House Bill 1541
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Florida House of Representatives - 1999 HB 1541
By Representative Bloom
1 A bill to be entitled
2 An act relating to health insurance policies,
3 contracts, and coverage; creating s. 627.6474,
4 F.S.; providing purposes; providing
5 definitions; authorizing point of service
6 coverage under arrangements between health
7 insurers and health maintenance organizations;
8 providing criteria; providing standards;
9 providing requirements; providing procedures;
10 providing applicability; providing rulemaking
11 authority of the Department of Insurance;
12 creating s. 627.64735, F.S.; prohibiting use of
13 certain words under certain circumstances;
14 amending s. 627.662, F.S.; providing for
15 application of s. 627.64735, F.S., to certain
16 insurance; creating s. 627.6693, F.S.;
17 requiring certain group health insurance
18 policies to comply with certain point of
19 service requirements; creating s. 641.185,
20 F.S.; establishing a subscriber's bill of
21 rights to serve as standards for certain
22 purposes; creating s. 641.2019, F.S.;
23 prohibiting health maintenance organizations
24 from excluding certain noncovered or covered
25 services under certain circumstances; amending
26 s. 641.30, F.S.; requiring certain health
27 maintenance organization agreements to comply
28 with certain point of service requirements;
29 providing application; amending s. 641.31,
30 F.S.; requiring the department to specify new
31 rates or rate schedules for health maintenance
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1 organizations under certain circumstances;
2 providing for return of excessive premiums
3 received; providing for continuation of care
4 under certain circumstances; amending s.
5 641.3108, F.S.; requiring certain notice to
6 group member subscribers prior to the effective
7 date of cancellation or termination of a group
8 health maintenance contract; amending s.
9 641.315, F.S.; requiring provider contracts to
10 provide for notice to the department of any
11 intent to cancel; creating s. 641.34, F.S.;
12 prohibiting use of certain words under certain
13 circumstances; amending s. 641.51, F.S.;
14 extending the time required to be provided to
15 subscribers for continued care by a terminating
16 treating provider under certain circumstances;
17 amending s. 641.511, F.S.; requiring a health
18 maintenance organization respond to an initial
19 complaint within a time certain; requiring
20 grievance managers to provide written
21 determinations of grievance panel review;
22 providing grievance process requirements
23 relating to subscribers; providing application;
24 providing an effective date.
25
26 Be It Enacted by the Legislature of the State of Florida:
27
28 Section 1. Section 627.6474, Florida Statutes, is
29 created to read:
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1 627.6474 Point of service policies; purpose of part;
2 definition; authority; standards, reporting; application of
3 other laws.--
4 (1) PURPOSE.--It is the purpose of this section to
5 encourage the issuance of coverage to persons that provides an
6 option, at the time medical services are secured, of accessing
7 benefits provided by a licensed health maintenance
8 organization or accessing benefits provided by a licensed
9 health insurer. By authorizing the issuance of that coverage,
10 the Legislature intends to maximize health care options for
11 consumers of health care policies.
12 (2) SCOPE.--Point of service coverage may be issued on
13 an individual or group basis.
14 (3) DEFINITIONS.--As used in this section:
15 (a) "Point of service agreement" is the contractual
16 means by which a health insurer and health maintenance
17 organization offer point of service coverage.
18 (b) "Point of service policy" is a policy providing
19 comprehensive health benefits under which an insured has:
20 1. Both a health insurance policy issued by an
21 authorized health insurer in conjunction with a health
22 maintenance contract issued by a licensed health maintenance
23 organization whereby the insured may choose at each time of
24 service whether to access indemnity benefits under the health
25 insurance policy or benefits under the health maintenance
26 contract, but not both; or
27 2. A single contract issued by a health maintenance
28 organization or a single policy issued by a health insurer,
29 pursuant to a point of service agreement between the health
30 insurer and the health maintenance organization, whereby the
31 insured may choose at each time of service whether to access
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1 indemnity benefits under the health insurance portion of the
2 policy or benefits under the health maintenance portion of the
3 policy, but not both.
4 (c) "Insured" means the policyholder or subscriber of
5 an individual point of service policy, or the subscriber or
6 certificateholder under a group point of service policy.
7 (4) AUTHORITY TO ISSUE.--
8 (a) Subject to the requirements contained in this
9 section, nothing in this code, including chapter 641, and
10 rules adopted under the code and such chapter, shall be deemed
11 to prohibit an authorized health insurer and a licensed health
12 maintenance organization, in conjunction, from soliciting,
13 offering, or providing point of service coverage either in a
14 separate policy issued by the health insurer and a separate
15 health maintenance contract issued by the health maintenance
16 organization or in a single contract issued by the health
17 maintenance organization or by a single policy by the health
18 insurer.
19 (b) Except as provided in this section, no insurer or
20 health maintenance organization shall solicit, offer, or
21 provide a point of service policy.
22 (5) PROVISIONS OF POINT OF SERVICE POLICIES.--Each
23 point of service policy shall contain the following
24 provisions, in addition to all others required under this
25 code, chapter 641, and rules adopted under the code and such
26 chapter:
27 (a) A provision clearly identifying both the health
28 insurer and the health maintenance organization and, in the
29 instance of a group policy, a provision in the member handbook
30 or certificate of coverage clearly identifying the health
31 insurer and the health maintenance organization.
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1 (b) A provision stating that an insured covered under
2 a point of service policy must elect either indemnity benefits
3 or health maintenance organization coverage for a given
4 medical treatment.
5 (c) A provision stating that whenever coverage has
6 been paid or provided with respect to a given medical
7 treatment by either the health insurer or the health
8 maintenance organization pursuant to a filed and approved
9 point of service policy, the provisions of s. 627.4235 shall
10 not apply with respect to the point of service policy but
11 shall apply as to other policies, plans, or contracts of the
12 insured.
13 (d) A provision stating that 60 days prior to the
14 termination of a point of service agreement, the terminating
15 company must provide each insured who has a policy under the
16 agreement notice in writing of the termination.
17 (e) A provision that, if a point of service agreement
18 is terminated, the policyholder in an individual contract or
19 the contract holder in a group contract may, within 60 days
20 after receiving notice of the termination, elect to continue
21 coverage with either the health maintenance organization or
22 the health insurer that was a party to the point of service
23 agreement for the remainder of the contract period.
24 (f) A provision that, if the insured is entitled to a
25 conversion plan, for reasons set forth in s. 627.646, s.
26 627.6675, or s. 641.3922, the insured is entitled to a choice
27 of either an indemnity plan from the health insurer or a
28 health maintenance organization contract, without prejudice.
29 (6) FILING AND REPORTING REQUIREMENTS.--
30 (a) The following requirements apply to point of
31 service policy forms and rate filings.
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1 1. All point of service policy form and rate filings
2 shall be made jointly, whether or not separate or combined
3 forms are used.
4 2. The point of service policy form and rate filing
5 shall include all forms and rates required by this section.
6 However, if using forms and rates previously approved to
7 satisfy the required separate health benefit policies and the
8 conversion policies to be used in conjunction with this point
9 of service policy, it shall be sufficient to identify the form
10 number and date of approval of these forms and related rates.
11 3. The point of service policy form and rate filing
12 shall contain certification from an officer of the health
13 insurer and an officer of the health maintenance organization
14 that each company agrees, as a condition precedent to
15 termination of the point of service agreement, to provide the
16 department with notice of its intention to terminate the point
17 of service arrangement no less than 90 days prior to the
18 effective date of termination. Further, each company agrees to
19 notify the department within 48 hours in the event of a
20 material breach by either company.
21 4. All point of service policy filings shall contain
22 an authorization from the health insurer and the health
23 maintenance organization, either as joint signatories or an
24 original letter of authorization from each company to the
25 other, to make the combined filing whenever a single policy
26 will be used and that both parties will be responsible for the
27 accuracy of the information contained in the combined filing.
28 5. All point of service policy forms and rates shall
29 be filed and approved prior to use. All form and rate changes
30 to said policy must be filed and approved prior to use.
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1 6. The health insurer and the health maintenance
2 organization shall each file and have approved a policy form
3 and rate to be made available to the insured when the point of
4 service agreement is terminated during an existing contract
5 period. The filing shall:
6 a. Contain levels of indemnity benefits or other
7 health benefit coverage no less than that provided under the
8 point of service policy.
9 b. Comply in all respects with the requirements of the
10 insurance code or chapter 641 as related to the product being
11 filed.
12 c. Clearly identify in the filing that this policy is
13 intended for use in conjunction with a point of service
14 policy.
15 7. The health insurer and the health maintenance
16 organization shall each have filed and approved a conversion
17 policy, with corresponding rates, to be made available to the
18 insured when the right to conversion is required.
19 8. The health insurer or the health maintenance
20 organization shall make, at a minimum, an annual rate filing
21 for each point of service policy form offered in this state.
22 Annual periodic rate adjustments shall be made to reflect the
23 actual premium split based on experience and compared with the
24 assumed split at the beginning of the contract. Except as so
25 described, no other experience adjustments shall be made on a
26 retrospective basis without approval by the department.
27 9. All rate filings for a point of service policy
28 shall contain the following terms and conditions, in addition
29 to all others required under by law or rule:
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1 a. The health insurer and the health maintenance
2 organization shall each perform its own pricing on a net claim
3 basis.
4 b. The health insurer and the health maintenance
5 organization shall each calculate its own expenses and profit
6 margins.
7 c. Expenses are to be itemized and shall clearly
8 identify which entity is performing which duty relative to
9 each expense item noted.
10 d. Minimum loss ratios, as defined in the code or in
11 any applicable rule adopted under the code, shall be met by
12 each company.
13 (b) The following requirements apply to point of
14 service information reporting.--
15 1. The health insurer and the health maintenance
16 organization shall each maintain separate records relating to
17 any point of service policy. On each financial report made to
18 the department, made on a form adopted by the department, each
19 company shall provide the following information:
20 a. Total point of service earned premium.
21 b. Total number of point of service policyholders,
22 certificateholders and subscribers by market, individual,
23 small group, or large group.
24 c. Loss ratios for point of service policies.
25 d. Expenses.
26 e. Any other information required by the department in
27 carrying out the department's duties under this section.
28 2. Each company shall disclose in the company's
29 audited financial statement, at a minimum in a footnote to
30 such report, the combined earned premium and total losses
31 incurred, including expenses incurred but not reported for
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1 this product. The annual actuarial certification shall also
2 contain a specific actuarial certification that the rates
3 charged for this product are not inadequate, excessive or
4 discriminatory.
5 (7) APPLICABILITY.--
6 (a) Any health insurer entering into a point of
7 service arrangement pursuant to this section, in addition to
8 the requirements of this section, shall be subject to all
9 provisions of the insurance code and other laws, and rules
10 adopted under the code or such laws, applicable to health
11 insurers generally.
12 (b) Any health maintenance organization entering into
13 a point of service arrangement pursuant to this section, in
14 addition to the requirements of this section, shall be subject
15 to all provisions of chapter 641 and rules adopted under such
16 chapter, and to all other provisions of this code and other
17 laws and rules adopted under such code and laws, applicable to
18 health maintenance organizations generally.
19 (c) The health insurance portion of a point of service
20 arrangement policy shall be subject to the provisions of part
21 III of chapter 631. The health maintenance portion of a point
22 of service arrangement shall be subject to part IV of chapter
23 631.
24 (d) Any health maintenance organization entering into
25 a point of service arrangement pursuant to this section shall
26 not be subject to part VII of chapter 626 when administering a
27 point of service policy.
28 (8) RULEMAKING.--The department may adopt any rule
29 necessary to implement the intent and provisions of this
30 section. In adopting such rule, the department shall consider
31 requirements to assure that experience adjustments and other
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1 adjustments are reasonable, fair, and equitable; that point of
2 service policies, advertisements, solicitation materials, and
3 other statements or related documents are clear and
4 understandable; that point of service policies are provided to
5 the insurance buying public in a fashion that meets the
6 purposes of this section and are provided in a fair and
7 equitable fashion; and that point of service policies provide
8 for a proper triggering of the conversion plan policies.
9 Section 2. Section 627.64735, Florida Statutes, is
10 created to read:
11 627.64735 Use of certain words prohibited.--A health
12 insurer or a health maintenance organization shall not use in
13 its contracts or literature or in any form of advertising the
14 phrase "point of service," or its abbreviation "POS," unless
15 the phrase or abbreviation relates to a policy which has been
16 filed and approved by the department pursuant to s. 627.6474.
17 Section 3. Section 11 is added to section 627.662,
18 Florida Statutes, to read:
19 627.662 Other provisions applicable.--The following
20 provisions apply to group health insurance, blanket health
21 insurance, and franchise health insurance:
22 (11) Section 627.64735, relating to prohibiting use of
23 the phrase "point of service."
24 Section 4. Section 627.6693, Florida Statutes, is
25 created to read:
26 627.6693 Point of service.--Any group health insurance
27 policy that provides coverage to a resident of this state
28 pursuant to a point of service agreement as defined in s.
29 627.6474 shall comply with all requirements set forth in s.
30 627.6474.
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1 Section 5. Section 641.185, Florida Statutes, is
2 created to read:
3 641.185 Health maintenance organization subscriber's
4 bill of rights.--
5 (1) With respect to the provisions of this part, and
6 consistent with the scope of covered conditions and treatments
7 under the contract, the principles expressed in the following
8 statements shall serve as standards to be followed by the
9 department and the agency in exercising their powers and
10 duties, in exercising administrative discretion, in dispensing
11 administrative interpretations of the law, in enforcing the
12 law, and in adopting rules:
13 (a) A subscriber has the right to receive quality,
14 medically necessary and appropriate health care services that
15 are available and accessible in a timely manner.
16 (b) A subscriber has the right to the provision of
17 medical care by the health maintenance organization with the
18 goal of maintaining the subscriber's good health in a
19 cost-effective fashion and to treat the subscriber's medical
20 conditions as may be necessary and appropriate.
21 (c) A subscriber has the right to accurate and easily
22 understood information to make informed decisions about health
23 plans, professionals, and facilities.
24 (d) A subscriber has the right to compassionate,
25 sympathetic, and respectful care from all health maintenance
26 organization providers and employees.
27 (e) A subscriber shall have access to simple, fair,
28 timely, and impartial procedures for resolving coverage
29 disputes.
30 (f) A subscriber has a right to a timely referral with
31 payment pre-authorization for covered treatment outside the
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1 health maintenance organization's provider network when a
2 health maintenance organization does not have a provider
3 specializing in or experienced with respect to the medical
4 care or course of treatment appropriate to the subscriber's
5 medical condition.
6 (g) A subscriber has a right to expedited treatment of
7 any covered condition that would jeopardize the life or health
8 of a subscriber or would jeopardize the subscriber's ability
9 to regain maximum function.
10 (h) A subscriber has a right to a quality assurance
11 program with respect to health maintenance organization
12 providers so as to provide medically necessary care and
13 treatment and to avoid unnecessary, inappropriate, or improper
14 medical care or services.
15 (2) This section shall not be construed as creating a
16 civil cause of action by any subscriber against any health
17 maintenance organization.
18 Section 6. Section 641.2019, Florida Statutes, is
19 created to read:
20 641.2019 Simultaneous delivery of covered and
21 noncovered medical treatment.--A health maintenance
22 organization shall not prohibit a subscriber from receiving
23 noncovered medically necessary treatment simultaneously with
24 covered treatment if a provider determines the simultaneous
25 treatment is not contrary to the best interests of the
26 subscriber. A health maintenance organization shall not
27 exclude coverage for a covered procedure if the subscriber
28 elects to have a noncovered medically necessary procedure
29 performed simultaneously or in conjunction with the covered
30 procedure. The health maintenance organization shall not
31 reduce the level of reimbursement to the provider performing
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1 the covered service in conjunction with the noncovered
2 service.
3 Section 7. Subsection (6) is added to section 641.30,
4 Florida Statutes, to read:
5 641.30 Construction and relationship to other laws.--
6 (6) Every health maintenance organization entering
7 into an arrangement to provide point of service coverage shall
8 comply with s. 627.6474.
9 Section 8. Paragraph (b) of subsection (3) of section
10 641.31, Florida Statutes, 1998 Supplement, is amended, and
11 subsection (36) is added to said section, to read:
12 641.31 Health maintenance contracts.--
13 (3)
14 (b) The department shall disapprove any form filed
15 under this subsection, or withdraw any previous approval
16 thereof, if the form:
17 1. Is in any respect in violation of, or does not
18 comply with, any provision of this part or rule adopted
19 thereunder.
20 2. Contains or incorporates by reference, where such
21 incorporation is otherwise permissible, any inconsistent,
22 ambiguous, or misleading clauses or exceptions and conditions
23 which deceptively affect the risk purported to be assumed in
24 the general coverage of the contract.
25 3. Has any title, heading, or other indication of its
26 provisions which is misleading.
27 4. Is printed or otherwise reproduced in such a manner
28 as to render any material provision of the form substantially
29 illegible.
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1 5. Contains provisions which are unfair, inequitable,
2 or contrary to the public policy of this state or which
3 encourage misrepresentation.
4 6. Charges rates that are determined by the department
5 to be inadequate, excessive, or unfairly discriminatory, or
6 the rating methodology followed by the health maintenance
7 organization is determined by the department to be
8 inconsistent, indeterminate, ambiguous, or encouraging
9 misrepresentation or misunderstanding. When the department
10 finds that a rate or rate change is excessive, inadequate, or
11 unfairly discriminatory, the department shall, in addition to
12 disapproving the form, specify that a new rate or rate
13 schedule, which responds to the findings of the department, be
14 filed by the health maintenance organization. The department
15 shall further require that premiums charged each contract
16 holder, constituting the portion of the rate above that which
17 was approved, be returned to such contract holder in the form
18 of a credit or refund. The refund or credit amount due shall
19 be calculated from the date of the original disapproval. When
20 the department finds that a health maintenance organization's
21 rate or rate change is inadequate, the new rate or rate
22 schedule filed with the department in response to such a
23 finding Use of the rating methodology must be discontinued
24 immediately upon disapproval unless the health maintenance
25 organization seeks administrative relief. If a new rating
26 methodology is filed with the department, the premiums
27 determined by such newly filed rating methodology may apply
28 prospectively only to new or renewal business written on or
29 after the effective date of the responsive filing made by the
30 health maintenance organization.
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1 7. Excludes coverage for human immunodeficiency virus
2 infection or acquired immune deficiency syndrome or contains
3 limitations in the benefits payable, or in the terms or
4 conditions of such contract, for human immunodeficiency virus
5 infection or acquired immune deficiency syndrome which are
6 different than those which apply to any other sickness or
7 medical condition.
8 (36) A health maintenance organization contract shall
9 include the provisions of s. 641.51(7).
10 Section 9. Section 641.3108, Florida Statutes, is
11 amended to read:
12 641.3108 Notice of cancellation or nonrenewal of
13 contract.--
14 (1) Except for nonpayment of premium or termination of
15 eligibility, no health maintenance organization may cancel or
16 otherwise terminate or fail to renew a health maintenance
17 contract without giving each the subscriber covered by the
18 contract at least 45 days' notice in writing of the
19 cancellation, termination, or nonrenewal of the contract. The
20 written notice shall state the reason or reasons for the
21 cancellation, termination, or nonrenewal. All health
22 maintenance contracts shall contain a clause which requires
23 that this notice be given. In the case of a health
24 maintenance contract issued to an employer or person holding
25 the contract on behalf of the subscriber group, the health
26 maintenance organization may make the notification through the
27 employer or group contract holder, and, if the health
28 maintenance organization elects to take this action through
29 the employer or group contract holder, the organization shall
30 be deemed to have complied with the provisions of this section
31 upon notifying the employer or group contract holder of the
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1 requirements of this section and requesting the employer or
2 group contract holder to forward to all subscribers the notice
3 required herein.
4 (2) No health maintenance organization may cancel or
5 otherwise terminate or fail to renew a group health
6 maintenance contract for nonpayment of premium or termination
7 of eligibility without giving each subscriber covered by the
8 contract at least 30 days' notice in writing of the
9 cancellation, termination, or nonrenewal of the contract. The
10 written notice shall state the reason or reasons for the
11 cancellation, termination, or nonrenewal. All group health
12 maintenance contracts shall contain a clause which requires
13 that this notice be given.
14 Section 10. Subsection (6) of section 641.315, Florida
15 Statutes, is amended to read:
16 641.315 Provider contracts.--
17 (6)(a) For all provider contracts executed after
18 October 1, 1999 1991, and within 180 days after October 1,
19 1991, for contracts in existence as of October 1, 1991:
20 1. The contracts must provide that the provider shall
21 provide 60 days' advance written notice to the health
22 maintenance organization and the department before canceling
23 the contract with the health maintenance organization for any
24 reason; and
25 2. The contract must also provide that nonpayment for
26 goods or services rendered by the provider to the health
27 maintenance organization shall not be a valid reason for
28 avoiding the 60-day advance notice of cancellation; and.
29 3. The contract must also provide that the health
30 maintenance organization shall, within 72 hours after receipt
31 of the notice required in subparagraph 1., notify the
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1 department of the provider's intent to cancel the contract
2 with the health maintenance organization.
3 (b) For all provider contracts executed after October
4 1, 1999 1996, and within 180 days after October 1, 1996, for
5 contracts in existence as of October 1, 1996, the contracts
6 must provide that the health maintenance organization will
7 provide 60 days' advance written notice to the provider and
8 the department before canceling, without cause, the contract
9 with the provider, except in a case in which a patient's
10 health is subject to imminent danger or a physician's ability
11 to practice medicine is effectively impaired by an action by
12 the Board of Medicine or other governmental agency.
13 Section 11. Section 641.34, Florida Statutes, is
14 created to read:
15 641.34 Use of certain words prohibited.--A health
16 maintenance organization shall not use in its contracts or
17 literature or in any form of advertising the phrase "point of
18 service," or its abbreviation "POS," unless the phrase or
19 abbreviation relates to a policy which has been filed and
20 approved by the department pursuant to s. 627.6474.
21 Section 12. Subsection (7) of section 641.51, Florida
22 Statutes, is amended to read:
23 641.51 Quality assurance program; second medical
24 opinion requirement.--
25 (7) Each organization shall allow subscribers to
26 continue care for 90 60 days with a terminated treating
27 provider when medically necessary, provided the subscriber has
28 a life-threatening condition or a disabling and degenerative
29 condition. Each organization shall allow a subscriber who is
30 in the third trimester of pregnancy to continue care with a
31 terminated treating provider until completion of postpartum
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1 care. The organization and the provider shall continue to be
2 bound by the terms of the contract for such continued care.
3 This subsection shall not apply to treating providers who have
4 been terminated by the organization for cause.
5 Section 13. Subsections (2) and (4) of section
6 641.511, Florida Statutes, 1998 Supplement, are amended to
7 read:
8 641.511 Subscriber grievance reporting and resolution
9 requirements.--
10 (2) When an organization receives an initial complaint
11 from a subscriber, the organization must respond to the
12 complaint within a reasonable time after its submission but
13 not exceed 15 days. At the time of receipt of the initial
14 complaint, the organization shall inform the subscriber that
15 the subscriber has a right to file a written grievance at any
16 time and that assistance in preparing the written grievance
17 shall be provided by the organization.
18 (4)(a) With respect to a grievance concerning an
19 adverse determination, an organization shall make available to
20 the subscriber a review of the grievance by an internal review
21 panel.; Such review shall must be requested within 30 days
22 after the organization's transmittal of the final decision, in
23 writing, by the grievance manager, pursuant to paragraph
24 (3)(f) determination notice of an adverse determination. A
25 majority of the panel shall be persons who previously were not
26 involved in the initial adverse determination. A person who
27 previously was involved in the adverse determination may
28 appear before the panel to present information or answer
29 questions. The panel shall have the authority to bind the
30 organization to the panel's decision.
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1 (b) An organization shall ensure that a majority of
2 the persons reviewing a grievance involving an adverse
3 determination are providers who have appropriate expertise.
4 An organization shall issue a copy of the written decision of
5 the review panel to the subscriber and to the provider, if
6 any, who submits a grievance on behalf of a subscriber. In
7 cases where there has been a denial of coverage of service,
8 the reviewing provider shall not be a provider previously
9 involved with the adverse determination.
10 (c) An organization shall establish written procedures
11 for a review of an adverse determination. Review procedures
12 shall be available to the subscriber and to a provider acting
13 on behalf of a subscriber.
14 (d) Each organization's grievance procedures for the
15 review panel, as required under this subsection, must provide
16 at a minimum:
17 1. For a hearing at which the subscriber may appear,
18 be heard, and submit documentation regarding the grievance.
19 2. That the subscriber is entitled to be represented
20 at the hearing by a person of his or her choice, including
21 legal counsel.
22 3. That the subscriber may be accompanied by the
23 provider who ordered the disputed treatment or service, who
24 shall be allowed to speak on the subscriber's behalf.
25 4. That the subscriber be allowed to document the
26 hearing by transcription or by video or audio recording.
27 (e)(d) In any case when the review process does not
28 resolve a difference of opinion between the organization and
29 the subscriber or the provider acting on behalf of the
30 subscriber, the subscriber or the provider acting on behalf of
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1 the subscriber may submit a written grievance to the Statewide
2 Provider and Subscriber Assistance Program.
3 Section 14. This act shall take effect October 1,
4 1999, and shall apply to policies and contracts issued or
5 renewed on or after such date.
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7 *****************************************
8 HOUSE SUMMARY
9
Authorizes licensed health insurers and health
10 maintenance organizations to issue optional point of
service coverage for indemnity benefits under a health
11 insurance policy or benefits under a health maintenance
contract. Provides a bill of rights for health
12 maintenance organization subscribers. Provides for
simultaneous treatment of covered and noncovered
13 services. Provides for continued treatment for terminal
illnesses, pregnancies, or institutional care under
14 terminated policies. Requires health maintenance
organizations to provide notice prior to canceling or
15 terminating, or failing to renew health maintenance
contracts. Specifies additional requirements for
16 grievance procedures of health maintenance organizations.
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24
25
26
27
28
29
30
31
20