offered or delivered to a small employer unless that

24  law is made expressly applicable to such policies or

25  contracts. A law restricting or limiting deductibles,

26  coinsurance, copayments, or annual or lifetime maximum

27  payments does not apply to any health plan policy, including a

28  standard or basic health benefit plan policy or contract,

29  offered or delivered to a small employer unless such law is

30  made expressly applicable to such policy or contract. However,

31  every small employer carrier must offer to eligible small

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 1  employers the standard benefit plan and the basic benefit

 2  plan, as required by subsection (5), as such plans have been

 3  approved by the office pursuant to subsection (12).

 4         (b)  Except as provided in this section, a standard or

 5  basic health benefit plan policy or contract or limited

 6  benefit policy or contract offered to a small employer is not

 7  subject to any provision of this code which:

 8         1.  Inhibits a small employer carrier from contracting

 9  with providers or groups of providers with respect to health

10  care services or benefits;

11         2.  Imposes any restriction on a small employer

12  carrier's ability to negotiate with providers regarding the

13  level or method of reimbursing care or services provided under

14  a health benefit plan; or

15         3.  Requires a small employer carrier to either include

16  a specific provider or class of providers when contracting for

17  health care services or benefits or to exclude any class of

18  providers that is generally authorized by statute to provide

19  such care.

20         (c)  Any second tier assessment paid by a carrier

21  pursuant to paragraph (11)(j) may be credited against

22  assessments levied against the carrier pursuant to s.

23  627.6494.

24         (d)  Notwithstanding chapter 641, a health maintenance

25  organization is authorized to issue contracts providing

26  benefits equal to the standard health benefit plan, the basic

27  health benefit plan, and the limited benefit policy authorized

28  by this section.

29         (17)(16)  RULEMAKING AUTHORITY.--The commission may

30  adopt rules to administer this section, including rules

31  

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 1  governing compliance by small employer carriers and small

 2  employers.

 3         Section 30.  Section 627.9175, Florida Statutes, is

 4  amended to read:

 5         627.9175  Reports of information on health and accident

 6  insurance.--

 7         (1)  Each health insurer, prepaid limited health

 8  services organization, and health maintenance organization

 9  shall submit, no later than April 1 of each year, annually to

10  the office information concerning health and accident

11  insurance coverage and medical plans being marketed and

12  currently in force in this state. The required information

13  shall be described by market segment, including, but not

14  limited to:

15         (a)  Issuing, servicing company, and entity contact

16  information.

17         (b)  Information on all health and accident insurance

18  policies and prepaid limited health service organizations and

19  health maintenance organization contracts in force and issued

20  in the previous year. Such information shall include, but not

21  be limited to, direct premiums earned, direct losses incurred,

22  number of policies, number of certificates, number of covered

23  lives, and the average number of days taken to pay claims. as

24  to policies of individual health insurance:

25         (a)  A summary of typical benefits, exclusions, and

26  limitations for each type of individual policy form currently

27  being issued in the state. The summary shall include, as

28  appropriate:

29         1.  The deductible amount;

30         2.  The coinsurance percentage;

31         3.  The out-of-pocket maximum;

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 1         4.  Outpatient benefits;

 2         5.  Inpatient benefits; and

 3         6.  Any exclusions for preexisting conditions.

 4  

 5  The commission shall determine other appropriate benefits,

 6  exclusions, and limitations to be reported for inclusion in

 7  the consumer's guide published pursuant to this section.

 8         (b)  A schedule of rates for each type of individual

 9  policy form reflecting typical variations by age, sex, region

10  of the state, or any other applicable factor which is in use

11  and is determined to be appropriate for inclusion by the

12  commission.

13  

14  The commission may establish rules governing shall provide by

15  rule a uniform format for the submission of this information

16  described in this section, including the use of uniform

17  formats and electronic data transmission order to allow for

18  meaningful comparisons of premiums charged for comparable

19  benefits. The office shall provide this information to the

20  department, which shall publish annually a consumer's guide

21  which summarizes and compares the information required to be

22  reported under this subsection.

23         (2)(a)  Every insurer transacting health insurance in

24  this state shall report annually to the office, not later than

25  April 1, information relating to any measure the insurer has

26  implemented or proposes to implement during the next calendar

27  year for the purpose of containing health insurance costs or

28  cost increases. The reports shall identify each measure and

29  the forms to which the measure is applied, shall provide an

30  explanation as to how the measure is used, and shall provide

31  an estimate of the cost effect of the measure.

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 1         (b)  The commission shall promulgate forms to be used

 2  by insurers in reporting information pursuant to this

 3  subsection and shall utilize such forms to analyze the effects

 4  of health care cost containment programs used by health

 5  insurers in this state.

 6         (c)  The office shall analyze the data reported under

 7  this subsection and shall annually make available to the

 8  department which shall provide to the public a summary of its

 9  findings as to the types of cost containment measures reported

10  and the estimated effect of these measures.

11         Section 31.  (1)  Effective January 1, 2005, chapter

12  636, Florida Statutes, is redesignated as "Prepaid Limited

13  Health Service Organizations and Discount Medical Plan

14  Organizations."

15         (2)  Effective January 1, 2005, sections

16  636.002-636.067, Florida Statutes, are designated as part I of

17  chapter 636, Florida Statutes, entitled "Prepaid Limited

18  Health Service Organizations."

19         Section 32.  Effective January 1, 2005, section

20  636.002, Florida Statutes, is amended to read:

21         636.002  Short title.--This part Sections 1-57, chapter

22  93-148, Laws of Florida, may be cited as the "Prepaid Limited

23  Health Service Organization Act of Florida."

24         Section 33.  Effective January 1, 2005, subsection (7)

25  of section 636.003, Florida Statutes, is amended to read:

26         636.003  Definitions.--As used in this act, the term:

27         (7)  "Prepaid limited health service organization"

28  means any person, corporation, partnership, or any other

29  entity which, in return for a prepayment, undertakes to

30  provide or arrange for, or provide access to, the provision of

31  a limited health service to enrollees through an exclusive

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 1  panel of providers. Prepaid limited health service

 2  organization does not include:

 3         (a)  An entity otherwise authorized pursuant to the

 4  laws of this state to indemnify for any limited health

 5  service;

 6         (b)  A provider or entity when providing limited health

 7  services pursuant to a contract with a prepaid limited health

 8  service organization, a health maintenance organization, a

 9  health insurer, or a self-insurance plan; or

10         (c)  Any person who is licensed pursuant to part II of

11  this chapter as a discount medical plan organization, in

12  exchange for fees, dues, charges or other consideration,

13  provides access to a limited health service provider without

14  assuming any responsibility for payment for the limited health

15  service or any portion thereof.

16         Section 34.  Effective January 1, 2005, part II of

17  chapter 636, Florida Statutes, consisting of sections 636.202,

18  636.204, 636.206, 636.208, 636.210, 636.212, 636.214, 636.216,

19  636.218, 636.220, 636.222, 636.224, 636.226, 636.228, 636.230,

20  636.232, 636.234, 636.236, 636.238, 636.240, 636.242, and

21  636.244, is created to read:

22                             Part II

23               Discount Medical Plan Organizations

24         636.202  Definitions.--As used in this part, the term:

25         (1)  "Commission" means the Financial Services

26  Commission.

27         (2)  "Discount medical plan" means a business

28  arrangement or contract in which a person, in exchange for

29  fees, dues, charges, or other consideration, provides access

30  for plan members to providers of medical services and the

31  right to receive medical services from those providers at a

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 1  discount. However, the term does not include any product

 2  regulated under chapter 627, chapter 641, or part I of this

 3  chapter.

 4         (3)  "Discount medical plan organization" means a

 5  person who, in exchange for fees, dues, charges, or other

 6  consideration, provides members a discount medical plan.

 7  Discount medical plan organization does not include an entity

 8  licensed under chapter 624, chapter 641, or part I of chapter

 9  636.

10         (4)  "Marketer" means a person that markets, promotes,

11  sells, or distributes a discount medical plan, including a

12  private label entity which places its name on and markets or

13  distributes a discount medical plan, but does not operate a

14  discount medical plan.

15         (5)  "Medical services" means any care, service, or

16  treatment of an illness or a dysfunction of, or injury to, the

17  human body, including, but not limited to, physician care,

18  inpatient care, hospital surgical services, emergency

19  services, ambulance services, dental care services, vision

20  care services, mental health services, substance abuse

21  services, chiropractic services, podiatric care services,

22  laboratory services, medical equipment and supplies. The term

23  does not include pharmaceutical supplies or prescriptions.

24         (6)  "Member" means any person who pays fees, dues,

25  charges, or other consideration for the right to receive the

26  benefits of a discount medical plan.

27         (7)  "Office" means the Office of Insurance Regulation

28  of the Financial Services Commission.

29         (8)  "Provider" means any person that contracts,

30  directly or indirectly, with a discount medical plan

31  organization to provide medical services to members.

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 1         (9)  "Provider network" means an entity that negotiates

 2  on behalf of more than one provider with a discount medical

 3  plan organization to provide medical services to members.

 4         636.204  License.--

 5         (1)  A person may not conduct business in this state as

 6  a discount medical plan organization unless the person:

 7         (a)  Is a corporation, either incorporated under the

 8  laws of this state, or, if a foreign corporation, is

 9  authorized to transact business in this state; and

10         (b)  Is licensed as a discount medical plan

11  organization by the office.

12         (2)  An application for a license to operate as a

13  discount medical plan organization must be filed with the

14  office on a form prescribed by the commission. The application

15  must be sworn to by an officer or authorized representative of

16  the applicant and must be accompanied by the following:

17         (a)  A copy of the applicant's articles of

18  incorporation, including all amendments.

19         (b)  A copy of the corporate bylaws.

20         (c)  A list of the names, addresses, official

21  positions, and biographical information of the individuals

22  responsible for conducting the applicant's affairs, including,

23  but not limited to, all members of the board of directors,

24  board of trustees, executive committee, or other governing

25  board or committee, the officers, contracted management

26  company personnel, and any person or entity owning or having

27  the right to acquire 10 percent or more of the voting

28  securities of the applicant. The list must fully disclose the

29  extent and nature of any contract or arrangement between any

30  individual who is responsible for conducting the applicant's

31  

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 1  affairs and the discount medical plan organization, including

 2  any possible conflicts of interest.

 3         (d)  A complete biographical statement, on forms

 4  prescribed by the commission, an independent investigation

 5  report, and a set of fingerprints, as provided in chapter 624,

 6  from each individual identified in subsection (c).

 7         (e)  A statement describing the applicant, its

 8  facilities, and personnel and the medical services it proposes

 9  to offer.

10         (f)  A copy of any form contract used by the applicant

11  with any provider or provider network regarding the provision

12  of medical services to members.

13         (g)  A copy of any form contract used by the applicant

14  with any person listed in subsection (c).

15         (h)  A copy of any form contract used by the applicant

16  with any person, corporation, partnership, or other entity for

17  the performance on the applicant's behalf of any function,

18  including, but not limited to, marketing, administration,

19  enrollment, investment management, and subcontracting for the

20  provision of health services to members.

21         (i)  A copy of the applicant's most recent financial

22  statements that have been audited by an independent certified

23  public accountant.

24         (j)  A description of the applicant's proposed method

25  of marketing.

26         (k)  A description of the member's complaint procedures

27  to be established and maintained by the applicant.

28         (l)  The fee for issuance of a license.

29         (m)  Such other information as the commission or office

30  may request from the applicant.

31  

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 1         (3)  The office shall issue a license that expires 1

 2  year after the date of issuance, and each year on that date

 3  thereafter. The office shall renew the license if the licensee

 4  pays the annual license fee of $50 and if the licensee is in

 5  compliance with this part.

 6         (4)  Before the office issues a license, each medical

 7  discount plan organization must establish a website in order

 8  to conform with the requirements of s. 636.226.

 9         (5)  The license fee under this section is $50 per

10  year, per licensee.  All amounts collected shall be deposited

11  in the General Revenue Fund.

12         (6)  This part does not require a provider who provides

13  discounts to his or her own patients to obtain and maintain a

14  license as a discount medical plan organization.

15         636.206  Examinations and investigations.--

16         (1)  The office may examine or investigate any discount

17  medical plan organization. The office may order any discount

18  medical plan organization or applicant to produce any records,

19  books, files, advertising and solicitation materials, or other

20  information and may take statements under oath to determine

21  whether the discount medical plan organization or applicant is

22  in violation of the law or is acting contrary to the public

23  interest. The expenses incurred in conducting an examination

24  or investigation must be paid by the discount medical plan

25  organization or applicant. Examinations and investigations

26  must be conducted as provided in chapter 624 and a discount

27  medical plan organization is subject to all applicable

28  provisions of the Florida Insurance Code.

29         (2)  Failure by a discount medical plan organization to

30  pay the costs incurred under this section is grounds for

31  denial or revocation of a license.

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 1         636.208  Fees.--A discount medical plan organization

 2  may charge a reasonable one-time processing fee and a periodic

 3  charge. If a discount medical plan charges a fee for a time

 4  period exceeding 1 month, it must, in the event of

 5  cancellation of the membership by either party, make a pro

 6  rata reimbursement of the fee to the member.

 7         636.210  Prohibited activities of a discount medical

 8  plan.--

 9         (1)  A discount medical plan organization may not:

10         (a)  Use in its advertisements, marketing material,

11  brochures, or discount cards the term "insurance" except as

12  otherwise authorized in this part;

13         (b)  Use in its advertisements, marketing material,

14  brochures, or discount cards the terms "health plan,"

15  "coverage," "co-pay," "co-payments," "pre-existing

16  conditions," "guaranteed issue," "premium," "enrollment,"

17  "PPO," "preferred provider organization," or other terms that

18  could reasonably mislead a person into believing the discount

19  medical plan was health insurance;

20         (c)  Have restrictions on free access to plan

21  providers, including, but not limited to, waiting periods and

22  notification periods; or

23         (d)  Pay providers any fees for medical services.

24         (2)  A discount medical plan organization is prohibited

25  from collecting or accepting money from a member for payment

26  to a provider for specific medical services furnished or to be

27  furnished to the member unless it has an active certificate of

28  authority from the office to act as an administrator.

29         636.212  Disclosures.--The following disclosures must

30  be made in writing to any prospective member, and must be on

31  the first page of any advertisements, marketing material, or

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 1  brochures relating to a discount medical plan. The disclosures

 2  must be printed in not less than 12-point type or no smaller

 3  than the largest type on the page if larger than 12-point

 4  type, and must state:

 5         (1)  That the plan is not a health insurance policy;

 6         (2)  That the plan provides discounts at certain

 7  healthcare providers for medical services;

 8         (3)  That the plan does not make payments directly to

 9  providers of medical services;

10         (4)  That the plan member is obligated to pay for all

11  health care services but will receive a discount from those

12  health care providers who have contracted with the discount

13  plan organization; and

14         (5)  The corporate name and the locations of the

15  licensed discount medical plan organization.

16         636.214  Provider agreements.--

17         (1)  A provider offering medical services to a member

18  under a discount medical plan must provide the service under a

19  written agreement with the organization. The agreement may be

20  entered into directly by the provider or by a provider network

21  to which the provider belongs.

22         (2)  A provider agreement must contain the following:

23         (a)  A list of the services and products to be

24  delivered at a discount;

25         (b)  A statement specifying the amount of the discounts

26  offered or, alternatively, a fee schedule that reflects the

27  provider's discounted rates; and

28         (c)  A statement that the provider will not charge

29  members more than the discounted rates.

30         (3)  A provider agreement between a discount medical

31  plan organization and a provider network shall require the

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 1  provider network to have written agreements with each

 2  provider. An agreement must:

 3         (a)  Contain the elements described in subsection (2);

 4         (b)  Authorize the provider network to contract with

 5  the medical discount medical plan organization on behalf of

 6  the provider; and

 7         (c)  Require the provider network to maintain an

 8  up-to-date list of the providers with whom it has a contract

 9  and to deliver that list to the discount medical plan

10  organization each month.

11         (4)  The discount medical plan organization shall

12  maintain a copy of each active provider agreement.

13         636.216  Form and fees filings.--

14         (1)  All fees charged to members must be filed with the

15  office and any fee or charge to members greater than $30 per

16  month or $360 per year must be approved by the office before

17  they can be imposed on a member. The discount medical plan

18  organization has the burden of proof that the fees charged

19  bear a reasonable relation to the benefits received by the

20  member.

21         (2)  There must be a written agreement between the

22  discount medical plan organization and the member specifying

23  the benefits under the discount medical plan and complying

24  with the disclosure requirements of this part.

25         (3)  Any form used by the discount medical plan

26  organization, including the written agreement between the

27  organization and the member, must first be filed with and

28  approved by the office. Every form filed shall be identified

29  by a unique form number placed in the lower left corner of

30  each form.

31  

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 1         (4)  If the office disapproves any filing, the office

 2  shall notify the discount medical plan organization in writing

 3  and must specify the reasons why the office disapproved the

 4  filing. The discount medical plan organization has 21 days

 5  from the date it receives the disapproval notice to request a

 6  hearing before the office under chapter 120.

 7         636.218  Annual reports.--

 8         (1)  Each discount medical plan organization must file

 9  with the office an annual report no later than 3 months after

10  the end of the organization's fiscal year.

11         (2)  The report must be on a form and in a format

12  prescribed by the commission and must include:

13         (a)  Audited financial statements prepared in

14  accordance with generally accepted accounting principles and

15  certified by an independent certified public accountant. The

16  financial statements shall include the organization's balance

17  sheet, income statement, and statement of changes in cash flow

18  for the preceding year.

19         (b)  A list of the names and residence addresses of all

20  persons responsible for the conduct of its affairs, together

21  with a disclosure of the extent and nature of any contracts or

22  arrangements between these persons and the discount medical

23  plan organization, including any possible conflicts of

24  interest.

25         (c)  The number of discount medical plan members.

26         (d)  Such other information relating to the performance

27  of the discount medical plan organization that is required by

28  the commission or office.

29         (3)  A discount medical plan organization that fails to

30  file an annual report in the form and within the time required

31  by this section shall forfeit up to $500 for each day for the

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 1  first 10 days during which the report is delinquent and shall

 2  forfeit up to $1,000 for each day after the first 10 days

 3  during which the report is delinquent. Upon notice by the

 4  office, the organization may no longer enroll new members or

 5  do business in this state until the organization complies with

 6  this section. The office shall deposit all sums collected by

 7  it under this section to the credit of the Insurance

 8  Regulatory Trust Fund. The office may not collect more than

 9  $50,000 for each delinquent report.

10         636.220  Minimum capital requirements.--

11         (1)  Each discount medical plan organization must at

12  all times maintain a net worth of at least $150,000.

13         (2)  The office may not issue a license unless the

14  medical discount medical plan organization has a net worth of

15  at least $150,000.

16         636.222  Suspension or revocation of license;

17  suspension of enrollment of new members; terms of

18  suspension.--

19         (1)  The office may suspend the authority of a discount

20  medical plan organization to enroll new members, may revoke a

21  license issued to a discount medical plan organization, or may

22  order compliance if it finds that any of the following

23  conditions exist:

24         (a)  The organization is not operating in compliance

25  with this part.

26         (b)  The discount medical plan organization does not

27  have the minimum net worth as required by this part.

28         (c)  The organization has advertised, merchandised, or

29  attempted to merchandise its services in a manner as to

30  misrepresent its services or capacity for service or has

31  

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 1  engaged in deceptive, misleading, or unfair practices with

 2  respect to advertising or merchandising.

 3         (d)  The discount medical plan organization is not

 4  fulfilling its obligations as a discount medical plan

 5  organization.

 6         (e)  The continued operation of the discount medical

 7  plan organization would be hazardous to its members.

 8         (2)  If the office has cause to believe that grounds

 9  for the suspension or revocation of a license exist, it shall

10  notify the discount medical plan organization in writing

11  specifically stating the grounds for suspension or revocation

12  and shall pursue a hearing on the matter in accordance with

13  chapter 120.

14         (3)  If the license of a discount medical plan

15  organization is surrendered or revoked, the organization must

16  proceed, immediately following the effective date of the order

17  of revocation, to wind up its affairs transacted under the

18  license. It may not engage in any further advertising,

19  solicitation, collecting of fees, or renewal of contracts.

20         (4)  The office shall, in its order suspending the

21  authority of a discount medical plan organization to enroll

22  new members, specify the period during which the suspension is

23  to be in effect and the conditions, if any, which must be met

24  by the discount medical plan organization before reinstatement

25  of its license to enroll new members. The order of suspension

26  is subject to rescission or modification by further order of

27  the office before expiration of the suspension period.

28  Reinstatement may not be made unless requested by the discount

29  medical plan organization. However, the office may not grant

30  reinstatement if it finds that the circumstances for which the

31  suspension occurred still exist or are likely to recur.

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 1         636.224  Notice of change of name or address of

 2  discount medical plan organization.--Each discount medical

 3  plan organization must notify the office at least 30 days in

 4  advance of any change in the discount medical plan

 5  organization's name, address, principal business address, or

 6  mailing address.

 7         636.226  Provider name listing.--

 8         (1)  Each discount medical plan organization must

 9  maintain an up-to-date list of the names and addresses of the

10  providers with whom it has a contract to deliver medical

11  services. The list must be stored on its website, the Internet

12  address of which must be prominently displayed on all its

13  advertisements, marketing material, brochures, and discount

14  cards.

15         (2)  This section applies to providers with whom the

16  discount medical plan organization has contracted directly and

17  to those who are members of a provider network with which the

18  discount medical plan organization has a contract to deliver

19  medical services.

20         636.228  Marketing of discount medical plans.--

21         (1)  All advertisements, marketing material, brochures,

22  and discount cards used by marketers must be approved in

23  writing for use by the discount medical plan organization.

24         (2)  The discount medical plan organization shall have

25  an executed written agreement with a marketer before the

26  marketer marketing, promoting, selling, or distributing the

27  discount medical plan and shall be responsible and financially

28  liable for any acts of its marketers which do not comply with

29  the provisions of this part.

30         636.230  Bundling discount medical plans with other

31  insurance products.--When a marketer or discount medical plan

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 1  organization sells a discount medical plan along with any

 2  other product, the fees for each product must be itemized

 3  separately and provided to the members in writing.

 4         636.232  Rules.--The commission may adopt rules to

 5  administer this part, including rules for the licensing of

 6  discount medical plan organizations; establishing standards

 7  for evaluating forms, advertisements, marketing material,

 8  brochures, and discount cards; the collection of data;

 9  disclosures to plan members; and rules defining terms used in

10  this act.

11         636.234  Service of process on a discount medical plan

12  organization.--Sections 624.422 and 624.423 apply to a

13  discount medical plan organization as if a discount medical

14  plan organization were an insurer.

15         636.236  Security deposit.--

16         (1)  A licensed discount medical plan organization must

17  deposit, and maintain deposited in trust with the department,

18  securities eligible for deposit under s. 625.52, in order that

19  the office might protect plan members. The securities must, at

20  all times, have a value of not less than $35,000.

21         (2)  A judgment creditor or other claimant of a

22  discount medical plan organization, other than the office or

23  the Department of Financial Services, does not have the right

24  to levy upon any of the assets or securities held in this

25  state as a deposit under this section.

26         636.238  Penalties for violation of this part.--

27         (1)  Except as provided in subsection (2), a person who

28  violates this part commits a misdemeanor of the second degree,

29  punishable as provided in s. 775.082 or s. 775.083.

30         (2)  A person who operates as or aids and abets another

31  operating as a discount medical plan organization in violation

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 1  of s. 636.204(1) commits a felony punishable as provided for

 2  in s. 624.401(4)(b), as if the unlicensed discount medical

 3  plan organization were an unauthorized insurer, and the fees,

 4  dues, charges, or other consideration collected from the

 5  members by the unlicensed discount medical plan organization

 6  or marketer were insurance premium.

 7         (3)  A person who collects fees for purported

 8  membership in a discount medical plan but fails to provide the

 9  promised benefits commits a theft punishable as provided in s.

10  812.014.

11         636.240  Injunction.--

12         (1)  In addition to the penalties and other enforcement

13  provisions of this act, the office may commence an action for

14  temporary and permanent injunctive relief if:

15         (a)  A discount medical plan is operated by a person

16  that is not licensed under this part.

17         (b)  A person, entity, or discount medical plan

18  organization has engaged in any activity prohibited by this

19  act or any rule adopted under this act.

20         (2)  Venue for any proceeding bought under this section

21  shall be in the Circuit Court for Leon County.

22         (3)  The office's authority to seek injunctive relief

23  is not conditioned on having conducted any proceeding under

24  chapter 120.

25         636.242  Civil remedies.--Any person injured by a

26  person acting in violation of this part may bring a civil

27  action against the person committing the violation in the

28  circuit court of the county in which the alleged violator

29  resides or has a principal place of business or in the county

30  where the alleged violation occurred. If the defendant is

31  found to have injured the plaintiff, the defendant is liable

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 1  for damages and the court may also award the prevailing

 2  plaintiff court costs and reasonable attorney's fees. If so

 3  awarded, the court costs and attorney's fees must be included

 4  in the judgment or decree rendered in the case. If it appears

 5  to the court that the suit brought by the plaintiff is

 6  frivolous or brought for purposes of harassment, the court may

 7  award the defendant court costs and reasonable attorney's fees

 8  and may apply sanctions against the plaintiff in accordance

 9  with chapter 57.

10         636.244  Unlicensed discount medical plan

11  organizations.--Sections 626.901 through 626.912 apply to the

12  activities of an unlicensed discount medical plan organization

13  as if an unlicensed discount medical plan organization were an

14  unauthorized insurer.

15         Section 35.  Section 627.65626, Florida Statutes, is

16  created to read:

17         627.65626  Insurance rebates for healthy lifestyles.--

18         (1)  Any rate, rating schedule, or rating manual for a

19  health insurance policy filed with the office shall provide

20  for an appropriate rebate of premiums paid in the last

21  calendar year when the majority of members of a health plan

22  have enrolled and maintained participation in any health

23  wellness, maintenance, or improvement program offered by the

24  employer. The employer must provide evidence of demonstrative

25  maintenance or improvement of the enrollees' health status as

26  determined by assessments of agreed-upon health status

27  indicators between the employer and the health insurer,

28  including, but not limited to, reduction in weight, body mass

29  index, and smoking cessation. Any rebate provided by the

30  health insurer is presumed to be appropriate unless credible

31  

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 1  data demonstrates otherwise, but shall not exceed 10 percent

 2  of paid premiums.

 3         (2)  The premium rebate authorized by this section

 4  shall be effective for an insured on an annual basis, unless

 5  the number of participating employees becomes less than the

 6  majority of the employees eligible for participation in the

 7  wellness program.

 8         Section 36.  Section 627.6402, Florida Statutes, is

 9  created to read:

10         627.6402  Insurance rebates for healthy lifestyles.--

11         (1)  Any rate, rating schedule, or rating manual for an

12  individual health insurance policy filed with the office shall

13  provide for an appropriate rebate of premiums paid in the last

14  calendar year when the individual covered by such plan is

15  enrolled in and maintains participation in any health

16  wellness, maintenance, or improvement program approved by the

17  health plan. The individual must provide evidence of

18  demonstrative maintenance or improvement of the individual's

19  health status as determined by assessments of agreed-upon

20  health status indicators between the individual and the health

21  insurer, including, but not limited to, reduction in weight,

22  body mass index, and smoking cessation. Any rebate provided by

23  the health insurer is presumed to be appropriate unless

24  credible data demonstrates otherwise, but shall not exceed 10

25  percent of paid premiums.

26         (2)  The premium rebate authorized by this section

27  shall be effective for an insured on an annual basis, unless

28  the individual fails to maintain or improve his or her health

29  status while participating in an approved wellness program, or

30  credible evidence demonstrates that the individual is not

31  participating in the approved wellness program.

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 1         Section 37.  Subsection (38) of section 641.31, Florida

 2  Statutes, is amended, and subsection (40) is added to that

 3  section, to read:

 4         641.31  Health maintenance contracts.--

 5         (38)(a)  Notwithstanding any other provision of this

 6  part, a health maintenance organization that meets the

 7  requirements of paragraph (b) may, through a point-of-service

 8  rider to its contract providing comprehensive health care

 9  services, include a point-of-service benefit. Under such a

10  rider, a subscriber or other covered person of the health

11  maintenance organization may choose, at the time of covered

12  service, a provider with whom the health maintenance

13  organization does not have a health maintenance organization

14  provider contract. The rider may not require a referral from

15  the health maintenance organization for the point-of-service

16  benefits.

17         (b)  A health maintenance organization offering a

18  point-of-service rider under this subsection must have a valid

19  certificate of authority issued under the provisions of the

20  chapter, must have been licensed under this chapter for a

21  minimum of 3 years, and must at all times that it has riders

22  in effect maintain a minimum surplus of $5 million. A health

23  maintenance organization offering a point-of-service rider to

24  its contract providing comprehensive health care services may

25  offer the rider to employers who have employees living and

26  working outside the health maintenance organization's approved

27  geographic service area without having to obtain a health care

28  provider certificate, as long as the master group contract is

29  issued to an employer that maintains its primary place of

30  business within the health maintenance organization's approved

31  service area. Any member or subscriber that lives and works

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 1  outside the health maintenance organization's service area and

 2  elects coverage under the health maintenance organization's

 3  point-of-service rider must provide a statement to the health

 4  maintenance organization which indicates that the member or

 5  subscriber understands the limitations of his or her policy

 6  and that only those benefits under the point-of-service rider

 7  will be covered when services are provided outside the service

 8  area.

 9         (c)  Premiums paid in for the point-of-service riders

10  may not exceed 15 percent of total premiums for all health

11  plan products sold by the health maintenance organization

12  offering the rider. If the premiums paid for point-of-service

13  riders exceed 15 percent, the health maintenance organization

14  must notify the office and, once this fact is known, must

15  immediately cease offering such a rider until it is in

16  compliance with the rider premium cap.

17         (d)  Notwithstanding the limitations of deductibles and

18  copayment provisions in this part, a point-of-service rider

19  may require the subscriber to pay a reasonable copayment for

20  each visit for services provided by a noncontracted provider

21  chosen at the time of the service. The copayment by the

22  subscriber may either be a specific dollar amount or a

23  percentage of the reimbursable provider charges covered by the

24  contract and must be paid by the subscriber to the

25  noncontracted provider upon receipt of covered services. The

26  point-of-service rider may require that a reasonable annual

27  deductible for the expenses associated with the

28  point-of-service rider be met and may include a lifetime

29  maximum benefit amount. The rider must include the language

30  required by s. 627.6044 and must comply with copayment limits

31  

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 1  described in s. 627.6471. Section 641.3154 does not apply to a

 2  point-of-service rider authorized under this subsection.

 3         (e)  The point-of-service rider must contain provisions

 4  that comply with s. 627.6044.

 5         (f)(e)  The term "point of service" may not be used by

 6  a health maintenance organization except with riders permitted

 7  under this section or with forms approved by the office in

 8  which a point-of-service product is offered with an indemnity

 9  carrier.

10         (g)(f)  A point-of-service rider must be filed and

11  approved under ss. 627.410 and 627.411.

12         (40)(a)  Any rate, rating schedule, or rating manual

13  for a health maintenance organization policy filed with the

14  office shall provide for an appropriate rebate of premiums

15  paid in the last calendar year when the individual covered by

16  such plan is enrolled in and maintains participation in any

17  health wellness, maintenance, or improvement program approved

18  by the health plan. The individual must provide evidence of

19  demonstrative maintenance or improvement of his or her health

20  status as determined by assessments of agreed-upon health

21  status indicators between the individual and the health

22  insurer, including, but not limited to, reduction in weight,

23  body mass index, and smoking cessation. Any rebate provided by

24  the health insurer is presumed to be appropriate unless

25  credible data demonstrates otherwise, but shall not exceed 10

26  percent of paid premiums.

27         (b)  The premium rebate authorized by this section

28  shall be effective for an insured on an annual basis, unless

29  the individual fails to maintain or improve his or her health

30  status while participating in an approved wellness program, or

31  

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 1  credible evidence demonstrates that the individual is not

 2  participating in the approved wellness program.

 3         Section 38.  Notwithstanding the amendment to section

 4  627.6699(5)(c), Florida Statutes, by this act, any right to an

 5  open enrollment offer of health benefit coverage for groups of

 6  fewer than two employees, pursuant to section 627.6699(5)(c),

 7  Florida Statutes, as it existed immediately before the

 8  effective date of this act, shall remain in full force and

 9  effect until the enactment of section 627.64872, Florida

10  Statutes, and the subsequent date upon which such plan begins

11  to accept new risks or members.

12         Section 39.  Section 408.02, Florida Statutes, is

13  repealed.

14         Section 40.  Subsection (1) of section 766.309, Florida

15  Statutes, is amended to read:

16         766.309  Determination of claims; presumption; findings

17  of administrative law judge binding on participants.--

18         (1)  The administrative law judge shall make the

19  following determinations based upon all available evidence:

20         (a)  Whether the injury claimed is a birth-related

21  neurological injury. If the claimant has demonstrated, to the

22  satisfaction of the administrative law judge, that the infant

23  has sustained a brain or spinal cord injury caused by oxygen

24  deprivation or mechanical injury and that the infant was

25  thereby rendered permanently and substantially mentally and

26  physically impaired, a rebuttable presumption shall arise that

27  the injury is a birth-related neurological injury as defined

28  in s. 766.302(2).

29         (b)  Whether obstetrical services were delivered by a

30  participating physician in the course of labor, delivery, or

31  resuscitation in the immediate postdelivery period in a

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 1  hospital; or by a certified nurse midwife in a teaching

 2  hospital supervised by a participating physician in the course

 3  of labor, delivery, or resuscitation in the immediate

 4  postdelivery period in a hospital.

 5         (c)  How much compensation, if any, is awardable

 6  pursuant to s. 766.31.

 7         (d)  Whether, if raised by the claimant or other party,

 8  the factual determinations regarding the notice requirements

 9  in s. 766.316 are satisfied.  The administrative law judge has

10  the exclusive jurisdiction to make these factual

11  determinations.

12         Section 41.  The Agency for Health Care Administration

13  shall adopt all rules necessary to implement this act no later

14  than January 1, 2005.

15         Section 42.  The amendment to section 766.309, Florida

16  Statutes, contained in this act, is intended to clarify that

17  the administrative law judge has always had the exclusive

18  jurisdiction to make factual determinations as to whether the

19  notice requirements in section 766.316, Florida Statutes, are

20  satisfied.

21         Section 43.  The Auditor General shall conduct a study

22  of nursing home finances which shall examine the following:

23         (1)  Profits of nursing home licensees, nursing home

24  management companies, related-party businesses, and owners of

25  real estate that is leased to nursing home operators in this

26  state;

27         (2)  Salaries of nonfacility-based nursing home

28  executives, nursing home operators, management companies, and

29  real estate entities; and

30  

31  

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 1         (3)  Home office costs and related party costs that are

 2  reported to the Agency for Health Care Administration by a

 3  nursing home.

 4  

 5  The Auditor General shall report the overall profits of all

 6  nursing home licensees and associated business entities,

 7  including home office operators, management companies, real

 8  estate entities, and related party organizations. The Auditor

 9  General shall report on the retained earnings for nonprofit

10  facilities and any home office, management, real estate

11  entities, and related party organizations. The Auditor General

12  shall report the total amount of executive salaries, home

13  office costs, and related party costs for the most recently

14  completed cost-reporting period. The Auditor General shall

15  report its findings to the Governor, the President of the

16  Senate, and the Speaker of the House of Representatives by

17  December 15, 2004.

18         Section 44.  The Agency for Health Care Administration

19  shall conduct a survey of all nursing home operators to

20  determine:

21         (1)  The number of nursing home operators offering

22  health insurance to their employees, and the requirements for

23  this coverage;

24         (2)  The number of nursing home employees not meeting

25  the employer's requirements for health insurance coverage;

26         (3)  The number of nursing home employees enrolled in

27  employer-sponsored health insurance plans and the actual

28  number of employees not enrolled in an employer-sponsored

29  health insurance plan;

30  

31  

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 1         (4)  The number of nursing home employees who have

 2  employee-only coverage and the actual number of employees who

 3  have dependent coverage; and

 4         (5)  The number of nursing home employees whose

 5  dependents are enrollees in KidCare, Healthy Kids, and

 6  Medicaid.

 7  

 8  The agency shall report its findings to the Governor, the

 9  President of the Senate, and the Speaker of the House of

10  Representatives by December 15, 2004.

11         Section 45.  The sum of $250,000 is appropriated from

12  the Insurance Regulatory Trust Fund in the Department of

13  Financial Services to the Office of Insurance Regulation for

14  the purpose of implementing the provisions in this act

15  relating to the Small Employers Access Program.

16         Section 46.  The sum of $350,000 in nonrecurring

17  general revenue funds is appropriated to the Agency for Health

18  Care Administration to support the establishment of and to

19  contract with the Florida Patient Safety Corporation to

20  implement the provisions of section 16 of this act during the

21  2004-2005 fiscal year.

22         Section 47.  The sum of $113,500 in nonrecurring

23  general revenue funds is appropriated to the Florida State

24  University College of Medicine for the purpose of conducting

25  the study required in section 17 of this act during the

26  2004-2005 fiscal year.

27         Section 48.  The sum of $250,000 is appropriated from

28  the Insurance Regulatory Trust Fund in the Department of

29  Financial Services to the Office of Insurance Regulation for

30  the board of the Florida Health Insurance Plan to contract for

31  an independent actuarial study for the interim report that the

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 1  board is required to submit pursuant to section 627.64872,

 2  Florida Statutes, as created by this act. In addition, the

 3  board shall include in that study an analysis of exempting

 4  health insurance rates for employers with 26 to 50 employees

 5  from the requirements of modified community rating, as

 6  provided in section 672.6699, Florida Statutes, and the

 7  potential impact that such an exemption would have on the

 8  accessibility and affordability of health insurance coverage

 9  in the small employer market.

10         Section 49.  The sum of $169,069 is appropriated from

11  the Insurance Regulatory Trust Fund in the Department of

12  Financial Services to the Office of Insurance Regulation for

13  the purpose of implementing the provisions in this act

14  relating to the regulation of discount medical plan

15  organizations.

16         Section 50.  The sum of $2 million in nonrecurring

17  general revenue funds is appropriated to the Agency for Health

18  Care Administration for its activities during the 2004-2005

19  fiscal year which relate to developing and implementing a

20  strategy for the adoption and use of electronic health

21  records.

22         Section 51.  Except as otherwise expressly provided in

23  this act, and except for this section, which shall take effect

24  upon becoming a law, this act shall take effect July 1, 2004.

25  

26  

27  

28  

29  

30  

31  

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 1          STATEMENT OF SUBSTANTIAL CHANGES CONTAINED IN
                       COMMITTEE SUBSTITUTE FOR
 2                      CS for CS for SB 2910

 3                                 

 4  Revises the transparency provisions to: 1) require licensed
    facilities to have a website link to the Agency for Health
 5  Care Administration's patient charge and performance outcome
    data, and deletes the exemption for rural hospitals with fewer
 6  than 50 beds; 2) requires a $500 fine for facilities that fail
    to provide this information or an estimate of charges; 3)
 7  require facilities to provide an itemized bill within 7 days
    after discharge; and 4) requires licensed facilities to make
 8  available to a patient, all records necessary for verification
    of the patient's bill.
 9  
    Makes the section that creates the Florida Patient Safety
10  Corporation take effect upon the bill becoming a law.

11  Adds a podiatrist, chiropractor and dentist to the board of
    directors of the Florida Patient Safety Corporation.
12  
    Specifies minimum duties of the advisory committees of the
13  Florida Patient Safety Corporation and adds physicians and
    health care facility representatives to the litigation
14  alternatives advisory committee.

15  Clarifies that the insurers have the discretion to determine
    the specific features of the emergency department diversion
16  program that health insurers must develop.

17  Changes the definition of "implementation" of the Florida
    Health Insurance Plan (FHIP) to mean the date when legal
18  authority and administrative ability exists for the board to
    subsume the powers of the Florida Comprehensive Health
19  Association (FCHA).

20  Deletes from the definition of "resident" for purposes of the
    FHIP, the provisions that HIPAA-eligible individuals do not
21  have to meet the six month residency requirement because the
    bill no longer makes HIPAA-eligible individuals automatically
22  eligible for the plan.

23  Specifies the initial terms of office of each of the board
    members of the FHIP and makes the Director of the Office of
24  Insurance Regulation responsible for any organizational
    requirements for the initial board meeting.
25  
    Clarifies that the board of the FHIP may take action to
26  administer coverage of individuals enrolled in the FCHA, prior
    to funds being appropriated.
27  
    Clarifies that the board of the FHIP subsumes the statutory
28  powers of the FCHA.

29  Requires the actuarial study done for the FHIP to determine
    the effect on the individual and small group market by
30  including HIPAA-eligible individual in the FHIP.

31  Requires the Auditor General to conduct a study of nursing
    home finances.
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 1  Deletes a reference to HIPAA-eligible individuals in the
    premium limits for the FHIP since the bill no longer makes
 2  HIPAA-eligible individuals automatically eligible for the
    plan.
 3  
    Clarifies that upon implementation of the FHIP, the FCHA is
 4  abolished and all individuals actively enrolled in the FCHA
    shall be enrolled in the FHIP, and will convert to the plan
 5  benefits by January 1, 2005.

 6  Requires small employer carriers to offer a high deductible
    plan that meets the federal requirements of a health
 7  reimbursement arrangement, as well as a health savings account
    plan.
 8  
    Requires the high deductible plan offered by small group
 9  carriers for health reimbursement arraignments, as well as
    health savings accounts, to meet the minimum benefits of this
10  section.

11  Deletes the requirement that the date submitted by health
    maintenance organizations (HMOs) to the Agency for Health Care
12  Administration include percentage of claims denied, percentage
    of claims meeting prompt pay requirements, and medical and
13  administrative loss ratios.

14  Provides that a discount medical plan does not include any
    health insurance policy or HMO contract regulated under the
15  insurance code.

16  Specifies that a discount medical plan organization does not
    include a licensed insurance company, HMO, or prepaid limited
17  health service organization.

18  Adds terms that would be prohibited in the marketing material
    for discount medical plans and clarifies language relating to
19  plan charges.

20  Limits prior approval of rates by the Office of Insurance
    Regulation for discount medical plans to those plans with fees
21  of more than $30 a month or $360 a year.

22  Deletes the requirement that marketers of discount medical
    plans be licensed and appointed insurance agents, but requires
23  plans to be responsible and financially liable for actions not
    complying with their contract or the provisions of law.
24  
    Requires the actuarial study done for the FHIP to analyze
25  exempting rates for employers with 26 to 50 employees from the
    requirements of modified community rating.
26  
    Requires the Auditor General to conduct a study of nursing
27  home finances.

28  Provides for the development and implementation of a strategy
    for the adoption and use of electronic health records.
29  
    Provides a $2 million nonrecurring general revenue
30  appropriation to the Agency for Health Care Administration
    during the 2004-05 fiscal year to develop and implement a
31  strategy for the adoption and use of electronic health
    records.
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