December 13, 2019
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Amendment CaShTmL-454326.HTM
                                                  SENATE AMENDMENT
    Bill No. CS for CS for CS for SB 2910
    Amendment No. ___   Barcode 454326
                            CHAMBER ACTION
              Senate                               House
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       04/26/2004 08:29 AM         .                    
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11  Senator Saunders moved the following amendment:
12  
13         Senate Amendment (with title amendment) 
14         On page 31, line 24, through
15            page 27, line 23, delete those lines
16  
17  and insert:  
18         Section 13.  Section 468.352, Florida Statutes, is
19  amended to read:
20         (Substantial rewording of section. See
21         s. 468.352, F.S., for present text.)
22         468.352  Definitions.--As used in this part, the term:
23         (1)  "Board" means the Board of Respiratory Care.
24         (2)  "Certified respiratory therapist" means any person
25  licensed pursuant to this part who is certified by the
26  National Board for Respiratory Care or its successor; who is
27  employed to deliver respiratory care services, under the order
28  of a physician licensed pursuant to chapter 458 or chapter
29  459, in accordance with protocols established by a hospital or
30  other health care provider or the board; and who functions in
31  situations of unsupervised patient contact requiring
                                  1
    1:45 PM   04/24/04                              s2910c3c-37t37

SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 individual judgment. 2 (3) "Critical care" means care given to a patient in 3 any setting involving a life-threatening emergency. 4 (4) "Department" means the Department of Health. 5 (5) "Direct supervision" means practicing under the 6 direction of a licensed, registered, or certified respiratory 7 therapist who is physically on the premises and readily 8 available, as defined by the board. 9 (6) "Physician supervision" means supervision and 10 control by a physician licensed under chapter 458 or chapter 11 459 who assumes the legal liability for the services rendered 12 by the personnel employed in his or her office. Except in the 13 case of an emergency, physician supervision requires the easy 14 availability of the physician within the office or the 15 physical presence of the physician for consultation and 16 direction of the actions of the persons who deliver 17 respiratory care services. 18 (7) "Practice of respiratory care" or "respiratory 19 therapy" means the allied health specialty associated with the 20 cardiopulmonary system that is practiced under the orders of a 21 physician licensed under chapter 458 or chapter 459 and in 22 accordance with protocols, policies, and procedures 23 established by a hospital or other health care provider or the 24 board, including the assessment, diagnostic evaluation, 25 treatment, management, control, rehabilitation, education, and 26 care of patients in all care settings. 27 (8) "Registered respiratory therapist" means any 28 person licensed under this part who is registered by the 29 National Board for Respiratory Care or its successor, and who 30 is employed to deliver respiratory care services under the 31 order of a physician licensed under chapter 458 or chapter 2 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 459, in accordance with protocols established by a hospital or 2 other health care provider or the board, and who functions in 3 situations of unsupervised patient contact requiring 4 individual judgment. 5 (9) "Respiratory care practitioner" means any person 6 licensed under this part who is employed to deliver 7 respiratory care services, under direct supervision, pursuant 8 to the order of a physician licensed under chapter 458 or 9 chapter 459. 10 (10) "Respiratory care services" includes: 11 (a) Evaluation and disease management. 12 (b) Diagnostic and therapeutic use of respiratory 13 equipment, devices, or medical gas. 14 (c) Administration of drugs, as duly ordered or 15 prescribed by a physician licensed under chapter 458 or 16 chapter 459 and in accordance with protocols, policies, and 17 procedures established by a hospital or other health care 18 provider or the board. 19 (d) Initiation, management, and maintenance of 20 equipment to assist and support ventilation and respiration. 21 (e) Diagnostic procedures, research, and therapeutic 22 treatment and procedures, including measurement of ventilatory 23 volumes, pressures, and flows; specimen collection and 24 analysis of blood for gas transport and acid/base 25 determinations; pulmonary-function testing; and other related 26 physiological monitoring of cardiopulmonary systems. 27 (f) Cardiopulmonary rehabilitation. 28 (g) Cardiopulmonary resuscitation, advanced cardiac 29 life support, neonatal resuscitation, and pediatric advanced 30 life support, or equivalent functions. 31 (h) Insertion and maintenance of artificial airways 3 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 and intravascular catheters. 2 (i) Education of patients, families, the public, or 3 other health care providers, including disease process and 4 management programs and smoking prevention and cessation 5 programs. 6 (j) Initiation and management of hyperbaric oxygen. 7 Section 14. Section 468.355, Florida Statutes, is 8 amended to read: 9 (Substantial rewording of section. See 10 s. 468.355, F.S., for present text.) 11 468.355 Licensure requirements.--To be eligible for 12 licensure by the board, an applicant must be an active 13 "Certified Respiratory Therapist" or an active "Registered 14 Respiratory Therapist" as designated by the National Board for 15 Respiratory Care, or its successor. 16 Section 15. Section 468.368, Florida Statutes, is 17 amended to read: 18 (Substantial rewording of section. See 19 s. 468.368, F.S., for present text.) 20 468.368 Exemptions.--This part may not be construed to 21 prevent or restrict the practice, service, or activities of: 22 (1) Any person licensed in this state by any other law 23 from engaging in the profession or occupation for which he or 24 she is licensed. 25 (2) Any legally qualified person in the state or 26 another state or territory who is employed by the United 27 States Government or any agency thereof while such person is 28 discharging his or her official duties. 29 (3) A friend or family member who is providing 30 respiratory care services to an ill person and who does not 31 represent himself or herself to be a respiratory care 4 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 practitioner or respiratory therapist. 2 (4) An individual providing respiratory care services 3 in an emergency who does not represent himself or herself as a 4 respiratory care practitioner or respiratory therapist. 5 (5) Any individual employed to deliver, assemble, set 6 up, or test equipment for use in a home, upon the order of a 7 physician licensed pursuant to chapter 458 or chapter 459. 8 This subsection does not, however, authorize the practice of 9 respiratory care without a license. 10 (6) Any individual certified or registered as a 11 pulmonary function technologist who is credentialed by the 12 National Board for Respiratory Care for performing 13 cardiopulmonary diagnostic studies. 14 (7) Any student who is enrolled in an accredited 15 respiratory care program approved by the board, while 16 performing respiratory care as an integral part of a required 17 course. 18 (8) The delivery of incidental respiratory care to 19 noninstitutionalized persons by surrogate family members who 20 do not represent themselves as registered or certified 21 respiratory care therapists. 22 (9) Any individual credentialed by the Underseas 23 Hyperbaric Society in hyperbaric medicine or its equivalent as 24 determined by the board, while performing related duties. This 25 subsection does not, however, authorize the practice of 26 respiratory care without a license. 27 Section 16. Effective January 1, 2005, sections 28 468.356 and 468.357, Florida Statutes, are repealed. 29 Section 17. Section 627.6499, Florida Statutes, is 30 amended to read: 31 627.6499 Reporting by insurers and third-party 5 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 administrators.-- 2 (1) The office may require any insurer, third-party 3 administrator, or service company to report any information 4 reasonably required to assist the board in assessing insurers 5 as required by this act. 6 (2) Each health insurance issuer shall make available 7 on its Internet website a link to the performance outcome and 8 financial data that is published by the Agency for Health Care 9 Administration pursuant to s. 408.05(3)(l) and shall include 10 in every policy delivered or issued for delivery to any person 11 in the state or any materials provided as required by s. 12 627.64725 notice that such information is available 13 electronically and the address of its Internet website. 14 Section 18. Subsections (6) and (7) are added to 15 section 641.54, Florida Statutes, to read: 16 641.54 Information disclosure.-- 17 (6) Each health maintenance organization shall make 18 available to its subscribers the estimated co-pay, coinsurance 19 percentage, or deductible, whichever is applicable, for any 20 covered services, the status of the subscriber's maximum 21 annual out-of-pocket payments for a covered individual or 22 family, and the status of the subscriber's maximum lifetime 23 benefit. Such estimate shall not preclude the actual co-pay, 24 coinsurance percentage, or deductible, whichever is 25 applicable, from exceeding the estimate. 26 (7) Each health maintenance organization shall make 27 available on its Internet website a link to the performance 28 outcome and financial data that is published by the Agency for 29 Health Care Administration pursuant to s. 408.05(3)(l) and 30 shall include in every policy delivered or issued for delivery 31 to any person in the state or any materials provided as 6 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 required by s. 627.64725 notice that such information is 2 available electronically and the address of its Internet 3 website. 4 Section 19. Section 408.7056, Florida Statutes, is 5 amended to read: 6 408.7056 Statewide Provider and Subscriber Assistance 7 Program.-- 8 (1) As used in this section, the term: 9 (a) "Agency" means the Agency for Health Care 10 Administration. 11 (b) "Department" means the Department of Financial 12 Services. 13 (c) "Grievance procedure" means an established set of 14 rules that specify a process for appeal of an organizational 15 decision. 16 (d) "Health care provider" or "provider" means a 17 state-licensed or state-authorized facility, a facility 18 principally supported by a local government or by funds from a 19 charitable organization that holds a current exemption from 20 federal income tax under s. 501(c)(3) of the Internal Revenue 21 Code, a licensed practitioner, a county health department 22 established under part I of chapter 154, a prescribed 23 pediatric extended care center defined in s. 400.902, a 24 federally supported primary care program such as a migrant 25 health center or a community health center authorized under s. 26 329 or s. 330 of the United States Public Health Services Act 27 that delivers health care services to individuals, or a 28 community facility that receives funds from the state under 29 the Community Alcohol, Drug Abuse, and Mental Health Services 30 Act and provides mental health services to individuals. 31 (e) "Managed care entity" means a health maintenance 7 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 organization or a prepaid health clinic certified under 2 chapter 641, a prepaid health plan authorized under s. 3 409.912, or an exclusive provider organization certified under 4 s. 627.6472. 5 (f) "Office" means the Office of Insurance Regulation 6 of the Financial Services Commission. 7 (g) "Panel" means a statewide provider and subscriber 8 assistance panel selected as provided in subsection (11). 9 (2) The agency shall adopt and implement a program to 10 provide assistance to subscribers and providers, including 11 those whose grievances are not resolved by the managed care 12 entity to the satisfaction of the subscriber or provider. The 13 program shall consist of one or more panels that meet as often 14 as necessary to timely review, consider, and hear grievances 15 and recommend to the agency or the office any actions that 16 should be taken concerning individual cases heard by the 17 panel. The panel shall hear every grievance filed by 18 subscribers and providers on behalf of subscribers, unless the 19 grievance: 20 (a) Relates to a managed care entity's refusal to 21 accept a provider into its network of providers; 22 (b) Is part of an internal grievance in a Medicare 23 managed care entity or a reconsideration appeal through the 24 Medicare appeals process which does not involve a quality of 25 care issue; 26 (c) Is related to a health plan not regulated by the 27 state such as an administrative services organization, 28 third-party administrator, or federal employee health benefit 29 program; 30 (d) Is related to appeals by in-plan suppliers and 31 providers, unless related to quality of care provided by the 8 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 plan; 2 (e) Is part of a Medicaid fair hearing pursued under 3 42 C.F.R. ss. 431.220 et seq.; 4 (f) Is the basis for an action pending in state or 5 federal court; 6 (g) Is related to an appeal by nonparticipating 7 providers, unless related to the quality of care provided to a 8 subscriber by the managed care entity and the provider is 9 involved in the care provided to the subscriber; 10 (h) Was filed before the subscriber or provider 11 completed the entire internal grievance procedure of the 12 managed care entity, the managed care entity has complied with 13 its timeframes for completing the internal grievance 14 procedure, and the circumstances described in subsection (6) 15 do not apply; 16 (i) Has been resolved to the satisfaction of the 17 subscriber or provider who filed the grievance, unless the 18 managed care entity's initial action is egregious or may be 19 indicative of a pattern of inappropriate behavior; 20 (j) Is limited to seeking damages for pain and 21 suffering, lost wages, or other incidental expenses, including 22 accrued interest on unpaid balances, court costs, and 23 transportation costs associated with a grievance procedure; 24 (k) Is limited to issues involving conduct of a health 25 care provider or facility, staff member, or employee of a 26 managed care entity which constitute grounds for disciplinary 27 action by the appropriate professional licensing board and is 28 not indicative of a pattern of inappropriate behavior, and the 29 agency, office, or department has reported these grievances to 30 the appropriate professional licensing board or to the health 31 facility regulation section of the agency for possible 9 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 investigation; or 2 (l) Is withdrawn by the subscriber or provider. 3 Failure of the subscriber or the provider to attend the 4 hearing shall be considered a withdrawal of the grievance. 5 (3) The agency shall review all grievances within 60 6 days after receipt and make a determination whether the 7 grievance shall be heard. Once the agency notifies the panel, 8 the subscriber or provider, and the managed care entity that a 9 grievance will be heard by the panel, the panel shall hear the 10 grievance either in the network area or by teleconference no 11 later than 120 days after the date the grievance was filed. 12 The agency shall notify the parties, in writing, by facsimile 13 transmission, or by phone, of the time and place of the 14 hearing. The panel may take testimony under oath, request 15 certified copies of documents, and take similar actions to 16 collect information and documentation that will assist the 17 panel in making findings of fact and a recommendation. The 18 panel shall issue a written recommendation, supported by 19 findings of fact, to the provider or subscriber, to the 20 managed care entity, and to the agency or the office no later 21 than 15 working days after hearing the grievance. If at the 22 hearing the panel requests additional documentation or 23 additional records, the time for issuing a recommendation is 24 tolled until the information or documentation requested has 25 been provided to the panel. The proceedings of the panel are 26 not subject to chapter 120. 27 (4) If, upon receiving a proper patient authorization 28 along with a properly filed grievance, the agency requests 29 medical records from a health care provider or managed care 30 entity, the health care provider or managed care entity that 31 has custody of the records has 10 days to provide the records 10 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 to the agency. Records include medical records, communication 2 logs associated with the grievance both to and from the 3 subscriber, contracts, and any other contents of the internal 4 grievance file associated with the complaint filed with the 5 Subscriber Assistance Program. Failure to provide requested 6 medical records may result in the imposition of a fine of up 7 to $500. Each day that records are not produced is considered 8 a separate violation. 9 (5) Grievances that the agency determines pose an 10 immediate and serious threat to a subscriber's health must be 11 given priority over other grievances. The panel may meet at 12 the call of the chair to hear the grievances as quickly as 13 possible but no later than 45 days after the date the 14 grievance is filed, unless the panel receives a waiver of the 15 time requirement from the subscriber. The panel shall issue a 16 written recommendation, supported by findings of fact, to the 17 office or the agency within 10 days after hearing the 18 expedited grievance. 19 (6) When the agency determines that the life of a 20 subscriber is in imminent and emergent jeopardy, the chair of 21 the panel may convene an emergency hearing, within 24 hours 22 after notification to the managed care entity and to the 23 subscriber, to hear the grievance. The grievance must be heard 24 notwithstanding that the subscriber has not completed the 25 internal grievance procedure of the managed care entity. The 26 panel shall, upon hearing the grievance, issue a written 27 emergency recommendation, supported by findings of fact, to 28 the managed care entity, to the subscriber, and to the agency 29 or the office for the purpose of deferring the imminent and 30 emergent jeopardy to the subscriber's life. Within 24 hours 31 after receipt of the panel's emergency recommendation, the 11 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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. 12 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 13 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 14 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 20. 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 15 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 21. 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 16 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 17 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 18 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 22. 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 19 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 23. 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 20 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 21 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 24. 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). 22 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 (c) A representative of the authorized medical 23 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 malpractice insurer with the largest market share as measured 2 by premiums written in the state for the most recent calendar 3 year, appointed by such insurer. 4 (d) The president of the Florida Health Care 5 Coalition. 6 (e) A representative of a hospital in the state that 7 is implementing innovative patient safety initiatives, 8 appointed by the Florida Hospital Association. 9 (f) A physician with expertise in patient safety, 10 appointed by the Florida Medical Association. 11 (g) A physician with expertise in patient safety, 12 appointed by the Florida Osteopathic Medical Association. 13 (h) A nurse with expertise in patient safety, 14 appointed by the Florida Nurses Association. 15 (i) An institutional pharmacist, appointed by the 16 Florida Society of Health System Pharmacists, Inc. 17 (j) A representative of Florida AARP, appointed by the 18 state director of the Florida AARP. 19 (k) An independent consultant on health care 20 information systems, appointed jointly by the Central Florida 21 Chapter and the South Florida Chapter of the Healthcare 22 Information and Management Systems Society. 23 (l) A physician with expertise in patient safety, 24 appointed by the Florida Podiatric Medical Association. 25 (m) A physician with expertise in patient safety, 26 appointed by the Florida Chiropractic Association. 27 (n) A dentist with expertise in patient safety, 28 appointed bt the Florida Dental Association. 29 (5) ADVISORY COMMITTEES.--In addition to any 30 committees that the corporation may establish, the corporation 31 shall establish the following advisory committees: 24 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (a) A scientific research advisory committee that 2 includes, at a minimum, a representative from each patient 3 safety center or other patient safety program in the 4 universities of this state who is a physician licensed under 5 chapter 458 or chapter 459, with experience in patient safety 6 and evidence-based medicine. The duties of the scientific 7 research advisory committee shall include, but not be limited 8 to, the analysis of existing data and research to improve 9 patient safety and encourage evidence-based medicine. 10 (b) A technology advisory committee that includes, at 11 a minimum, a representative of a hospital that has implemented 12 a computerized physician order entry system and a health care 13 provider that has implemented an electronic medical records 14 system. The duties of the technology advisory committee shall 15 include, but not be limited to, fostering development and use 16 of new patient safety technologies, including electronic 17 medical records. 18 (c) A health care provider advisory committee that 19 includes, at a minimum, representatives of hospitals, 20 ambulatory surgical centers, physicians, nurses, and 21 pharmacists licensed in this state and a representative of the 22 Veterans Integrated Service Network 8 VA Patient Safety 23 Center. The duties of the health care provider advisory 24 committee shall include, but not be limited to, promotion of a 25 culture of patient safety that reduces errors. 26 (d) A health care consumer advisory committee that 27 includes, at a minimum, representatives of businesses that 28 provide health insurance coverage to their employees, consumer 29 advocacy groups, and representatives of patient organizations. 30 The duties of the health care consumer advisory committee 31 shall include, but not be limited to, identification of 25 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 incentives to encourage patient safety and the efficiency and 2 quality of care. 3 (e) A state agency advisory committee that includes, 4 at a minimum, a representative from each state agency that has 5 regulatory responsibilities related to patient safety. The 6 duties of the state agency advisory committee shall include, 7 but not be limited to, fostering coordination of patient 8 safety activities among state agencies. 9 (f) A litigation alternatives advisory committee that 10 includes, at a minimum, representatives of attorneys who 11 represent plaintiffs and defendants in medical malpractice 12 cases, a representative of each law school in the state, 13 physicians, and health care facilities. The duties of the 14 litigation alternatives advisory committee shall include, but 15 not be limited to, identification of alternative systems to 16 compensate for injuries. 17 (g) An education advisory committee that includes, at 18 a minimum, the associate dean for education, or the equivalent 19 position, as a representative from each school of medicine, 20 nursing, public health, or allied health to provide advice on 21 the development, implementation, and measurement of core 22 competencies for patient safety to be considered for 23 incorporation in the educational programs of the universities 24 and colleges of this state. 25 (6) ORGANIZATION; MEETINGS.-- 26 (a) The Agency for Health Care Administration shall 27 assist the corporation in its organizational activities 28 required under chapter 617, including, but not limited to: 29 1. Eliciting appointments for the initial board of 30 directors. 31 2. Convening the first meeting of the board of 26 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 directors and assisting with other meetings of the board of 2 directors, upon the request of the board of directors, during 3 the first year of operation of the corporation. 4 3. Drafting articles of incorporation for the board of 5 directors and, upon the request of the board of directors, 6 delivering articles of incorporation to the Department of 7 State for filing. 8 4. Drafting proposed bylaws for the corporation. 9 5. Paying fees related to incorporation. 10 6. Providing office space and administrative support, 11 at the request of the board of directors, but not beyond July 12 1, 2005. 13 (b) The board of directors must conduct its first 14 meeting no later than August 1, 2004, and shall meet 15 thereafter as frequently as necessary to carry out the duties 16 of the corporation. 17 (7) POWERS AND DUTIES.--In addition to the powers and 18 duties prescribed in chapter 617 and the articles and bylaws 19 adopted under that chapter, the corporation shall directly or 20 through contract: 21 (a) Secure staff necessary to properly administer the 22 corporation. 23 (b) Collect, analyze, and evaluate patient safety 24 data, quality and patient safety indicators, medical 25 malpractice closed claims, and adverse incidents reported to 26 the Agency for Health Care Administration and the Department 27 of Health for the purpose of recommending changes in practices 28 and procedures which may be implemented by health care 29 practitioners and health care facilities to improve the 30 quality of health care and to prevent future adverse 31 incidents. Notwithstanding any other law, the Agency for 27 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 Health Care Administration and the Department of Health shall 2 make available to the corporation any adverse incident report 3 submitted under s. 395.0197, s. 458.351, or s. 459.026. To the 4 extent that adverse incident reports submitted under s. 5 395.0197 are confidential and exempt from disclosure, the 6 confidential and exempt status of such reports must be 7 maintained by the corporation. 8 (c) Maintain an active library of best practices 9 relating to patient safety and patient safety literature, 10 along with the emerging evidence supporting the retention or 11 modification of such practices, and make this information 12 available to health care practitioners, health care 13 facilities, and the public. 14 (d) Assess the patient safety culture at volunteering 15 hospitals and recommend methods to improve the working 16 environment related to patient safety at these hospitals. 17 (e) Inventory the information technology capabilities 18 related to patient safety of health care facilities and health 19 care practitioners and recommend a plan for expediting 20 implementation of safety technologies statewide. 21 (f) Facilitate the development of core competencies 22 relevant to patient safety which can be made available to be 23 considered for incorporation into the undergraduate and 24 graduate curriculums in schools of medicine, nursing, and 25 allied health in this state. 26 (g) Facilitate continuing professional education 27 regarding patient safety for practicing health care 28 practitioners. 29 (h) Study and facilitate the testing of alternative 30 systems of encouraging the implementation of effective risk 31 management strategies and clinical best practices, and of 28 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 compensating injured patients as a means of reducing and 2 preventing medical errors and promoting patient safety. 3 (i) Develop programs to educate the public about the 4 role of health care consumers in promoting patient safety. 5 (j) Provide interagency coordination of patient safety 6 efforts in this state. 7 (k) Conduct other activities identified by the board 8 of directors to promote patient safety in this state. 9 (8) ANNUAL REPORT.--By December 1, 2004, the 10 corporation shall prepare a report on the start-up activities 11 of the corporation and any proposals for legislative action 12 needed to enable the corporation to fulfill its purposes under 13 this section. By December 1 of each year thereafter, the 14 corporation shall prepare a report for the preceding fiscal 15 year. The report, at a minimum, must include: 16 (a) A description of the activities of the corporation 17 under this section. 18 (b) Progress made in improving patient safety and 19 reducing medical errors. 20 (c) A compliance and financial audit of the accounts 21 and records of the corporation at the end of the preceding 22 fiscal year conducted by an independent certified public 23 accountant. 24 (d) An assessment of the ability of the corporation to 25 fulfill the duties specified in subsection (7) and the 26 appropriateness of those duties for the corporation. 27 (e) Recommendations for legislative action needed to 28 improve patient safety in this state. 29 30 The corporation shall submit the report to the Governor, the 31 President of the Senate, and the Speaker of the House of 29 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 Representatives. 2 (9) PERFORMANCE EXPECTATIONS.--The Office of Program 3 Policy Analysis and Government Accountability, in consultation 4 with the Agency for Health Care Administration, the Department 5 of Health, and the corporation, shall develop performance 6 standards by which to measure the success of the corporation 7 in organizing to fulfill and beginning to implement the 8 purposes and duties established in this section. The Office of 9 Program Policy Analysis and Government Accountability shall 10 conduct a performance audit of the corporation during 2006, 11 using the performance standards, and shall submit a report to 12 the Governor, the President of the Senate, and the Speaker of 13 the House of Representatives by January 1, 2007. 14 Section 25. The Patient Safety Center at the Florida 15 State University College of Medicine, in collaboration with 16 researchers at other state universities, shall conduct a study 17 to analyze the return on investment that hospitals in this 18 state could realize from implementing computerized physician 19 order entry and other information technologies related to 20 patient safety. For the purposes of this analysis, the return 21 on investment shall include both financial results and 22 benefits relating to quality of care and patient safety. The 23 study must include a representative sample of large and small 24 hospitals, located in urban and rural areas, in the north, 25 central, and southern regions of the state. By February 1, 26 2005, the Patient Safety Center at the Florida State 27 University College of Medicine must submit a report to the 28 Governor, the President of the Senate, and the Speaker of the 29 House of Representatives concerning the results of the study. 30 Section 26. Section 395.1012, Florida Statutes, is 31 amended to read: 30 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 395.1012 Patient safety.-- 2 (1) Each licensed facility must adopt a patient safety 3 plan. A plan adopted to implement the requirements of 42 4 C.F.R. part 482.21 shall be deemed to comply with this 5 requirement. 6 (2) Each licensed facility shall appoint a patient 7 safety officer and a patient safety committee, which shall 8 include at least one person who is neither employed by nor 9 practicing in the facility, for the purpose of promoting the 10 health and safety of patients, reviewing and evaluating the 11 quality of patient safety measures used by the facility, 12 recommending improvements in the patient safety measures used 13 by the facility, and assisting in the implementation of the 14 facility patient safety plan. 15 (3) Each licensed facility shall adopt a plan to 16 reduce medication errors and adverse drug events, which must 17 consider the use of computerized physician order entry and 18 other information technologies related to patient safety. 19 Section 27. Subsection (3) of section 409.91255, 20 Florida Statutes, is amended to read: 21 409.91255 Federally qualified health center access 22 program.-- 23 (3) ASSISTANCE TO FEDERALLY QUALIFIED HEALTH 24 CENTERS.--The Department of Health shall develop a program for 25 the expansion of federally qualified health centers for the 26 purpose of providing comprehensive primary and preventive 27 health care and urgent care services, including services that 28 may reduce the morbidity, mortality, and cost of care among 29 the uninsured population of the state. The program shall 30 provide for distribution of financial assistance to federally 31 qualified health centers that apply and demonstrate a need for 31 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 such assistance in order to sustain or expand the delivery of 2 primary and preventive health care services. In selecting 3 centers to receive this financial assistance, the program: 4 (a) Shall give preference to communities that have few 5 or no community-based primary care services or in which the 6 current services are unable to meet the community's needs. 7 (b) Shall require that primary care services be 8 provided to the medically indigent using a sliding fee 9 schedule based on income. 10 (c) Shall allow innovative and creative uses of 11 federal, state, and local health care resources. 12 (d) Shall require that the funds provided be used to 13 pay for operating costs of a projected expansion in patient 14 caseloads or services or for capital improvement projects. 15 Capital improvement projects may include renovations to 16 existing facilities or construction of new facilities, 17 provided that an expansion in patient caseloads or services to 18 a new patient population will occur as a result of the capital 19 expenditures. The department shall include in its standard 20 contract document a requirement that any state funds provided 21 for the purchase of or improvements to real property are 22 contingent upon the contractor granting to the state a 23 security interest in the property at least to the amount of 24 the state funds provided for at least 5 years from the date of 25 purchase or the completion of the improvements or as further 26 required by law. The contract must include a provision that, 27 as a condition of receipt of state funding for this purpose, 28 the contractor agrees that, if it disposes of the property 29 before the department's interest is vacated, the contractor 30 will refund the proportionate share of the state's initial 31 investment, as adjusted by depreciation. 32 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (e) May require in-kind support from other sources. 2 (f) May encourage coordination among federally 3 qualified health centers, other private-sector providers, and 4 publicly supported programs. 5 (g) Shall allow the development of community emergency 6 room diversion programs in conjunction with local resources, 7 providing extended hours of operation to urgent care patients. 8 Diversion programs shall include case management for emergency 9 room followup care. 10 Section 28. Paragraph (a) of subsection (6) of section 11 627.410, Florida Statutes, is amended to read: 12 627.410 Filing, approval of forms.-- 13 (6)(a) An insurer shall not deliver or issue for 14 delivery or renew in this state any health insurance policy 15 form until it has filed with the office a copy of every 16 applicable rating manual, rating schedule, change in rating 17 manual, and change in rating schedule; if rating manuals and 18 rating schedules are not applicable, the insurer must file 19 with the office order applicable premium rates and any change 20 in applicable premium rates. This paragraph does not apply to 21 group health insurance policies, effectuated and delivered in 22 this state, insuring groups of 51 or more persons, except for 23 Medicare supplement insurance, long-term care insurance, and 24 any coverage under which the increase in claim costs over the 25 lifetime of the contract due to advancing age or duration is 26 prefunded in the premium. 27 Section 29. Section 627.6405, Florida Statutes, is 28 created to read: 29 627.6405 Decrease in inappropriate utilization of 30 emergency care.-- 31 (1) The Legislature finds and declares it to be of 33 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 vital importance that emergency services and care be provided 2 by hospitals and physicians to every person in need of such 3 care, but with the double-digit increases in health insurance 4 premiums, health care providers and insurers should encourage 5 patients and the insured to assume responsibility for their 6 treatment, including emergency care. The Legislature finds 7 that inappropriate utilization of emergency department 8 services increases the overall cost of providing health care 9 and these costs are ultimately borne by the hospital, the 10 insured patients, and, many times, by the taxpayers of this 11 state. Finally, the Legislature declares that the providers 12 and insurers must share the responsibility of providing 13 alternative treatment options to urgent care patients outside 14 of the emergency department. Therefore, it is the intent of 15 the Legislature to place the obligation for educating 16 consumers and creating mechanisms for delivery of care that 17 will decrease the overutilization of emergency service on 18 health insurers and providers. 19 (2) Health insurers shall provide on their websites 20 information regarding appropriate utilization of emergency 21 care services which shall include, but not be limited to, a 22 list of alternative urgent care contracted providers, the 23 types of services offered by these providers, and what to do 24 in the event of a true emergency. 25 (3) Health insurers shall develop community emergency 26 department diversion programs. Such programs may include, at 27 the discretion of the insurer, but are not limited to, 28 enlisting providers to be on call to insurers after hours, 29 coordinating care through local community resources, and 30 incentives to providers for case management. 31 (4) As a disincentive for insureds to inappropriately 34 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 use emergency department services, health insurers may require 2 higher copayments for nonemergency use of emergency 3 departments and higher copayments for use of out-of-network 4 emergency departments. For the purposes of this section, the 5 term "emergency care" has the same meaning as provided in s. 6 395.002, and shall include services provided to rule out an 7 emergency medical condition. 8 Section 30. Effective upon this act becoming a law, 9 section 627.64872, Florida Statutes, is created to read: 10 627.64872 Florida Health Insurance Plan.-- 11 (1) LEGISLATIVE INTENT; FLORIDA HEALTH INSURANCE 12 PLAN.-- 13 (a) The Legislature recognizes that to secure a more 14 stable and orderly health insurance market, the establishment 15 of a plan to assume risks deemed uninsurable by the private 16 marketplace is required. 17 (b) The Florida Health Insurance Plan is created to 18 make coverage available to individuals who have no other 19 option for similar coverage, at a premium that is commensurate 20 with the risk and benefits provided, and with benefit designs 21 that are reasonable in relation to the general market. While 22 plan operations may include supplementary funding, the plan 23 shall fundamentally operate on sound actuarial principles, 24 using basic insurance management techniques to ensure that the 25 plan is run in an economical, cost-efficient, and sound 26 manner, conserving plan resources to serve the maximum number 27 of people possible in a sustainable fashion. 28 (2) DEFINITIONS.--As used in this section: 29 (a) "Board" means the board of directors of the plan. 30 (b) "Commission" means the Financial Services 31 Commission. 35 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (c) "Dependent" means a resident spouse or resident 2 unmarried child under the age of 19 years, a child who is a 3 student under the age of 25 years and who is financially 4 dependent upon the parent, or a child of any age who is 5 disabled and dependent upon the parent. 6 (d) "Director" means the director of the Office of 7 Insurance Regulation. 8 (e) "Health insurance" means any hospital or medical 9 expense incurred policy pursuant to this chapter or health 10 maintenance organization subscriber contract pursuant to 11 chapter 641. The term does not include short term, accident, 12 dental-only, vision-only, fixed indemnity, limited benefit, 13 credit, or disability income insurance; coverage for onsite 14 medical clinics; insurance coverage specified in federal 15 regulations issued pursuant to Pub. L. No. 104-191, under 16 which benefits for medical care are secondary or incidental to 17 other insurance benefits; benefits for long-term care, nursing 18 home care, home health care, community-based care, or any 19 combination thereof, or other similar, limited benefits 20 specified in federal regulations issued pursuant to Pub. L. 21 No. 104-191; benefits provided under a separate policy, 22 certificate, or contract of insurance where there is no 23 coordination between the provision of the benefits and any 24 exclusion of benefits under any group health plan maintained 25 by the same plan sponsor, and the benefits are paid with 26 respect to an event without regard to whether benefits are 27 provided with respect to such an event under any group health 28 plan maintained by the same plan sponsor, such as for coverage 29 only for a specified disease or illness; hospital indemnity or 30 other fixed indemnity insurance; coverage offered as a 31 separate policy, certificate, or contract of insurance, such 36 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 as Medicare supplemental health insurance as defined under s. 2 1882(g)(1) of the Social Security Act; coverage supplemental 3 to the coverage provided under Chapter 55 of Title 10, United 4 States Code (Civilian Health and Medical Program of the 5 Uniformed Services (CHAMPUS)); similar supplemental coverage 6 provided to coverage under a group health plan; coverage 7 issued as a supplement to liability insurance; insurance 8 arising out of a workers' compensation or similar law; 9 automobile medical-payment insurance; or insurance under which 10 benefits are payable with or without regard to fault and which 11 is statutorily required to be contained in any liability 12 insurance policy or equivalent self-insurance. 13 (f) "Implementation" means the effective date after 14 the first meeting of the board when legal authority and 15 administrative ability exist for the board to subsume the 16 transfer of all statutory powers, duties, functions, assets, 17 records, personnel, and property of the Florida Comprehensive 18 Health Association as specified in s. 627.6488. 19 (g) "Insurer" means any entity that provides health 20 insurance in this state. For purposes of this section, insurer 21 includes an insurance company with a valid certificate in 22 accordance with chapter 624, a health maintenance organization 23 with a valid certificate of authority in accordance with part 24 I or part III of chapter 641, a prepaid health clinic 25 authorized to transact business in this state pursuant to part 26 II of chapter 641, multiple employer welfare arrangements 27 authorized to transact business in this state pursuant to ss. 28 624.436-624.45, or a fraternal benefit society providing 29 health benefits to its members as authorized pursuant to 30 chapter 632. 31 (h) "Medicare" means coverage under both Parts A and B 37 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 of Title XVIII of the Social Security Act, 42 USC 1395 et 2 seq., as amended. 3 (i) "Medicaid" means coverage under Title XIX of the 4 Social Security Act. 5 (j) "Office" means the Office of Insurance Regulation 6 of the Financial Services Commission. 7 (k) "Participating insurer" means any insurer 8 providing health insurance to citizens of this state. 9 (l) "Provider" means any physician, hospital, or other 10 institution, organization, or person that furnishes health 11 care services and is licensed or otherwise authorized to 12 practice in the state. 13 (m) "Plan" means the Florida Health Insurance Plan 14 created in subsection (1). 15 (n) "Plan of operation" means the articles, bylaws, 16 and operating rules and procedures adopted by the board 17 pursuant to this section. 18 (o) "Resident" means an individual who has been 19 legally domiciled in this state for a period of at least 6 20 months. 21 (3) BOARD OF DIRECTORS.-- 22 (a) The plan shall operate subject to the supervision 23 and control of the board. The board shall consist of the 24 director or his or her designated representative, who shall 25 serve as a member of the board and shall be its chair, and an 26 additional eight members, five of whom shall be appointed by 27 the Governor, at least three of whom shall be individuals not 28 representative of insurers or health care providers, one of 29 whom shall be appointed by the Chief Financial Officer, one of 30 whom shall be appointed by the President of the Senate, and 31 one of whom shall be appointed by the Speaker of the House of 38 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 Representatives. 2 (b) The Director of the Office of Insurance 3 Regulation's term on the board shall be determined by 4 continued employment in the position. The remaining initial 5 board members shall serve for a period of time as follows: two 6 members appointed by the Governor and the members appointed by 7 the President of the Senate and the Speaker of the House of 8 Representatives shall serve 2-year terms; and three members 9 appointed by the Governor and the state's Chief Financial 10 Officer shall serve 4-year terms. Subsequent board members 11 shall serve for 3-year terms. A board member's term shall 12 continue until his or her successor is appointed. 13 (c) Vacancies on the board shall be filled by the 14 appointing authority, the authority being the Governor, the 15 President of the Senate, the Speaker of the House of 16 Representatives, or the Chief Financial Officer. Board members 17 may be removed by the appointing authority for cause. 18 (d) The director, or his or her representative, is 19 responsible for any organizational requirements necessary for 20 the initial meeting of the board which shall take place no 21 later than September 1, 2004. 22 (e) Members shall not be compensated in their capacity 23 as board members but shall be reimbursed for reasonable 24 expenses incurred in the necessary performance of their duties 25 in accordance with s. 112.061. 26 (f) The board shall submit to the commission a plan of 27 operation for the plan and any amendments thereto necessary or 28 suitable to ensure the fair, reasonable, and equitable 29 administration of the plan. The plan of operation shall ensure 30 that the plan qualifies to apply for any available funding 31 from the Federal Government that adds to the financial 39 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 viability of the plan. The plan of operation shall become 2 effective upon approval in writing by the commission 3 consistent with the date on which the coverage under this 4 section must be made available. If the board fails to submit a 5 suitable plan of operation within 1 year after the appointment 6 of the board of directors, or at any time thereafter fails to 7 submit suitable amendments to the plan of operation, the 8 commission shall adopt such rules as are necessary or 9 advisable to effectuate the provisions of this section. Such 10 rules shall continue in force until modified by the office or 11 superseded by a plan of operation submitted by the board and 12 approved by the commission. 13 (g) The board shall take no action to implement the 14 plan, other than the administration of coverage of individuals 15 enrolled in the Florida Comprehensive Health Association, as 16 specified in subsection (20) and the completion of the 17 actuarial study authorized in subsection (6), until funds are 18 appropriated for start-up costs and any projected deficits. 19 (4) PLAN OF OPERATION.--The plan of operation shall: 20 (a) Establish procedures for operation of the plan. 21 (b) Establish procedures for selecting an 22 administrator in accordance with subsection (11). 23 (c) Establish procedures to create a fund, under 24 management of the board, for administrative expenses. 25 (d) Establish procedures for the handling, accounting, 26 and auditing of assets, moneys, and claims of the plan and the 27 plan administrator. 28 (e) Develop and implement a program to publicize the 29 existence of the plan, plan eligibility requirements, and 30 procedures for enrollment and maintain public awareness of the 31 plan. 40 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (f) Establish procedures under which applicants and 2 participants may have grievances reviewed by a grievance 3 committee appointed by the board. The grievances shall be 4 reported to the board after completion of the review, with the 5 committee's recommendation for grievance resolution. The board 6 shall retain all written grievances regarding the plan for at 7 least 3 years. 8 (g) Provide for other matters as may be necessary and 9 proper for the execution of the board's powers, duties, and 10 obligations under this section. 11 (5) POWERS OF THE PLAN.--The plan shall have the 12 general powers and authority granted under the laws of this 13 state to health insurers and, in addition thereto, the 14 specific authority to: 15 (a) Enter into such contracts as are necessary or 16 proper to carry out the provisions and purposes of this 17 section, including the authority, with the approval of the 18 commission, to enter into contracts with similar plans of 19 other states for the joint performance of common 20 administrative functions, or with persons or other 21 organizations for the performance of administrative functions. 22 (b) Take any legal actions necessary or proper to 23 recover or collect assessments due the plan. 24 (c) Take such legal action as is necessary to: 25 1. Avoid payment of improper claims against the plan 26 or the coverage provided by or through the plan; 27 2. Recover any amounts erroneously or improperly paid 28 by the plan; 29 3. Recover any amounts paid by the plan as a result of 30 mistake of fact or law; or 31 4. Recover other amounts due the plan. 41 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (d) Establish, and modify as appropriate, rates, rate 2 schedules, rate adjustments, expense allowances, agents' 3 commissions, claims reserve formulas, and any other actuarial 4 functions appropriate to the operation of the plan. Rates and 5 rate schedules may be adjusted for appropriate factors such as 6 age, sex, and geographic variation in claim cost and shall 7 take into consideration appropriate factors in accordance with 8 established actuarial and underwriting practices. For purposes 9 of this paragraph, usual and customary agent's commissions 10 shall be paid for the initial placement of coverage with the 11 plan and for one renewal only. 12 (e) Issue policies of insurance in accordance with the 13 requirements of this section. 14 (f) Appoint appropriate legal, actuarial, investment, 15 and other committees as necessary to provide technical 16 assistance in the operation of the plan and develop and 17 educate its policyholders regarding health savings accounts, 18 policy and contract design, and any other function within the 19 authority of the plan. 20 (g) Borrow money to effectuate the purposes of the 21 plan. Any notes or other evidence of indebtedness of the plan 22 not in default shall be legal investments for insurers and may 23 be carried as admitted assets. 24 (h) Employ and fix the compensation of employees. 25 (i) Prepare and distribute certificate of eligibility 26 forms and enrollment instruction forms to insurance producers 27 and to the general public. 28 (j) Provide for reinsurance of risks incurred by the 29 plan. 30 (k) Provide for and employ cost-containment measures 31 and requirements, including, but not limited to, preadmission 42 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 screening, second surgical opinion, concurrent utilization 2 review, and individual case management for the purpose of 3 making the plan more cost-effective. 4 (l) Design, use, contract, or otherwise arrange for 5 the delivery of cost-effective health care services, 6 including, but not limited to, establishing or contracting 7 with preferred provider organizations, health maintenance 8 organizations, and other limited network provider 9 arrangements. 10 (m) Adopt such bylaws, policies, and procedures as may 11 be necessary or convenient for the implementation of this 12 section and the operation of the plan. 13 (n) Subsume the transfer of statutory powers, duties, 14 functions, assets, records, personnel, and property of the 15 Florida Comprehensive Health Association as specified in ss. 16 627.6488, 627.6489, 627.649, 627.6492, 627.6496, 627.6498, and 17 627.6499, unless otherwise specified by law. 18 (6)(a) Interim report.--No later than December 1, 19 2004, the board shall submit to the Governor, the President of 20 the Senate, and the Speaker of the House of Representatives an 21 actuarial study to determine, including, but not limited to: 22 1. The impact the creation of this plan will have on 23 the small group insurance market, specifically on the premiums 24 paid by insureds. This shall include an estimate of the total 25 anticipated aggregate savings for all small employers in the 26 state. 27 2. The number of individuals the pool could reasonably 28 cover at various funding levels. 29 3. A recommendation as to the best source of funding 30 for the anticipated deficits of the pool. 31 4. The effect on the individual and small group market 43 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 by including in the Florida Health Insurance Plan persons 2 eligible for coverage under s. 627.6487, as well as the cost 3 of including these individuals. 4 (b) Annual report.--No later than December 1, 2005, 5 and annually thereafter, the board shall submit to the 6 Governor, the President of the Senate, the Speaker of the 7 House of Representatives, and the substantive legislative 8 committees of the Legislature a report which includes an 9 independent actuarial study to determine, including, but not 10 be limited to: 11 1. The impact the creation of the plan has on the 12 small group and individual insurance market, specifically on 13 the premiums paid by insureds. This shall include an estimate 14 of the total anticipated aggregate savings for all small 15 employers in the state. 16 2. The actual number of individuals covered at the 17 current funding and benefit level, the projected number of 18 individuals that may seek coverage in the forthcoming fiscal 19 year, and the projected funding needed to cover anticipated 20 increase or decrease in plan participation. 21 3. A recommendation as to the best source of funding 22 for the anticipated deficits of the pool. 23 4. A summarization of the activities of the plan in 24 the preceding calendar year, including the net written and 25 earned premiums, plan enrollment, the expense of 26 administration, and the paid and incurred losses. 27 5. A review of the operation of the plan as to whether 28 the plan has met the intent of this section. 29 (7) LIABILITY OF THE PLAN.--Neither the board nor its 30 employees shall be liable for any obligations of the plan. No 31 member or employee of the board shall be liable, and no cause 44 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 of action of any nature may arise against a member or employee 2 of the board, for any act or omission related to the 3 performance of any powers and duties under this section, 4 unless such act or omission constitutes willful or wanton 5 misconduct. The board may provide in its bylaws or rules for 6 indemnification of, and legal representation for, its members 7 and employees. 8 (8) AUDITED FINANCIAL STATEMENT.--No later than June 1 9 following the close of each calendar year, the plan shall 10 submit to the Governor an audited financial statement prepared 11 in accordance with statutory accounting principles as adopted 12 by the National Association of Insurance Commissioners. 13 (9) ELIGIBILITY.-- 14 (a) Any individual person who is and continues to be a 15 resident of this state shall be eligible for coverage under 16 the plan if: 17 1. Evidence is provided that the person received 18 notices of rejection or refusal to issue substantially similar 19 insurance for health reasons from two or more health insurers. 20 A rejection or refusal by an insurer offering only stoploss, 21 excess of loss, or reinsurance coverage with respect to the 22 applicant shall not be sufficient evidence under this 23 paragraph; or 24 2. The person is enrolled in the Florida Comprehensive 25 Health Association as of the date the plan is implemented. 26 (b) Each resident dependent of a person who is 27 eligible for coverage under the plan shall also be eligible 28 for such coverage. 29 (c) A person shall not be eligible for coverage under 30 the plan if: 31 1. The person has or obtains health insurance coverage 45 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 substantially similar to or more comprehensive than a plan 2 policy, or would be eligible to obtain such coverage, unless a 3 person may maintain other coverage for the period of time the 4 person is satisfying any preexisting condition waiting period 5 under a plan policy or may main tain plan coverage for the 6 period of time the person is satisfying a preexisting 7 condition waiting period under another health insurance policy 8 intended to replace the plan policy; 9 2. The person is determined to be eligible for health 10 care benefits under Medicaid, Medicare, the state's children's 11 health insurance program, or any other federal, state, or 12 local government program that provides health benefits; 13 3. The person voluntarily terminated plan coverage 14 unless 12 months have elapsed since such termination; 15 4. The person is an inmate or resident of a public 16 institution; or 17 5. The person's premiums are paid for or reimbursed 18 under any government-sponsored program or by any government 19 agency or health care provider. 20 (d) Coverage shall cease: 21 1. On the date a person is no longer a resident of 22 this state; 23 2. On the date a person requests coverage to end; 24 3. Upon the death of the covered person; 25 4. On the date state law requires cancellation or 26 nonrenewal of the policy; 27 5. At the option of the plan, 30 days after the plan 28 makes any inquiry concerning the person's eligibility or place 29 of residence to which the person does not reply; or 30 6. Upon failure of the insured to pay for continued 31 coverage. 46 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (e) Except under the circumstances described in this 2 subsection, coverage of a person who ceased to meet the 3 eligibility requirements of this subsection shall be 4 terminated at the end of the policy period for which the 5 necessary premiums have been paid. 6 (10) UNFAIR REFERRAL TO PLAN.--It is an unfair trade 7 practice for the purposes of part IX of chapter 626 or s. 8 641.3901 for an insurer, health maintenance organization 9 insurance agent, insurance broker, or third-party 10 administrator to refer an individual employee to the plan, or 11 arrange for an individual employee to apply to the plan, for 12 the purpose of separating that employee from group health 13 insurance coverage provided in connection with the employee's 14 employment. 15 (11) PLAN ADMINISTRATOR.--The board shall select 16 through a competitive bidding process a plan administrator to 17 administer the plan. The board shall evaluate bids submitted 18 based on criteria established by the board, which shall 19 include: 20 (a) The plan administrator's proven ability to handle 21 health insurance coverage to individuals. 22 (b) The efficiency and timeliness of the plan 23 administrator's claim processing procedures. 24 (c) An estimate of total charges for administering the 25 plan. 26 (d) The plan administrator's ability to apply 27 effective cost-containment programs and procedures and to 28 administer the plan in a cost-efficient manner. 29 (e) The financial condition and stability of the plan 30 administrator. 31 47 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 The administrator shall be an insurer, a health maintenance 2 organization, or a third-party administrator, or another 3 organization duly authorized to provide insurance pursuant to 4 the Florida Insurance Code. 5 (12) ADMINISTRATOR TERM LIMITS.--The plan 6 administrator shall serve for a period specified in the 7 contract between the plan and the plan administrator subject 8 to removal for cause and subject to any terms, conditions, and 9 limitations of the contract between the plan and the plan 10 administrator. At least 1 year prior to the expiration of each 11 period of service by a plan administrator, the board shall 12 invite eligible entities, including the current plan 13 administrator, to submit bids to serve as the plan 14 administrator. Selection of the plan administrator for each 15 succeeding period shall be made at least 6 months prior to the 16 end of the current period. 17 (13) DUTIES OF THE PLAN ADMINISTRATOR.-- 18 (a) The plan administrator shall perform such 19 functions relating to the plan as may be assigned to it, 20 including, but not limited to: 21 1. Determination of eligibility. 22 2. Payment of claims. 23 3. Establishment of a premium billing procedure for 24 collection of premiums from persons covered under the plan. 25 4. Other necessary functions to ensure timely payment 26 of benefits to covered persons under the plan. 27 (b) The plan administrator shall submit regular 28 reports to the board regarding the operation of the plan. The 29 frequency, content, and form of the reports shall be specified 30 in the contract between the board and the plan administrator. 31 (c) On March 1 following the close of each calendar 48 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 year, the plan administrator shall determine net written and 2 earned premiums, the expense of administration, and the paid 3 and incurred losses for the year and report this information 4 to the board and the Governor on a form prescribed by the 5 Governor. 6 (14) PAYMENT OF THE PLAN ADMINISTRATOR.--The plan 7 administrator shall be paid as provided in the contract 8 between the plan and the plan administrator. 9 (15) FUNDING OF THE PLAN.-- 10 (a) Premiums.-- 11 1. The plan shall establish premium rates for plan 12 coverage as provided in this section. Separate schedules of 13 premium rates based on age, sex, and geographical location may 14 apply for individual risks. Premium rates and schedules shall 15 be submitted to the office for approval prior to use. 16 2. Initial rates for plan coverage shall be limited to 17 200 percent of rates established as applicable for individual 18 standard risks as specified in s. 627.6675(3)(c). Subject to 19 the limits provided in this paragraph, subsequent rates shall 20 be established to provide fully for the expected costs of 21 claims, including recovery of prior losses, expenses of 22 operation, investment income of claim reserves, and any other 23 cost factors subject to the limitations described herein, but 24 in no event shall premiums exceed the 200-percent rate 25 limitation provided in this section. Notwithstanding the 26 200-percent rate limitation, sliding scale premium surcharges 27 based upon the insured's income may apply to all enrollees, 28 provided that such premiums do not exceed 300 percent of the 29 standard risk rate. 30 (b) Sources of additional revenue.--Any deficit 31 incurred by the plan shall be primarily funded through amounts 49 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 appropriated by the Legislature from general revenue sources, 2 including, but not limited to, a portion of the annual growth 3 in existing net insurance premium taxes. The board shall 4 operate the plan in such a manner that the estimated cost of 5 providing health insurance during any fiscal year will not 6 exceed total income the plan expects to receive from policy 7 premiums and funds appropriated by the Legislature, including 8 any interest on investments. After determining the amount of 9 funds appropriated to the board for a fiscal year, the board 10 shall estimate the number of new policies it believes the plan 11 has the financial capacity to insure during that year so that 12 costs do not exceed income. The board shall take steps 13 necessary to ensure that plan enrollment does not exceed the 14 number of residents it has estimated it has the financial 15 capacity to insure. 16 (16) BENEFITS.-- 17 (a) The benefits provided shall be the same as the 18 standard and basic plans for small employers as outlined in s. 19 627.6699. The board shall also establish an option of 20 alternative coverage such as catastrophic coverage that 21 includes a minimum level of primary care coverage and a high 22 deductible plan that meets the federal requirements of a 23 health savings account. 24 (b) In establishing the plan coverage, the board shall 25 take into consideration the levels of health insurance 26 provided in the state and such medical economic factors as may 27 be deemed appropriate and adopt benefit levels, deductibles, 28 copayments, coinsurance factors, exclusions, and limitations 29 determined to be generally reflective of and commensurate with 30 health insurance provided through a representative number of 31 large employers in the state. 50 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (c) The board may adjust any deductibles and 2 coinsurance factors annually according to the medical 3 component of the Consumer Price Index. 4 (d)1. Plan coverage shall exclude charges or expenses 5 incurred during the first 6 months following the effective 6 date of coverage for any condition for which medical advice, 7 care, or treatment was recommended or received for such 8 condition during the 6-month period immediately preceding the 9 effective date of coverage. 10 2. Such preexisting condition exclusions shall be 11 waived to the extent that similar exclusions, if any, have 12 been satisfied under any prior health insurance coverage which 13 was involuntarily terminated, provided application for pool 14 coverage is made not later than 63 days following such 15 involuntary termination. In such case, coverage under the plan 16 shall be effective from the date on which such prior coverage 17 was terminated and the applicant is not eligible for 18 continuation or conversion rights that would provide coverage 19 substantially similar to plan coverage. 20 (17) NONDUPLICATION OF BENEFITS.-- 21 (a) The plan shall be payor of last resort of benefits 22 whenever any other benefit or source of third-party payment is 23 available. Benefits otherwise payable under plan coverage 24 shall be reduced by all amounts paid or payable through any 25 other health insurance, by all hospital and medical expense 26 benefits paid or payable under any workers' compensation 27 coverage, automobile medical payment, or liability insurance, 28 whether provided on the basis of fault or nonfault, and by any 29 hospital or medical benefits paid or payable under or provided 30 pursuant to any state or federal law or program. 31 (b) The plan shall have a cause of action against an 51 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 eligible person for the recovery of the amount of benefits 2 paid that are not for covered expenses. Benefits due from the 3 plan may be reduced or refused as a setoff against any amount 4 recoverable under this paragraph. 5 (18) ANNUAL AND MAXIMUM BENEFITS.--Maximum benefits 6 under the plan shall be determined by the board. 7 (19) TAXATION.--The plan is exempt from any tax 8 imposed by this state. The plan shall apply for federal tax 9 exemption status. 10 (20) COMBINING MEMBERSHIP OF THE FLORIDA COMPREHENSIVE 11 HEALTH ASSOCIATION.-- 12 (a)1. Upon implementation of the Florida Health 13 Insurance Plan, the Florida Comprehensive Health Association, 14 as specified in s. 627.6488 is abolished as a separate 15 nonprofit entity and shall be subsumed under the Board of 16 Directors of the Florida Health Insurance Plan. All 17 individuals actively enrolled in the Florida Comprehensive 18 Health Association shall be enrolled in th plan subject to its 19 rules and requirements, except as otherwise specified in this 20 section. Maximum lifetime benefits paid to an individual in 21 the plan may not exceed the amount established under 22 subsection (16), and benefits previously paid for any 23 individual by the Florida Comprehensive Health Association 24 shall be used in the determination of the total lifetime 25 benefits paid under the plan. 26 2. All persons enrolled in the Florida Comprehensive 27 Health Association upon implementation of the Florida Health 28 Insurance Plan are eligible only for the benefits authorized 29 under subsection (16). Persons identified by this section 30 shall convert to the benefits authorized under subsection (16) 31 no later than January 1, 2005. 52 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 3. Except as otherwise provided in this section, the 2 Florida Comprehensive Health Association shall operate under 3 the existing plan of operation without modification until the 4 adoption of the new plan of operation for the Florida Health 5 Insurance Plan. 6 (b)1. As a condition of doing business in this state, 7 an insurer shall pay an assessment to the board in the amount 8 prescribed by this paragraph. For operating losses incurred on 9 or after July 1, 2004, by persons previously enrolled in the 10 Florida Comprehensive Health Association, each insurer shall 11 annually be assessed by the board in the following calendar 12 year a portion of such incurred operating losses of the plan. 13 Such portion shall be determined by multiplying such operating 14 losses by a fraction, the numerator of which equals the 15 insurer's earned premium pertaining to direct writings of 16 health insurance in the state during the calendar year 17 proceeding that for which the assessment is levied, and the 18 denominator of which equals the total of all such premiums 19 earned by participating insurers in the state during such 20 calendar year. 21 2. The total of all assessments under this paragraph 22 upon a participating insurer shall not exceed 1 percent of 23 such insurer's health insurance premium earned in this state 24 during the calendar year preceding the year for which the 25 assessments were levied. 26 3. All rights, title, and interest in the assessment 27 funds collected under this paragraph shall vest in this state. 28 However, all of such funds and interest earned shall be used 29 by the plan to pay claims and administrative expenses. 30 (c) If assessments and other receipts by the plan, 31 board, or plan administrator exceed the actual losses and 53 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 administrative expenses of the plan, the excess shall be held 2 in interest and used by the board to offset future losses. As 3 used in this subsection, the term "future losses" includes 4 reserves for claims incurred but not reported. 5 (d) Each insurer's assessment shall be determined 6 annually by the board or plan administrator based on annual 7 statements and other reports deemed necessary by the board or 8 plan administrator and filed with the board or plan 9 administrator by the insurer. Any deficit incurred under the 10 plan by persons previously enrolled in the Florida 11 Comprehensive Health Association shall be recouped by the 12 assessments against participating insurers by the board or 13 plan administrator in the manner provided in paragraph (b), 14 and the insurers may recover the assessment in the normal 15 course of their respective businesses without time limitation. 16 (e) If a person enrolled in the Florida Comprehensive 17 Health Association as of July 1, 2004, loses eligibility for 18 participation in the plan, such person shall not be included 19 in the calculation of incurred operational losses as described 20 in paragraph (b) if the person later regains eligibility for 21 participation in the plan. 22 (f) After all persons enrolled in the Florida 23 Comprehensive Health Association as of July 1, 2004, are no 24 longer eligible for participation in the plan, the plan, 25 board, or plan administrator shall no longer be allowed to 26 assess insurers in this state for incurred losses as described 27 in paragraph (b). 28 Section 31. Upon implementation, as defined in section 29 627.64872(2), Florida Statutes, and provided in section 30 627.64872(20), Florida Statutes, of the Florida Health Benefit 31 Plan created under section 627.64872, Florida Statutes, 54 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 2 627.6496, and 627.6498, Florida Statutes, are repealed. 3 Section 32. Subsections (12) and (13) are added to 4 section 627.662, Florida Statutes, to read: 5 627.662 Other provisions applicable.--The following 6 provisions apply to group health insurance, blanket health 7 insurance, and franchise health insurance: 8 (12) Section 627.6044, relating to the use of specific 9 methodology for payment of claims. 10 (13) Section 627.6405, relating to inappropriate 11 utilization of emergency care. 12 Section 33. Paragraphs (c) and (d) of subsection (5), 13 subsection (6), and subsection (12) of section 627.6699, 14 Florida Statutes, are amended, subsections (15) and (16) of 15 that section are renumbered as subsections (16) and (17), 16 respectively, present subsection (15) of that section is 17 amended, and new subsections (15) and (18) are added to that 18 section, to read: 19 627.6699 Employee Health Care Access Act.-- 20 (5) AVAILABILITY OF COVERAGE.-- 21 (c) Every small employer carrier must, as a condition 22 of transacting business in this state: 23 1. Offer and issue all small employer health benefit 24 plans on a guaranteed-issue basis to every eligible small 25 employer, with 2 to 50 eligible employees, that elects to be 26 covered under such plan, agrees to make the required premium 27 payments, and satisfies the other provisions of the plan. A 28 rider for additional or increased benefits may be medically 29 underwritten and may only be added to the standard health 30 benefit plan. The increased rate charged for the additional or 31 increased benefit must be rated in accordance with this 55 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 section. 2 2. In the absence of enrollment availability in the 3 Florida Health Insurance Plan, offer and issue basic and 4 standard small employer health benefit plans on a 5 guaranteed-issue basis, during a 31-day open enrollment period 6 of August 1 through August 31 of each year, to every eligible 7 small employer, with fewer than two eligible employees, which 8 small employer is not formed primarily for the purpose of 9 buying health insurance and which elects to be covered under 10 such plan, agrees to make the required premium payments, and 11 satisfies the other provisions of the plan. Coverage provided 12 under this subparagraph shall begin on October 1 of the same 13 year as the date of enrollment, unless the small employer 14 carrier and the small employer agree to a different date. A 15 rider for additional or increased benefits may be medically 16 underwritten and may only be added to the standard health 17 benefit plan. The increased rate charged for the additional or 18 increased benefit must be rated in accordance with this 19 section. For purposes of this subparagraph, a person, his or 20 her spouse, and his or her dependent children constitute a 21 single eligible employee if that person and spouse are 22 employed by the same small employer and either that person or 23 his or her spouse has a normal work week of less than 25 24 hours. Any right to an open enrollment of health benefit 25 coverage for groups of fewer than two employees, pursuant to 26 this section, shall remain in full force and effect in the 27 absence of the availability of new enrollment into the Florida 28 Health Insurance Plan. 29 3. This paragraph does not limit a carrier's ability 30 to offer other health benefit plans to small employers if the 31 standard and basic health benefit plans are offered and 56 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 rejected. 2 (d) A small employer carrier must file with the 3 office, in a format and manner prescribed by the committee, a 4 standard health care plan, a high deductible plan that meets 5 the federal requirements of a health savings account plan or a 6 health reimbursement arrangement, and a basic health care plan 7 to be used by the carrier. The provisions of this section 8 which require the filing of a high deductible plan shall take 9 effect September 1, 2004. 10 (6) RESTRICTIONS RELATING TO PREMIUM RATES.-- 11 (a) The commission may, by rule, establish regulations 12 to administer this section and to assure that rating practices 13 used by small employer carriers are consistent with the 14 purpose of this section, including assuring that differences 15 in rates charged for health benefit plans by small employer 16 carriers are reasonable and reflect objective differences in 17 plan design, not including differences due to the nature of 18 the groups assumed to select particular health benefit plans. 19 (b) For all small employer health benefit plans that 20 are subject to this section and are issued by small employer 21 carriers on or after January 1, 1994, premium rates for health 22 benefit plans subject to this section are subject to the 23 following: 24 1. Small employer carriers must use a modified 25 community rating methodology in which the premium for each 26 small employer must be determined solely on the basis of the 27 eligible employee's and eligible dependent's gender, age, 28 family composition, tobacco use, or geographic area as 29 determined under paragraph (5)(j) and in which the premium may 30 be adjusted as permitted by this paragraph. 31 2. Rating factors related to age, gender, family 57 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 composition, tobacco use, or geographic location may be 2 developed by each carrier to reflect the carrier's experience. 3 The factors used by carriers are subject to office review and 4 approval. 5 3. Small employer carriers may not modify the rate for 6 a small employer for 12 months from the initial issue date or 7 renewal date, unless the composition of the group changes or 8 benefits are changed. However, a small employer carrier may 9 modify the rate one time prior to 12 months after the initial 10 issue date for a small employer who enrolls under a previously 11 issued group policy that has a common anniversary date for all 12 employers covered under the policy if: 13 a. The carrier discloses to the employer in a clear 14 and conspicuous manner the date of the first renewal and the 15 fact that the premium may increase on or after that date. 16 b. The insurer demonstrates to the office that 17 efficiencies in administration are achieved and reflected in 18 the rates charged to small employers covered under the policy. 19 4. A carrier may issue a group health insurance policy 20 to a small employer health alliance or other group association 21 with rates that reflect a premium credit for expense savings 22 attributable to administrative activities being performed by 23 the alliance or group association if such expense savings are 24 specifically documented in the insurer's rate filing and are 25 approved by the office. Any such credit may not be based on 26 different morbidity assumptions or on any other factor related 27 to the health status or claims experience of any person 28 covered under the policy. Nothing in this subparagraph exempts 29 an alliance or group association from licensure for any 30 activities that require licensure under the insurance code. A 31 carrier issuing a group health insurance policy to a small 58 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 employer health alliance or other group association shall 2 allow any properly licensed and appointed agent of that 3 carrier to market and sell the small employer health alliance 4 or other group association policy. Such agent shall be paid 5 the usual and customary commission paid to any agent selling 6 the policy. 7 5. Any adjustments in rates for claims experience, 8 health status, or duration of coverage may not be charged to 9 individual employees or dependents. For a small employer's 10 policy, such adjustments may not result in a rate for the 11 small employer which deviates more than 15 percent from the 12 carrier's approved rate. Any such adjustment must be applied 13 uniformly to the rates charged for all employees and 14 dependents of the small employer. A small employer carrier may 15 make an adjustment to a small employer's renewal premium, not 16 to exceed 10 percent annually, due to the claims experience, 17 health status, or duration of coverage of the employees or 18 dependents of the small employer. Semiannually, small group 19 carriers shall report information on forms adopted by rule by 20 the commission, to enable the office to monitor the 21 relationship of aggregate adjusted premiums actually charged 22 policyholders by each carrier to the premiums that would have 23 been charged by application of the carrier's approved modified 24 community rates. If the aggregate resulting from the 25 application of such adjustment exceeds the premium that would 26 have been charged by application of the approved modified 27 community rate by 4 5 percent for the current reporting 28 period, the carrier shall limit the application of such 29 adjustments only to minus adjustments beginning not more than 30 60 days after the report is sent to the office. For any 31 subsequent reporting period, if the total aggregate adjusted 59 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 premium actually charged does not exceed the premium that 2 would have been charged by application of the approved 3 modified community rate by 4 5 percent, the carrier may apply 4 both plus and minus adjustments. A small employer carrier may 5 provide a credit to a small employer's premium based on 6 administrative and acquisition expense differences resulting 7 from the size of the group. Group size administrative and 8 acquisition expense factors may be developed by each carrier 9 to reflect the carrier's experience and are subject to office 10 review and approval. 11 6. A small employer carrier rating methodology may 12 include separate rating categories for one dependent child, 13 for two dependent children, and for three or more dependent 14 children for family coverage of employees having a spouse and 15 dependent children or employees having dependent children 16 only. A small employer carrier may have fewer, but not 17 greater, numbers of categories for dependent children than 18 those specified in this subparagraph. 19 7. Small employer carriers may not use a composite 20 rating methodology to rate a small employer with fewer than 10 21 employees. For the purposes of this subparagraph, a "composite 22 rating methodology" means a rating methodology that averages 23 the impact of the rating factors for age and gender in the 24 premiums charged to all of the employees of a small employer. 25 8.a. A carrier may separate the experience of small 26 employer groups with fewer less than 2 eligible employees from 27 the experience of small employer groups with 2-50 eligible 28 employees for purposes of determining an alternative modified 29 community rating. 30 b. If a carrier separates the experience of small 31 employer groups as provided in sub-subparagraph a., the rate 60 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 to be charged to small employer groups of fewer less than 2 2 eligible employees may not exceed 150 percent of the rate 3 determined for small employer groups of 2-50 eligible 4 employees. However, the carrier may charge excess losses of 5 the experience pool consisting of small employer groups with 6 fewer less than 2 eligible employees to the experience pool 7 consisting of small employer groups with 2-50 eligible 8 employees so that all losses are allocated and the 150-percent 9 rate limit on the experience pool consisting of small employer 10 groups with fewer less than 2 eligible employees is 11 maintained. Notwithstanding s. 627.411(1), the rate to be 12 charged to a small employer group of fewer than 2 eligible 13 employees, insured as of July 1, 2002, may be up to 125 14 percent of the rate determined for small employer groups of 15 2-50 eligible employees for the first annual renewal and 150 16 percent for subsequent annual renewals. 17 (c) For all small employer health benefit plans that 18 are subject to this section, that are issued by small employer 19 carriers before January 1, 1994, and that are renewed on or 20 after January 1, 1995, renewal rates must be based on the same 21 modified community rating standard applied to new business. 22 (d) Notwithstanding s. 627.401(2), this section and 23 ss. 627.410 and 627.411 apply to any health benefit plan 24 provided by a small employer carrier that is an insurer, and 25 this section and s. 641.31 apply to any health benefit 26 provided by a small employer carrier that is a health 27 maintenance organization, that provides coverage to one or 28 more employees of a small employer regardless of where the 29 policy, certificate, or contract is issued or delivered, if 30 the health benefit plan covers employees or their covered 31 dependents who are residents of this state. 61 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (12) STANDARD, BASIC, HIGH DEDUCTIBLE, AND LIMITED 2 HEALTH BENEFIT PLANS.-- 3 (a)1. The Chief Financial Officer shall appoint a 4 health benefit plan committee composed of four representatives 5 of carriers which shall include at least two representatives 6 of HMOs, at least one of which is a staff model HMO, two 7 representatives of agents, four representatives of small 8 employers, and one employee of a small employer. The carrier 9 members shall be selected from a list of individuals 10 recommended by the board. The Chief Financial Officer may 11 require the board to submit additional recommendations of 12 individuals for appointment. 13 2. The plans shall comply with all of the requirements 14 of this subsection. 15 3. The plans must be filed with and approved by the 16 office prior to issuance or delivery by any small employer 17 carrier. 18 4. After approval of the revised health benefit plans, 19 if the office determines that modifications to a plan might be 20 appropriate, the Chief Financial Officer shall appoint a new 21 health benefit plan committee in the manner provided in 22 subparagraph 1. to submit recommended modifications to the 23 office for approval. 24 (b)1. Each small employer carrier issuing new health 25 benefit plans shall offer to any small employer, upon request, 26 a standard health benefit plan, and a basic health benefit 27 plan, and a high deductible plan that meets the requirements 28 of a health savings account plan or health reimbursement 29 account as defined by federal law, that meet meets the 30 criteria set forth in this section. 31 2. For purposes of this subsection, the terms 62 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 "standard health benefit plan," and "basic health benefit 2 plan," and "high deductible plan" mean policies or contracts 3 that a small employer carrier offers to eligible small 4 employers that contain: 5 a. An exclusion for services that are not medically 6 necessary or that are not covered preventive health services; 7 and 8 b. A procedure for preauthorization by the small 9 employer carrier, or its designees. 10 3. A small employer carrier may include the following 11 managed care provisions in the policy or contract to control 12 costs: 13 a. A preferred provider arrangement or exclusive 14 provider organization or any combination thereof, in which a 15 small employer carrier enters into a written agreement with 16 the provider to provide services at specified levels of 17 reimbursement or to provide reimbursement to specified 18 providers. Any such written agreement between a provider and a 19 small employer carrier must contain a provision under which 20 the parties agree that the insured individual or covered 21 member has no obligation to make payment for any medical 22 service rendered by the provider which is determined not to be 23 medically necessary. A carrier may use preferred provider 24 arrangements or exclusive provider arrangements to the same 25 extent as allowed in group products that are not issued to 26 small employers. 27 b. A procedure for utilization review by the small 28 employer carrier or its designees. 29 30 This subparagraph does not prohibit a small employer carrier 31 from including in its policy or contract additional managed 63 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 care and cost containment provisions, subject to the approval 2 of the office, which have potential for controlling costs in a 3 manner that does not result in inequitable treatment of 4 insureds or subscribers. The carrier may use such provisions 5 to the same extent as authorized for group products that are 6 not issued to small employers. 7 4. The standard health benefit plan shall include: 8 a. Coverage for inpatient hospitalization; 9 b. Coverage for outpatient services; 10 c. Coverage for newborn children pursuant to s. 11 627.6575; 12 d. Coverage for child care supervision services 13 pursuant to s. 627.6579; 14 e. Coverage for adopted children upon placement in the 15 residence pursuant to s. 627.6578; 16 f. Coverage for mammograms pursuant to s. 627.6613; 17 g. Coverage for handicapped children pursuant to s. 18 627.6615; 19 h. Emergency or urgent care out of the geographic 20 service area; and 21 i. Coverage for services provided by a hospice 22 licensed under s. 400.602 in cases where such coverage would 23 be the most appropriate and the most cost-effective method for 24 treating a covered illness. 25 5. The standard health benefit plan and the basic 26 health benefit plan may include a schedule of benefit 27 limitations for specified services and procedures. If the 28 committee develops such a schedule of benefits limitation for 29 the standard health benefit plan or the basic health benefit 30 plan, a small employer carrier offering the plan must offer 31 the employer an option for increasing the benefit schedule 64 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 amounts by 4 percent annually. 2 6. The basic health benefit plan shall include all of 3 the benefits specified in subparagraph 4.; however, the basic 4 health benefit plan shall place additional restrictions on the 5 benefits and utilization and may also impose additional cost 6 containment measures. 7 7. Sections 627.419(2), (3), and (4), 627.6574, 8 627.6612, 627.66121, 627.66122, 627.6616, 627.6618, 627.668, 9 and 627.66911 apply to the standard health benefit plan and to 10 the basic health benefit plan. However, notwithstanding said 11 provisions, the plans may specify limits on the number of 12 authorized treatments, if such limits are reasonable and do 13 not discriminate against any type of provider. 14 8. The high deductible plan associated with a health 15 savings account or a health reimbursement arrangement shall 16 include all the benefits specified in subparagraph 4. 17 9.8. Each small employer carrier that provides for 18 inpatient and outpatient services by allopathic hospitals may 19 provide as an option of the insured similar inpatient and 20 outpatient services by hospitals accredited by the American 21 Osteopathic Association when such services are available and 22 the osteopathic hospital agrees to provide the service. 23 (c) If a small employer rejects, in writing, the 24 standard health benefit plan, and the basic health benefit 25 plan, and the high deductible health savings account plan or a 26 health reimbursement arrangement, the small employer carrier 27 may offer the small employer a limited benefit policy or 28 contract. 29 (d)1. Upon offering coverage under a standard health 30 benefit plan, a basic health benefit plan, or a limited 31 benefit policy or contract for any small employer, the small 65 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 employer carrier shall provide such employer group with a 2 written statement that contains, at a minimum: 3 a. An explanation of those mandated benefits and 4 providers that are not covered by the policy or contract; 5 b. An explanation of the managed care and cost control 6 features of the policy or contract, along with all appropriate 7 mailing addresses and telephone numbers to be used by insureds 8 in seeking information or authorization; and 9 c. An explanation of the primary and preventive care 10 features of the policy or contract. 11 12 Such disclosure statement must be presented in a clear and 13 understandable form and format and must be separate from the 14 policy or certificate or evidence of coverage provided to the 15 employer group. 16 2. Before a small employer carrier issues a standard 17 health benefit plan, a basic health benefit plan, or a limited 18 benefit policy or contract, it must obtain from the 19 prospective policyholder a signed written statement in which 20 the prospective policyholder: 21 a. Certifies as to eligibility for coverage under the 22 standard health benefit plan, basic health benefit plan, or 23 limited benefit policy or contract; 24 b. Acknowledges the limited nature of the coverage and 25 an understanding of the managed care and cost control features 26 of the policy or contract; 27 c. Acknowledges that if misrepresentations are made 28 regarding eligibility for coverage under a standard health 29 benefit plan, a basic health benefit plan, or a limited 30 benefit policy or contract, the person making such 31 misrepresentations forfeits coverage provided by the policy or 66 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 contract; and 2 d. If a limited plan is requested, acknowledges that 3 the prospective policyholder had been offered, at the time of 4 application for the insurance policy or contract, the 5 opportunity to purchase any health benefit plan offered by the 6 carrier and that the prospective policyholder had rejected 7 that coverage. 8 9 A copy of such written statement shall be provided to the 10 prospective policyholder no later than at the time of delivery 11 of the policy or contract, and the original of such written 12 statement shall be retained in the files of the small employer 13 carrier for the period of time that the policy or contract 14 remains in effect or for 5 years, whichever period is longer. 15 3. Any material statement made by an applicant for 16 coverage under a health benefit plan which falsely certifies 17 as to the applicant's eligibility for coverage serves as the 18 basis for terminating coverage under the policy or contract. 19 4. Each marketing communication that is intended to be 20 used in the marketing of a health benefit plan in this state 21 must be submitted for review by the office prior to use and 22 must contain the disclosures stated in this subsection. 23 (e) A small employer carrier may not use any policy, 24 contract, form, or rate under this section, including 25 applications, enrollment forms, policies, contracts, 26 certificates, evidences of coverage, riders, amendments, 27 endorsements, and disclosure forms, until the insurer has 28 filed it with the office and the office has approved it under 29 ss. 627.410 and 627.411 and this section. 30 (15) SMALL EMPLOYERS ACCESS PROGRAM.-- 31 (a) Popular name.--This subsection may be referred to 67 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 by the popular name "The Small Employers Access Program." 2 (b) Intent.--The Legislature finds that increased 3 access to health care coverage for small employers with up to 4 25 employees could improve employees' health and reduce the 5 incidence and costs of illness and disabilities among 6 residents in this state. Many employers do not offer health 7 care benefits to their employees citing the increased cost of 8 this benefit. It is the intent of the Legislature to create 9 the Small Business Health Plan to provide small employers the 10 option and ability to provide health care benefits to their 11 employees at an affordable cost through the creation of 12 purchasing pools for employers with up to 25 employees, and 13 rural hospital employers and nursing home employers regardless 14 of the number of employees. 15 (c) Definitions.--For purposes of this subsection, the 16 term: 17 1. "Fair commission" means a commission structure 18 determined by the insurers and reflected in the insurers' rate 19 filings made pursuant to this subsection. 20 2. "Insurer" means any entity that provides health 21 insurance in this state. For purposes of this subsection, 22 insurer includes an insurance company holding a certificate of 23 authority pursuant to chapter 624 or a health maintenance 24 organization holding a certificate of authority pursuant to 25 chapter 641, which qualifies to provide coverage to small 26 employer groups pursuant to this section. 27 3. "Mutually supported benefit plan" means an optional 28 alternative coverage plan developed within a defined 29 geographic region which may include, but is not limited to, a 30 minimum level of primary care coverage in which the percentage 31 of the premium is distributed among the employer, the 68 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 employee, and community-generated revenue either alone or in 2 conjunction with federal matching funds. 3 4. "Office" means the Office of Insurance Regulation 4 of the Department of Financial Services. 5 5. "Participating insurer" means any insurer providing 6 health insurance to small employers that has been selected by 7 the office in accordance with this subsection for its 8 designated region. 9 6. "Program" means the Small Employer Access Program 10 as created by this subsection. 11 (d) Eligibility.-- 12 1. Any small employer group of up to 25 employees. 13 2. Any municipality, county, school district, or 14 hospital located in a rural community as defined in s. 15 288.0636(2)(b). 16 3. Nursing home employers may participate. 17 4. Each dependent of a person eligible for coverage is 18 also eligible to participate. 19 5. Any small employer that is actively engaged in 20 business, has its principal place of business in this state, 21 employed up to 25 eligible employees on business days during 22 the preceding calendar year, and employs at least 2 employees 23 on the first day of the plan year may participate. 24 25 Coverage for a small employer group that ceases to meet the 26 eligibility requirements of this section may be terminated at 27 the end of the policy period for which the necessary premiums 28 have been paid. 29 (e) Administration.-- 30 1. The office shall by competitive bid, in accordance 31 with current state law, select an insurer to provide coverage 69 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 through the program to eligible small employers within an 2 established geographical area of this state. The office may 3 develop exclusive regions for the program similar to those 4 used by the Healthy Kids Corporation. However the office is 5 not precluded from developing, in conjunction with insurers, 6 regions different from those used by the Healthy Kids 7 Corporation if the office deems that such a region will carry 8 out the intentions of this subsection. 9 2. The office shall evaluate bids submitted based upon 10 criteria established by the office, which shall include, but 11 not be limited to: 12 a. The insurer's proven ability to handle health 13 insurance coverage to small employer groups. 14 b. The efficiency and timeliness of the insurer's 15 claim processing procedures. 16 c. The insurer's ability to apply effective 17 cost-containment programs and procedures and to administer the 18 program in a cost-efficient manner. 19 d. The financial condition and stability of the 20 insurer. 21 e. The insurer's ability to develop an optional 22 mutually supported benefit plan. 23 24 The office may use any financial information available to it 25 through its regulatory duties to make this evaluation. 26 (f) Insurer qualifications.--The insurer shall be a 27 duly authorized insurer or health maintenance organization. 28 (g) Duties of the insurer.--The insurer shall: 29 1. Develop and implement a program to publicize the 30 existence of the program, program eligibility requirements, 31 and procedures for enrollment and maintain public awareness of 70 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 the program. 2 2. Maintain employer awareness of the program. 3 3. Demonstrate the ability to use delivery of 4 cost-effective health care services. 5 4. Encourage, educate, advise, and administer the 6 effective use of health savings accounts by covered employees 7 and dependents. 8 5. Serve for a period specified in the contract 9 between the office and the insurer, subject to removal for 10 cause and subject to any terms, conditions, and limitations of 11 the contract between the office and the insurer as may be 12 specified in the request for proposal. 13 (h) Contract term.--The contract term shall not exceed 14 3 years. At least 6 months prior to the expiration of each 15 contract period, the office shall invite eligible entities, 16 including the current insurer, to submit bids to serve as the 17 insurer for a designated geographic area. Selection of the 18 insurer for the succeeding period shall be made at least 3 19 months prior to the end of the current period. If a protest is 20 filed and not resolved by the end of the contract period, the 21 contract with the existing administrator may be extended for a 22 period not to exceed 6 months. During the contract extension 23 period, the administrator shall be paid at a rate to be 24 negotiated by the office. 25 (i) Insurer reporting requirements.--On March 1 26 following the close of each calendar year, the insurer shall 27 determine net written and earned premiums, the expense of 28 administration, and the paid and incurred losses for the year 29 and report this information to the office on a form prescribed 30 by the office. 31 (j) Application requirements.--The insurer shall 71 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 permit or allow any licensed and duly appointed health 2 insurance agent residing in the designated region to submit 3 applications for coverage, and such agent shall be paid a fair 4 commission if coverage is written. The agent must be appointed 5 to at least one insurer. 6 (k) Benefits.--The benefits provided by the plan shall 7 be the same as the coverage required for small employers under 8 subsection (12). Upon the approval of the office, the insurer 9 may also establish an optional mutually supported benefit plan 10 which is an alternative plan developed within a defined 11 geographic region of this state or any other such alternative 12 plan which will carry out the intent of this subsection. Any 13 small employer carrier issuing new health benefit plans may 14 offer a benefit plan with coverages similar to, but not less 15 than, any alternative coverage plan developed pursuant to this 16 subsection. 17 (l) Annual reporting.--The office shall make an annual 18 report to the Governor, the President of the Senate, and the 19 Speaker of the House of Representatives. The report shall 20 summarize the activities of the program in the preceding 21 calendar year, including the net written and earned premiums, 22 program enrollment, the expense of administration, and the 23 paid and incurred losses. The report shall be submitted no 24 later than March 15 following the close of the prior calendar 25 year. 26 (16)(15) APPLICABILITY OF OTHER STATE LAWS.-- 27 (a) Except as expressly provided in this section, a 28 law requiring coverage for a specific health care service or 29 benefit, or a law requiring reimbursement, utilization, or 30 consideration of a specific category of licensed health care 31 practitioner, does not apply to a standard or basic health 72 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 benefit plan policy or contract or a limited benefit policy or 2 contract offered or delivered to a small employer unless that 3 law is made expressly applicable to such policies or 4 contracts. A law restricting or limiting deductibles, 5 coinsurance, copayments, or annual or lifetime maximum 6 payments does not apply to any health plan policy, including a 7 standard or basic health benefit plan policy or contract, 8 offered or delivered to a small employer unless such law is 9 made expressly applicable to such policy or contract. However, 10 every small employer carrier must offer to eligible small 11 employers the standard benefit plan and the basic benefit 12 plan, as required by subsection (5), as such plans have been 13 approved by the office pursuant to subsection (12). 14 (b) Except as provided in this section, a standard or 15 basic health benefit plan policy or contract or limited 16 benefit policy or contract offered to a small employer is not 17 subject to any provision of this code which: 18 1. Inhibits a small employer carrier from contracting 19 with providers or groups of providers with respect to health 20 care services or benefits; 21 2. Imposes any restriction on a small employer 22 carrier's ability to negotiate with providers regarding the 23 level or method of reimbursing care or services provided under 24 a health benefit plan; or 25 3. Requires a small employer carrier to either include 26 a specific provider or class of providers when contracting for 27 health care services or benefits or to exclude any class of 28 providers that is generally authorized by statute to provide 29 such care. 30 (c) Any second tier assessment paid by a carrier 31 pursuant to paragraph (11)(j) may be credited against 73 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 assessments levied against the carrier pursuant to s. 2 627.6494. 3 (d) Notwithstanding chapter 641, a health maintenance 4 organization is authorized to issue contracts providing 5 benefits equal to the standard health benefit plan, the basic 6 health benefit plan, and the limited benefit policy authorized 7 by this section. 8 (17)(16) RULEMAKING AUTHORITY.--The commission may 9 adopt rules to administer this section, including rules 10 governing compliance by small employer carriers and small 11 employers. 12 Section 34. Section 627.9175, Florida Statutes, is 13 amended to read: 14 627.9175 Reports of information on health and accident 15 insurance.-- 16 (1) Each health insurer, prepaid limited health 17 services organization, and health maintenance organization 18 shall submit, no later than April 1 of each year, annually to 19 the office information concerning health and accident 20 insurance coverage and medical plans being marketed and 21 currently in force in this state. The required information 22 shall be described by market segment, including, but not 23 limited to: 24 (a) Issuing, servicing company, and entity contact 25 information. 26 (b) Information on all health and accident insurance 27 policies and prepaid limited health service organizations and 28 health maintenance organization contracts in force and issued 29 in the previous year. Such information shall include, but not 30 be limited to, direct premiums earned, direct losses incurred, 31 number of policies, number of certificates, number of covered 74 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 lives, and the average number of days taken to pay claims. as 2 to policies of individual health insurance: 3 (a) A summary of typical benefits, exclusions, and 4 limitations for each type of individual policy form currently 5 being issued in the state. The summary shall include, as 6 appropriate: 7 1. The deductible amount; 8 2. The coinsurance percentage; 9 3. The out-of-pocket maximum; 10 4. Outpatient benefits; 11 5. Inpatient benefits; and 12 6. Any exclusions for preexisting conditions. 13 14 The commission shall determine other appropriate benefits, 15 exclusions, and limitations to be reported for inclusion in 16 the consumer's guide published pursuant to this section. 17 (b) A schedule of rates for each type of individual 18 policy form reflecting typical variations by age, sex, region 19 of the state, or any other applicable factor which is in use 20 and is determined to be appropriate for inclusion by the 21 commission. 22 23 The commission may establish rules governing shall provide by 24 rule a uniform format for the submission of this information 25 described in this section, including the use of uniform 26 formats and electronic data transmission order to allow for 27 meaningful comparisons of premiums charged for comparable 28 benefits. The office shall provide this information to the 29 department, which shall publish annually a consumer's guide 30 which summarizes and compares the information required to be 31 reported under this subsection. 75 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (2)(a) Every insurer transacting health insurance in 2 this state shall report annually to the office, not later than 3 April 1, information relating to any measure the insurer has 4 implemented or proposes to implement during the next calendar 5 year for the purpose of containing health insurance costs or 6 cost increases. The reports shall identify each measure and 7 the forms to which the measure is applied, shall provide an 8 explanation as to how the measure is used, and shall provide 9 an estimate of the cost effect of the measure. 10 (b) The commission shall promulgate forms to be used 11 by insurers in reporting information pursuant to this 12 subsection and shall utilize such forms to analyze the effects 13 of health care cost containment programs used by health 14 insurers in this state. 15 (c) The office shall analyze the data reported under 16 this subsection and shall annually make available to the 17 department which shall provide to the public a summary of its 18 findings as to the types of cost containment measures reported 19 and the estimated effect of these measures. 20 Section 35. (1) Effective January 1, 2005, chapter 21 636, Florida Statutes, is redesignated as "Prepaid Limited 22 Health Service Organizations and Discount Medical Plan 23 Organizations." 24 (2) Effective January 1, 2005, sections 25 636.002-636.067, Florida Statutes, are designated as part I of 26 chapter 636, Florida Statutes, entitled "Prepaid Limited 27 Health Service Organizations." 28 Section 36. Effective January 1, 2005, section 29 636.002, Florida Statutes, is amended to read: 30 636.002 Short title.--This part Sections 1-57, chapter 31 93-148, Laws of Florida, may be cited as the "Prepaid Limited 76 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 Health Service Organization Act of Florida." 2 Section 37. Effective January 1, 2005, subsection (7) 3 of section 636.003, Florida Statutes, is amended to read: 4 636.003 Definitions.--As used in this act, the term: 5 (7) "Prepaid limited health service organization" 6 means any person, corporation, partnership, or any other 7 entity which, in return for a prepayment, undertakes to 8 provide or arrange for, or provide access to, the provision of 9 a limited health service to enrollees through an exclusive 10 panel of providers. Prepaid limited health service 11 organization does not include: 12 (a) An entity otherwise authorized pursuant to the 13 laws of this state to indemnify for any limited health 14 service; 15 (b) A provider or entity when providing limited health 16 services pursuant to a contract with a prepaid limited health 17 service organization, a health maintenance organization, a 18 health insurer, or a self-insurance plan; or 19 (c) Any person who is licensed pursuant to part II of 20 this chapter as a discount medical plan organization, in 21 exchange for fees, dues, charges or other consideration, 22 provides access to a limited health service provider without 23 assuming any responsibility for payment for the limited health 24 service or any portion thereof. 25 Section 38. Effective January 1, 2005, part II of 26 chapter 636, Florida Statutes, consisting of sections 636.202, 27 636.204, 636.206, 636.208, 636.210, 636.212, 636.214, 636.216, 28 636.218, 636.220, 636.222, 636.224, 636.226, 636.228, 636.230, 29 636.232, 636.234, 636.236, 636.238, 636.240, 636.242, and 30 636.244, is created to read: 31 Part II 77 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 Discount Medical Plan Organizations 2 636.202 Definitions.--As used in this part, the term: 3 (1) "Commission" means the Financial Services 4 Commission. 5 (2) "Discount medical plan" means a business 6 arrangement or contract in which a person, in exchange for 7 fees, dues, charges, or other consideration, provides access 8 for plan members to providers of medical services and the 9 right to receive medical services from those providers at a 10 discount. However, the term does not include any product 11 regulated under chapter 627, chapter 641, or part I of this 12 chapter. 13 (3) "Discount medical plan organization" means a 14 person who, in exchange for fees, dues, charges, or other 15 consideration, provides members a discount medical plan. 16 Discount medical plan organization does not include an entity 17 licensed under chapter 624, chapter 641, or part I of chapter 18 636. 19 (4) "Marketer" means a person that markets, promotes, 20 sells, or distributes a discount medical plan, including a 21 private label entity which places its name on and markets or 22 distributes a discount medical plan, but does not operate a 23 discount medical plan. 24 (5) "Medical services" means any care, service, or 25 treatment of an illness or a dysfunction of, or injury to, the 26 human body, including, but not limited to, physician care, 27 inpatient care, hospital surgical services, emergency 28 services, ambulance services, dental care services, vision 29 care services, mental health services, substance abuse 30 services, chiropractic services, podiatric care services, 31 laboratory services, medical equipment and supplies. The term 78 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 does not include pharmaceutical supplies or prescriptions. 2 (6) "Member" means any person who pays fees, dues, 3 charges, or other consideration for the right to receive the 4 benefits of a discount medical plan. 5 (7) "Office" means the Office of Insurance Regulation 6 of the Financial Services Commission. 7 (8) "Provider" means any person that contracts, 8 directly or indirectly, with a discount medical plan 9 organization to provide medical services to members. 10 (9) "Provider network" means an entity that negotiates 11 on behalf of more than one provider with a discount medical 12 plan organization to provide medical services to members. 13 636.204 License.-- 14 (1) A person may not conduct business in this state as 15 a discount medical plan organization unless the person: 16 (a) Is a corporation, either incorporated under the 17 laws of this state, or, if a foreign corporation, is 18 authorized to transact business in this state; and 19 (b) Is licensed as a discount medical plan 20 organization by the office. 21 (2) An application for a license to operate as a 22 discount medical plan organization must be filed with the 23 office on a form prescribed by the commission. The application 24 must be sworn to by an officer or authorized representative of 25 the applicant and must be accompanied by the following: 26 (a) A copy of the applicant's articles of 27 incorporation, including all amendments. 28 (b) A copy of the corporate bylaws. 29 (c) A list of the names, addresses, official 30 positions, and biographical information of the individuals 31 responsible for conducting the applicant's affairs, including, 79 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 but not limited to, all members of the board of directors, 2 board of trustees, executive committee, or other governing 3 board or committee, the officers, contracted management 4 company personnel, and any person or entity owning or having 5 the right to acquire 10 percent or more of the voting 6 securities of the applicant. The list must fully disclose the 7 extent and nature of any contract or arrangement between any 8 individual who is responsible for conducting the applicant's 9 affairs and the discount medical plan organization, including 10 any possible conflicts of interest. 11 (d) A complete biographical statement, on forms 12 prescribed by the commission, an independent investigation 13 report, and a set of fingerprints, as provided in chapter 624, 14 from each individual identified in subsection (c). 15 (e) A statement describing the applicant, its 16 facilities, and personnel and the medical services it proposes 17 to offer. 18 (f) A copy of any form contract used by the applicant 19 with any provider or provider network regarding the provision 20 of medical services to members. 21 (g) A copy of any form contract used by the applicant 22 with any person listed in subsection (c). 23 (h) A copy of any form contract used by the applicant 24 with any person, corporation, partnership, or other entity for 25 the performance on the applicant's behalf of any function, 26 including, but not limited to, marketing, administration, 27 enrollment, investment management, and subcontracting for the 28 provision of health services to members. 29 (i) A copy of the applicant's most recent financial 30 statements that have been audited by an independent certified 31 public accountant. 80 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (j) A description of the applicant's proposed method 2 of marketing. 3 (k) A description of the member's complaint procedures 4 to be established and maintained by the applicant. 5 (l) The fee for issuance of a license. 6 (m) Such other information as the commission or office 7 may request from the applicant. 8 (3) The office shall issue a license that expires 1 9 year after the date of issuance, and each year on that date 10 thereafter. The office shall renew the license if the licensee 11 pays the annual license fee of $50 and if the licensee is in 12 compliance with this part. 13 (4) Before the office issues a license, each medical 14 discount plan organization must establish a website in order 15 to conform with the requirements of s. 636.226. 16 (5) The license fee under this section is $50 per 17 year, per licensee. All amounts collected shall be deposited 18 in the General Revenue Fund. 19 (6) This part does not require a provider who provides 20 discounts to his or her own patients to obtain and maintain a 21 license as a discount medical plan organization. 22 636.206 Examinations and investigations.-- 23 (1) The office may examine or investigate any discount 24 medical plan organization. The office may order any discount 25 medical plan organization or applicant to produce any records, 26 books, files, advertising and solicitation materials, or other 27 information and may take statements under oath to determine 28 whether the discount medical plan organization or applicant is 29 in violation of the law or is acting contrary to the public 30 interest. The expenses incurred in conducting an examination 31 or investigation must be paid by the discount medical plan 81 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 organization or applicant. Examinations and investigations 2 must be conducted as provided in chapter 624 and a discount 3 medical plan organization is subject to all applicable 4 provisions of the Florida Insurance Code. 5 (2) Failure by a discount medical plan organization to 6 pay the costs incurred under this section is grounds for 7 denial or revocation of a license. 8 636.208 Fees.--A discount medical plan organization 9 may charge a reasonable one-time processing fee and a periodic 10 charge. If a discount medical plan charges a fee for a time 11 period exceeding 1 month, it must, in the event of 12 cancellation of the membership by either party, make a pro 13 rata reimbursement of the fee to the member. 14 636.210 Prohibited activities of a discount medical 15 plan.-- 16 (1) A discount medical plan organization may not: 17 (a) Use in its advertisements, marketing material, 18 brochures, or discount cards the term "insurance" except as 19 otherwise authorized in this part; 20 (b) Use in its advertisements, marketing material, 21 brochures, or discount cards the terms "health plan," 22 "coverage," "co-pay," "co-payments," "pre-existing 23 conditions," "guaranteed issue," "premium," "enrollment," 24 "PPO," "preferred provider organization," or other terms that 25 could reasonably mislead a person into believing the discount 26 medical plan was health insurance; 27 (c) Have restrictions on free access to plan 28 providers, including, but not limited to, waiting periods and 29 notification periods; or 30 (d) Pay providers any fees for medical services. 31 (2) A discount medical plan organization is prohibited 82 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 from collecting or accepting money from a member for payment 2 to a provider for specific medical services furnished or to be 3 furnished to the member unless it has an active certificate of 4 authority from the office to act as an administrator. 5 636.212 Disclosures.--The following disclosures must 6 be made in writing to any prospective member, and must be on 7 the first page of any advertisements, marketing material, or 8 brochures relating to a discount medical plan. The disclosures 9 must be printed in not less than 12-point type or no smaller 10 than the largest type on the page if larger than 12-point 11 type, and must state: 12 (1) That the plan is not a health insurance policy; 13 (2) That the plan provides discounts at certain 14 healthcare providers for medical services; 15 (3) That the plan does not make payments directly to 16 providers of medical services; 17 (4) That the plan member is obligated to pay for all 18 health care services but will receive a discount from those 19 health care providers who have contracted with the discount 20 plan organization; and 21 (5) The corporate name and the locations of the 22 licensed discount medical plan organization. 23 636.214 Provider agreements.-- 24 (1) A provider offering medical services to a member 25 under a discount medical plan must provide the service under a 26 written agreement with the organization. The agreement may be 27 entered into directly by the provider or by a provider network 28 to which the provider belongs. 29 (2) A provider agreement must contain the following: 30 (a) A list of the services and products to be 31 delivered at a discount; 83 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (b) A statement specifying the amount of the discounts 2 offered or, alternatively, a fee schedule that reflects the 3 provider's discounted rates; and 4 (c) A statement that the provider will not charge 5 members more than the discounted rates. 6 (3) A provider agreement between a discount medical 7 plan organization and a provider network shall require the 8 provider network to have written agreements with each 9 provider. An agreement must: 10 (a) Contain the elements described in subsection (2); 11 (b) Authorize the provider network to contract with 12 the medical discount medical plan organization on behalf of 13 the provider; and 14 (c) Require the provider network to maintain an 15 up-to-date list of the providers with whom it has a contract 16 and to deliver that list to the discount medical plan 17 organization each month. 18 (4) The discount medical plan organization shall 19 maintain a copy of each active provider agreement. 20 636.216 Form and fees filings.-- 21 (1) All fees charged to members must be filed with the 22 office and any fee or charge to members greater than $30 per 23 month or $360 per year must be approved by the office before 24 they can be imposed on a member. The discount medical plan 25 organization has the burden of proof that the fees charged 26 bear a reasonable relation to the benefits received by the 27 member. 28 (2) There must be a written agreement between the 29 discount medical plan organization and the member specifying 30 the benefits under the discount medical plan and complying 31 with the disclosure requirements of this part. 84 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (3) Any form used by the discount medical plan 2 organization, including the written agreement between the 3 organization and the member, must first be filed with and 4 approved by the office. Every form filed shall be identified 5 by a unique form number placed in the lower left corner of 6 each form. 7 (4) If the office disapproves any filing, the office 8 shall notify the discount medical plan organization in writing 9 and must specify the reasons why the office disapproved the 10 filing. The discount medical plan organization has 21 days 11 from the date it receives the disapproval notice to request a 12 hearing before the office under chapter 120. 13 636.218 Annual reports.-- 14 (1) Each discount medical plan organization must file 15 with the office an annual report no later than 3 months after 16 the end of the organization's fiscal year. 17 (2) The report must be on a form and in a format 18 prescribed by the commission and must include: 19 (a) Audited financial statements prepared in 20 accordance with generally accepted accounting principles and 21 certified by an independent certified public accountant. The 22 financial statements shall include the organization's balance 23 sheet, income statement, and statement of changes in cash flow 24 for the preceding year. 25 (b) A list of the names and residence addresses of all 26 persons responsible for the conduct of its affairs, together 27 with a disclosure of the extent and nature of any contracts or 28 arrangements between these persons and the discount medical 29 plan organization, including any possible conflicts of 30 interest. 31 (c) The number of discount medical plan members. 85 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (d) Such other information relating to the performance 2 of the discount medical plan organization that is required by 3 the commission or office. 4 (3) A discount medical plan organization that fails to 5 file an annual report in the form and within the time required 6 by this section shall forfeit up to $500 for each day for the 7 first 10 days during which the report is delinquent and shall 8 forfeit up to $1,000 for each day after the first 10 days 9 during which the report is delinquent. Upon notice by the 10 office, the organization may no longer enroll new members or 11 do business in this state until the organization complies with 12 this section. The office shall deposit all sums collected by 13 it under this section to the credit of the Insurance 14 Regulatory Trust Fund. The office may not collect more than 15 $50,000 for each delinquent report. 16 636.220 Minimum capital requirements.-- 17 (1) Each discount medical plan organization must at 18 all times maintain a net worth of at least $150,000. 19 (2) The office may not issue a license unless the 20 medical discount medical plan organization has a net worth of 21 at least $150,000. 22 636.222 Suspension or revocation of license; 23 suspension of enrollment of new members; terms of 24 suspension.-- 25 (1) The office may suspend the authority of a discount 26 medical plan organization to enroll new members, may revoke a 27 license issued to a discount medical plan organization, or may 28 order compliance if it finds that any of the following 29 conditions exist: 30 (a) The organization is not operating in compliance 31 with this part. 86 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (b) The discount medical plan organization does not 2 have the minimum net worth as required by this part. 3 (c) The organization has advertised, merchandised, or 4 attempted to merchandise its services in a manner as to 5 misrepresent its services or capacity for service or has 6 engaged in deceptive, misleading, or unfair practices with 7 respect to advertising or merchandising. 8 (d) The discount medical plan organization is not 9 fulfilling its obligations as a discount medical plan 10 organization. 11 (e) The continued operation of the discount medical 12 plan organization would be hazardous to its members. 13 (2) If the office has cause to believe that grounds 14 for the suspension or revocation of a license exist, it shall 15 notify the discount medical plan organization in writing 16 specifically stating the grounds for suspension or revocation 17 and shall pursue a hearing on the matter in accordance with 18 chapter 120. 19 (3) If the license of a discount medical plan 20 organization is surrendered or revoked, the organization must 21 proceed, immediately following the effective date of the order 22 of revocation, to wind up its affairs transacted under the 23 license. It may not engage in any further advertising, 24 solicitation, collecting of fees, or renewal of contracts. 25 (4) The office shall, in its order suspending the 26 authority of a discount medical plan organization to enroll 27 new members, specify the period during which the suspension is 28 to be in effect and the conditions, if any, which must be met 29 by the discount medical plan organization before reinstatement 30 of its license to enroll new members. The order of suspension 31 is subject to rescission or modification by further order of 87 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 the office before expiration of the suspension period. 2 Reinstatement may not be made unless requested by the discount 3 medical plan organization. However, the office may not grant 4 reinstatement if it finds that the circumstances for which the 5 suspension occurred still exist or are likely to recur. 6 636.224 Notice of change of name or address of 7 discount medical plan organization.--Each discount medical 8 plan organization must notify the office at least 30 days in 9 advance of any change in the discount medical plan 10 organization's name, address, principal business address, or 11 mailing address. 12 636.226 Provider name listing.-- 13 (1) Each discount medical plan organization must 14 maintain an up-to-date list of the names and addresses of the 15 providers with whom it has a contract to deliver medical 16 services. The list must be stored on its website, the Internet 17 address of which must be prominently displayed on all its 18 advertisements, marketing material, brochures, and discount 19 cards. 20 (2) This section applies to providers with whom the 21 discount medical plan organization has contracted directly and 22 to those who are members of a provider network with which the 23 discount medical plan organization has a contract to deliver 24 medical services. 25 636.228 Marketing of discount medical plans.-- 26 (1) All advertisements, marketing material, brochures, 27 and discount cards used by marketers must be approved in 28 writing for use by the discount medical plan organization. 29 (2) The discount medical plan organization shall have 30 an executed written agreement with a marketer before the 31 marketer marketing, promoting, selling, or distributing the 88 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 discount medical plan and shall be responsible and financially 2 liable for any acts of its marketers which do not comply with 3 the provisions of this part. 4 636.230 Bundling discount medical plans with other 5 insurance products.--When a marketer or discount medical plan 6 organization sells a discount medical plan along with any 7 other product, the fees for each product must be itemized 8 separately and provided to the members in writing. 9 636.232 Rules.--The commission may adopt rules to 10 administer this part, including rules for the licensing of 11 discount medical plan organizations; establishing standards 12 for evaluating forms, advertisements, marketing material, 13 brochures, and discount cards; the collection of data; 14 disclosures to plan members; and rules defining terms used in 15 this act. 16 636.234 Service of process on a discount medical plan 17 organization.--Sections 624.422 and 624.423 apply to a 18 discount medical plan organization as if a discount medical 19 plan organization were an insurer. 20 636.236 Security deposit.-- 21 (1) A licensed discount medical plan organization must 22 deposit, and maintain deposited in trust with the department, 23 securities eligible for deposit under s. 625.52, in order that 24 the office might protect plan members. The securities must, at 25 all times, have a value of not less than $35,000. 26 (2) A judgment creditor or other claimant of a 27 discount medical plan organization, other than the office or 28 the Department of Financial Services, does not have the right 29 to levy upon any of the assets or securities held in this 30 state as a deposit under this section. 31 636.238 Penalties for violation of this part.-- 89 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 (1) Except as provided in subsection (2), a person who 2 violates this part commits a misdemeanor of the second degree, 3 punishable as provided in s. 775.082 or s. 775.083. 4 (2) A person who operates as or aids and abets another 5 operating as a discount medical plan organization in violation 6 of s. 636.204(1) commits a felony punishable as provided for 7 in s. 624.401(4)(b), as if the unlicensed discount medical 8 plan organization were an unauthorized insurer, and the fees, 9 dues, charges, or other consideration collected from the 10 members by the unlicensed discount medical plan organization 11 or marketer were insurance premium. 12 (3) A person who collects fees for purported 13 membership in a discount medical plan but fails to provide the 14 promised benefits commits a theft punishable as provided in s. 15 812.014. 16 636.240 Injunction.-- 17 (1) In addition to the penalties and other enforcement 18 provisions of this act, the office may commence an action for 19 temporary and permanent injunctive relief if: 20 (a) A discount medical plan is operated by a person 21 that is not licensed under this part. 22 (b) A person, entity, or discount medical plan 23 organization has engaged in any activity prohibited by this 24 act or any rule adopted under this act. 25 (2) Venue for any proceeding bought under this section 26 shall be in the Circuit Court for Leon County. 27 (3) The office's authority to seek injunctive relief 28 is not conditioned on having conducted any proceeding under 29 chapter 120. 30 636.242 Civil remedies.--Any person injured by a 31 person acting in violation of this part may bring a civil 90 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 action against the person committing the violation in the 2 circuit court of the county in which the alleged violator 3 resides or has a principal place of business or in the county 4 where the alleged violation occurred. If the defendant is 5 found to have injured the plaintiff, the defendant is liable 6 for damages and the court may also award the prevailing 7 plaintiff court costs and reasonable attorney's fees. If so 8 awarded, the court costs and attorney's fees must be included 9 in the judgment or decree rendered in the case. If it appears 10 to the court that the suit brought by the plaintiff is 11 frivolous or brought for purposes of harassment, the court may 12 award the defendant court costs and reasonable attorney's fees 13 and may apply sanctions against the plaintiff in accordance 14 with chapter 57. 15 636.244 Unlicensed discount medical plan 16 organizations.--Sections 626.901 through 626.912 apply to the 17 activities of an unlicensed discount medical plan organization 18 as if an unlicensed discount medical plan organization were an 19 unauthorized insurer. 20 Section 39. Section 627.65626, Florida Statutes, is 21 created to read: 22 627.65626 Insurance rebates for healthy lifestyles.-- 23 (1) Any rate, rating schedule, or rating manual for a 24 health insurance policy filed with the office shall provide 25 for an appropriate rebate of premiums paid in the last 26 calendar year when the majority of members of a health plan 27 have enrolled and maintained participation in any health 28 wellness, maintenance, or improvement program offered by the 29 employer. The employer must provide evidence of demonstrative 30 maintenance or improvement of the enrollees' health status as 31 determined by assessments of agreed-upon health status 91 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 indicators between the employer and the health insurer, 2 including, but not limited to, reduction in weight, body mass 3 index, and smoking cessation. Any rebate provided by the 4 health insurer is presumed to be appropriate unless credible 5 data demonstrates otherwise, but shall not exceed 10 percent 6 of paid premiums. 7 (2) The premium rebate authorized by this section 8 shall be effective for an insured on an annual basis, unless 9 the number of participating employees becomes less than the 10 majority of the employees eligible for participation in the 11 wellness program. 12 Section 40. Section 627.6402, Florida Statutes, is 13 created to read: 14 627.6402 Insurance rebates for healthy lifestyles.-- 15 (1) Any rate, rating schedule, or rating manual for an 16 individual health insurance policy filed with the office shall 17 provide for an appropriate rebate of premiums paid in the last 18 calendar year when the individual covered by such plan is 19 enrolled in and maintains participation in any health 20 wellness, maintenance, or improvement program approved by the 21 health plan. The individual must provide evidence of 22 demonstrative maintenance or improvement of the individual's 23 health status as determined by assessments of agreed-upon 24 health status indicators between the individual and the health 25 insurer, including, but not limited to, reduction in weight, 26 body mass index, and smoking cessation. Any rebate provided by 27 the health insurer is presumed to be appropriate unless 28 credible data demonstrates otherwise, but shall not exceed 10 29 percent of paid premiums. 30 (2) The premium rebate authorized by this section 31 shall be effective for an insured on an annual basis, unless 92 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 the individual fails to maintain or improve his or her health 2 status while participating in an approved wellness program, or 3 credible evidence demonstrates that the individual is not 4 participating in the approved wellness program. 5 Section 41. Subsection (38) of section 641.31, Florida 6 Statutes, is amended, and subsection (40) is added to that 7 section, to read: 8 641.31 Health maintenance contracts.-- 9 (38)(a) Notwithstanding any other provision of this 10 part, a health maintenance organization that meets the 11 requirements of paragraph (b) may, through a point-of-service 12 rider to its contract providing comprehensive health care 13 services, include a point-of-service benefit. Under such a 14 rider, a subscriber or other covered person of the health 15 maintenance organization may choose, at the time of covered 16 service, a provider with whom the health maintenance 17 organization does not have a health maintenance organization 18 provider contract. The rider may not require a referral from 19 the health maintenance organization for the point-of-service 20 benefits. 21 (b) A health maintenance organization offering a 22 point-of-service rider under this subsection must have a valid 23 certificate of authority issued under the provisions of the 24 chapter, must have been licensed under this chapter for a 25 minimum of 3 years, and must at all times that it has riders 26 in effect maintain a minimum surplus of $5 million. A health 27 maintenance organization offering a point-of-service rider to 28 its contract providing comprehensive health care services may 29 offer the rider to employers who have employees living and 30 working outside the health maintenance organization's approved 31 geographic service area without having to obtain a health care 93 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 provider certificate, as long as the master group contract is 2 issued to an employer that maintains its primary place of 3 business within the health maintenance organization's approved 4 service area. Any member or subscriber that lives and works 5 outside the health maintenance organization's service area and 6 elects coverage under the health maintenance organization's 7 point-of-service rider must provide a statement to the health 8 maintenance organization which indicates that the member or 9 subscriber understands the limitations of his or her policy 10 and that only those benefits under the point-of-service rider 11 will be covered when services are provided outside the service 12 area. 13 (c) Premiums paid in for the point-of-service riders 14 may not exceed 15 percent of total premiums for all health 15 plan products sold by the health maintenance organization 16 offering the rider. If the premiums paid for point-of-service 17 riders exceed 15 percent, the health maintenance organization 18 must notify the office and, once this fact is known, must 19 immediately cease offering such a rider until it is in 20 compliance with the rider premium cap. 21 (d) Notwithstanding the limitations of deductibles and 22 copayment provisions in this part, a point-of-service rider 23 may require the subscriber to pay a reasonable copayment for 24 each visit for services provided by a noncontracted provider 25 chosen at the time of the service. The copayment by the 26 subscriber may either be a specific dollar amount or a 27 percentage of the reimbursable provider charges covered by the 28 contract and must be paid by the subscriber to the 29 noncontracted provider upon receipt of covered services. The 30 point-of-service rider may require that a reasonable annual 31 deductible for the expenses associated with the 94 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 point-of-service rider be met and may include a lifetime 2 maximum benefit amount. The rider must include the language 3 required by s. 627.6044 and must comply with copayment limits 4 described in s. 627.6471. Section 641.3154 does not apply to a 5 point-of-service rider authorized under this subsection. 6 (e) The point-of-service rider must contain provisions 7 that comply with s. 627.6044. 8 (f)(e) The term "point of service" may not be used by 9 a health maintenance organization except with riders permitted 10 under this section or with forms approved by the office in 11 which a point-of-service product is offered with an indemnity 12 carrier. 13 (g)(f) A point-of-service rider must be filed and 14 approved under ss. 627.410 and 627.411. 15 (40)(a) Any rate, rating schedule, or rating manual 16 for a health maintenance organization policy filed with the 17 office shall provide for an appropriate rebate of premiums 18 paid in the last calendar year when the individual covered by 19 such plan is enrolled in and maintains participation in any 20 health wellness, maintenance, or improvement program approved 21 by the health plan. The individual must provide evidence of 22 demonstrative maintenance or improvement of his or her health 23 status as determined by assessments of agreed-upon health 24 status indicators between the individual and the health 25 insurer, including, but not limited to, reduction in weight, 26 body mass index, and smoking cessation. Any rebate provided by 27 the health insurer is presumed to be appropriate unless 28 credible data demonstrates otherwise, but shall not exceed 10 29 percent of paid premiums. 30 (b) The premium rebate authorized by this section 31 shall be effective for an insured on an annual basis, unless 95 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 the individual fails to maintain or improve his or her health 2 status while participating in an approved wellness program, or 3 credible evidence demonstrates that the individual is not 4 participating in the approved wellness program. 5 Section 42. Notwithstanding the amendment to section 6 627.6699(5)(c), Florida Statutes, by this act, any right to an 7 open enrollment offer of health benefit coverage for groups of 8 fewer than two employees, pursuant to section 627.6699(5)(c), 9 Florida Statutes, as it existed immediately before the 10 effective date of this act, shall remain in full force and 11 effect until the enactment of section 627.64872, Florida 12 Statutes, and the subsequent date upon which such plan begins 13 to accept new risks or members. 14 Section 43. Section 408.02, Florida Statutes, is 15 repealed. 16 Section 44. Subsection (1) of section 766.309, Florida 17 Statutes, is amended to read: 18 766.309 Determination of claims; presumption; findings 19 of administrative law judge binding on participants.-- 20 (1) The administrative law judge shall make the 21 following determinations based upon all available evidence: 22 (a) Whether the injury claimed is a birth-related 23 neurological injury. If the claimant has demonstrated, to the 24 satisfaction of the administrative law judge, that the infant 25 has sustained a brain or spinal cord injury caused by oxygen 26 deprivation or mechanical injury and that the infant was 27 thereby rendered permanently and substantially mentally and 28 physically impaired, a rebuttable presumption shall arise that 29 the injury is a birth-related neurological injury as defined 30 in s. 766.302(2). 31 (b) Whether obstetrical services were delivered by a 96 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 participating physician in the course of labor, delivery, or 2 resuscitation in the immediate postdelivery period in a 3 hospital; or by a certified nurse midwife in a teaching 4 hospital supervised by a participating physician in the course 5 of labor, delivery, or resuscitation in the immediate 6 postdelivery period in a hospital. 7 (c) How much compensation, if any, is awardable 8 pursuant to s. 766.31. 9 (d) Whether, if raised by the claimant or other party, 10 the factual determinations regarding the notice requirements 11 in s. 766.316 are satisfied. The administrative law judge has 12 the exclusive jurisdiction to make these factual 13 determinations. 14 Section 45. The Agency for Health Care Administration 15 shall adopt all rules necessary to implement this act no later 16 than January 1, 2005. 17 Section 46. The amendment to section 766.309, Florida 18 Statutes, contained in this act, is intended to clarify that 19 the administrative law judge has always had the exclusive 20 jurisdiction to make factual determinations as to whether the 21 notice requirements in section 766.316, Florida Statutes, are 22 satisfied. 23 Section 47. The Auditor General shall conduct a study 24 of nursing home finances which shall examine the following: 25 (1) Profits of nursing home licensees, nursing home 26 management companies, related-party businesses, and owners of 27 real estate that is leased to nursing home operators in this 28 state; 29 (2) Salaries of nonfacility-based nursing home 30 executives, nursing home operators, management companies, and 31 real estate entities; and 97 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 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 48. 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 (4) The number of nursing home employees who have 31 employee-only coverage and the actual number of employees who 98 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 have dependent coverage; and 2 (5) The number of nursing home employees whose 3 dependents are enrollees in KidCare, Healthy Kids, and 4 Medicaid. 5 6 The agency shall report its findings to the Governor, the 7 President of the Senate, and the Speaker of the House of 8 Representatives by December 15, 2004. 9 Section 49. The sum of $250,000 is appropriated from 10 the Insurance Regulatory Trust Fund in the Department of 11 Financial Services to the Office of Insurance Regulation for 12 the purpose of implementing the provisions in this act 13 relating to the Small Employers Access Program. 14 Section 50. The sum of $350,000 in nonrecurring 15 general revenue funds is appropriated to the Agency for Health 16 Care Administration to support the establishment of and to 17 contract with the Florida Patient Safety Corporation to 18 implement the provisions of section 16 of this act during the 19 2004-2005 fiscal year. 20 Section 51. The sum of $113,500 in nonrecurring 21 general revenue funds is appropriated to the Florida State 22 University College of Medicine for the purpose of conducting 23 the study required in section 17 of this act during the 24 2004-2005 fiscal year. 25 Section 52. The sum of $250,000 is appropriated from 26 the Insurance Regulatory Trust Fund in the Department of 27 Financial Services to the Office of Insurance Regulation for 28 the board of the Florida Health Insurance Plan to contract for 29 an independent actuarial study for the interim report that the 30 board is required to submit pursuant to section 627.64872, 31 Florida Statutes, as created by this act. In addition, the 99 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 board shall include in that study an analysis of exempting 2 health insurance rates for employers with 26 to 50 employees 3 from the requirements of modified community rating, as 4 provided in section 672.6699, Florida Statutes, and the 5 potential impact that such an exemption would have on the 6 accessibility and affordability of health insurance coverage 7 in the small employer market. 8 Section 53. The sum of $169,069 is appropriated from 9 the Insurance Regulatory Trust Fund in the Department of 10 Financial Services to the Office of Insurance Regulation for 11 the purpose of implementing the provisions in this act 12 relating to the regulation of discount medical plan 13 organizations. 14 Section 54. The sum of $2 million in nonrecurring 15 general revenue funds is appropriated to the Agency for Health 16 Care Administration for its activities during the 2004-2005 17 fiscal year which relate to developing and implementing a 18 strategy for the adoption and use of electronic health 19 records. 20 Section 55. Except as otherwise expressly provided in 21 this act, and except for sections 13-15 and this section, 22 which shall take effect 23 24 25 ================ T I T L E A M E N D M E N T =============== 26 And the title is amended as follows: 27 On page 1, line 2, through 28 page 3, line 21, delete those lines 29 30 and insert: 31 An act relating to affordable and safe health 100 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 care; providing a popular name; providing 2 purpose; amending s. 381.026, F.S.; requiring 3 certain licensed facilities to provide public 4 Internet access to certain financial 5 information; amending s. 381.734, F.S.; 6 including participation by health care 7 providers, small businesses, and health 8 insurers in the Healthy Communities, Healthy 9 People Program; requiring the Department of 10 Health to provide public Internet access to 11 certain public health programs; requiring the 12 department to monitor and assess the 13 effectiveness of such programs; requiring a 14 report; requiring the Office of Program Policy 15 and Government Accountability to evaluate the 16 effectiveness of such programs; requiring a 17 report; amending s. 395.003, F.S.; prohibiting 18 the Agency for Health Care Administration from 19 issuing licenses for certain emergency 20 departments located off the primary premises of 21 a hospital before July 1, 2005; requiring a 22 study and report to the Legislature; amending 23 s. 395.1041, F.S.; authorizing hospitals to 24 develop certain emergency room diversion 25 programs; amending s. 395.301, F.S.; requiring 26 certain licensed facilities to provide 27 prospective patients certain estimates of 28 charges for services; requiring such facilities 29 to provide patients with certain bill 30 verification information; providing for a fine 31 for failure to provide such information; 101 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 providing charge limitations; requiring such 2 facilities to establish a patient question 3 review and response methodology; providing 4 requirements; requiring certain licensed 5 facilities to provide public Internet access to 6 certain financial information; providing an 7 exception for specified rural hospitals; 8 amending s. 408.061, F.S.; requiring the Agency 9 for Health Care Administration to require 10 health care facilities, health care providers, 11 and health insurers to submit certain 12 information; providing requirements; requiring 13 the agency to adopt certain risk and severity 14 adjustment methodologies; requiring the agency 15 to adopt certain rules; requiring certain 16 information to be certified; amending s. 17 408.062, F.S.; requiring the agency to conduct 18 certain health care costs and access research, 19 analyses, and studies; expanding the scope of 20 such studies to include collection of pharmacy 21 retail price data, use of emergency 22 departments, physician information, and 23 Internet patient charge information 24 availability; requiring publication of 25 information collected on the Internet; 26 requiring a report; requiring the agency to 27 conduct additional data-based studies and make 28 recommendations to the Legislature; requiring 29 the agency to develop and implement a strategy 30 to adopt and use electronic health records; 31 authorizing the agency to develop rules to 102 1:45 PM 04/24/04 s2910c3c-37t37
SENATE AMENDMENT Bill No. CS for CS for CS for SB 2910 Amendment No. ___ Barcode 454326 1 protect electronic records confidentiality; 2 requiring a report to the Governor and 3 Legislature; amending s. 408.05, F.S.; 4 requiring the agency to develop a plan to make 5 performance outcome and financial data 6 available to consumers for health care services 7 comparison purposes; requiring submittal of the 8 plan to the Governor and Legislature; requiring 9 the agency to update the plan; requiring the 10 agency to make the plan available 11 electronically; providing plan requirements; 12 amending s. 409.9066, F.S.; requiring the 13 agency to provide certain information relating 14 to the Medicare prescription discount program; 15 creating s. 465.0244, F.S.; requiring each 16 pharmacy to make available on its Internet 17 website a link to certain performance outcome 18 and financial data of the Agency for Health 19 Care Administration and a notice of the 20 availability of such information; amending s. 21 468.352, F.S.; revising and providing 22 definitions applicable to the regulation of 23 respiratory therapy; amending s. 468.355, F.S.; 24 revising provisions relating to respiratory 25 therapy licensure and testing requirements; 26 amending s. 468.368, F.S.; revising exemptions 27 from respiratory therapy licensure 28 requirements; repealing s. 468.356, F.S., 29 relating to the approval of educational 30 programs; repealing s. 468.357, F.S., relating 31 to licensure by examination; amending s. 103 1:45 PM 04/24/04 s2910c3c-37t37
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