Senate Bill 0232er
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2 An act relating to health care; amending s.
3 641.3903, F.S.; providing that certain actions
4 by a health maintenance organization against a
5 provider based on the provider's communication
6 of certain information to a patient are unfair
7 or deceptive practices; amending s. 641.315,
8 F.S.; requiring certain written notice in order
9 to terminate certain provider contracts;
10 providing limitations on the use of such
11 notice; amending s. 641.51, F.S.; providing for
12 continued care of subscribers when certain
13 provider contracts are terminated; amending s.
14 110.123, F.S.; requiring the state-contracted
15 health maintenance organization to provide an
16 enrollee with continued access to a treating
17 health care provider who loses provider status
18 under the program; providing limitations;
19 providing applicability; amending s. 641.31,
20 F.S.; revising the procedures and standards for
21 rate changes made by an organization; deleting
22 current provisions that allow rate changes to
23 be implemented immediately upon filing with the
24 Department of Insurance, subject to
25 disapproval; requiring rate changes to be filed
26 with the department a specified time period
27 prior to use; providing that a filing is deemed
28 approved after a certain time period absent
29 affirmative approval or disapproval by the
30 department; making conforming changes;
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1 providing for applicability of the act;
2 providing an effective date.
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4 Be It Enacted by the Legislature of the State of Florida:
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6 Section 1. Subsection (14) is added to section
7 641.3903, Florida Statutes, to read:
8 641.3903 Unfair methods of competition and unfair or
9 deceptive acts or practices defined.--The following are
10 defined as unfair methods of competition and unfair or
11 deceptive acts or practices:
12 (14) ADVERSE ACTION AGAINST A PROVIDER.--Any
13 retaliatory action by a health maintenance organization
14 against a contracted provider, including, but not limited to,
15 termination of a contract with the provider, on the basis that
16 the provider communicated information to the provider's
17 patient regarding medical care or treatment options for the
18 patient when the provider deems knowledge of such information
19 by the patient to be in the best interest of the patient.
20 Section 2. Subsection (9) is added to section 641.315,
21 Florida Statutes, to read:
22 641.315 Provider contracts.--
23 (9) A health maintenance organization or health care
24 provider may not terminate a contract with a health care
25 provider or health maintenance organization unless the party
26 terminating the contract provides the terminated party with a
27 written reason for the contract termination, which may include
28 termination for business reasons of the terminating party. The
29 reason provided in the notice required in this section or any
30 other information relating to the reason for termination does
31 not create any new administrative or civil action and may not
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1 be used as substantive evidence in any such action, but may be
2 used for impeachment purposes. As used in this subsection, the
3 term "health care provider" means a physician licensed under
4 ch. 458, ch. 459, ch. 460, or ch. 461, or a dentist licensed
5 under chapter 466.
6 Section 3. Subsection (7) of section 641.51, Florida
7 Statutes, is amended to read:
8 641.51 Quality assurance program; second medical
9 opinion requirement.--
10 (7) When a contract between an organization and a
11 treating provider is terminated for any reason other than for
12 cause, each party Each organization shall allow subscribers
13 for whom treatment was active to continue coverage and care
14 when medically necessary, through completion of treatment of a
15 condition for which the subscriber was receiving care at the
16 time of the termination, until the subscriber selects another
17 treating provider, or during the next open enrollment period
18 offered by the organization, whichever is longer, but not
19 longer than 6 months after termination of the contract. for 60
20 days with a terminated treating provider when medically
21 necessary, provided the subscriber has a life-threatening
22 condition or a disabling and degenerative condition. Each
23 party to the terminated contract organization shall allow a
24 subscriber who has initiated a course of prenatal care,
25 regardless of is in the third trimester in which care was
26 initiated, of pregnancy to continue care and coverage with a
27 terminated treating provider until completion of postpartum
28 care. This does not prevent a provider from refusing to
29 continue to provide care to a subscriber who is abusive,
30 noncompliant, or in arrears in payments for services provided.
31 For care continued under this subsection, the organization and
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1 the provider shall continue to be bound by the terms of the
2 terminated contract for such continued care. This subsection
3 shall not apply to treating providers who have been terminated
4 by the organization for cause. Changes made within 30 days
5 before termination of a contract are effective only if agreed
6 to by both parties.
7 Section 4. Paragraph (h) of subsection (3) of section
8 110.123, Florida Statutes, 1998 Supplement, is amended to
9 read:
10 110.123 State group insurance program.--
11 (3) STATE GROUP INSURANCE PROGRAM.--
12 (h)1. A person eligible to participate in the state
13 group health insurance plan may be authorized by rules adopted
14 by the division, in lieu of participating in the state group
15 health insurance plan, to exercise an option to elect
16 membership in a health maintenance organization plan which is
17 under contract with the state in accordance with criteria
18 established by this section and by said rules. The offer of
19 optional membership in a health maintenance organization plan
20 permitted by this paragraph may be limited or conditioned by
21 rule as may be necessary to meet the requirements of state and
22 federal laws.
23 2. The division shall contract with health maintenance
24 organizations to participate in the state group insurance
25 program through a request for proposal based upon a premium
26 and a minimum benefit package as follows:
27 a. A minimum benefit package to be provided by a
28 participating HMO shall include: physician services; inpatient
29 and outpatient hospital services; emergency medical services,
30 including out-of-area emergency coverage; diagnostic
31 laboratory and diagnostic and therapeutic radiologic services;
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1 mental health, alcohol, and chemical dependency treatment
2 services meeting the minimum requirements of state and federal
3 law; skilled nursing facilities and services; prescription
4 drugs; and other benefits as may be required by the division.
5 Additional services may be provided subject to the contract
6 between the division and the HMO.
7 b. A uniform schedule for deductibles and copayments
8 may be established for all participating HMOs.
9 c. Based upon the minimum benefit package and
10 copayments and deductibles contained in sub-subparagraphs a.
11 and b., the division shall issue a request for proposal for
12 all HMOs which are interested in participating in the state
13 group insurance program. Upon receipt of all proposals, the
14 division may, as it deems appropriate, enter into contract
15 negotiations with HMOs submitting bids. As part of the request
16 for proposal process, the division may require detailed
17 financial data from each HMO which participates in the bidding
18 process for the purpose of determining the financial stability
19 of the HMO.
20 d. In determining which HMOs to contract with, the
21 division shall, at a minimum, consider: each proposed
22 contractor's previous experience and expertise in providing
23 prepaid health benefits; each proposed contractor's historical
24 experience in enrolling and providing health care services to
25 participants in the state group insurance program; the cost of
26 the premiums; the plan's ability to adequately provide service
27 coverage and administrative support services as determined by
28 the division; plan benefits in addition to the minimum benefit
29 package; accessibility to providers; and the financial
30 solvency of the plan. Nothing shall preclude the division from
31 negotiating regional or statewide contracts with health
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1 maintenance organization plans when this is cost-effective and
2 when the division determines the plan has the best overall
3 benefit package for the service areas involved. However, no
4 HMO shall be eligible for a contract if the HMO's retiree
5 Medicare premium exceeds the retiree rate as set by the
6 division for the state group health insurance plan.
7 e. The division may limit the number of HMOs that it
8 contracts with in each service area based on the nature of the
9 bids the division receives, the number of state employees in
10 the service area, and any unique geographical characteristics
11 of the service area. The division shall establish by rule
12 service areas throughout the state.
13 f. All persons participating in the state group
14 insurance program who are required to contribute towards a
15 total state group health premium shall be subject to the same
16 dollar contribution regardless of whether the enrollee enrolls
17 in the state group health insurance plan or in an HMO plan.
18 3. The division is authorized to negotiate and to
19 contract with specialty psychiatric hospitals for mental
20 health benefits, on a regional basis, for alcohol, drug abuse,
21 and mental and nervous disorders. The division may establish,
22 subject to the approval of the Legislature pursuant to
23 subsection (5), any such regional plan upon completion of an
24 actuarial study to determine any impact on plan benefits and
25 premiums.
26 4. In addition to contracting pursuant to subparagraph
27 2., the division shall enter into contract with any HMO to
28 participate in the state group insurance program which:
29 a. Serves greater than 5,000 recipients on a prepaid
30 basis under the Medicaid program;
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1 b. Does not currently meet the 25 percent
2 non-Medicare/non-Medicaid enrollment composition requirement
3 established by the Department of Health and Human Services
4 excluding participants enrolled in the state group insurance
5 program;
6 c. Meets the minimum benefit package and copayments
7 and deductibles contained in sub-subparagraphs 2.a. and b.;
8 d. Is willing to participate in the state group
9 insurance program at a cost of premiums that is not greater
10 than 95 percent of the cost of HMO premiums accepted by the
11 division in each service area; and
12 e. Meets the minimum surplus requirements of s.
13 641.225.
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15 The division is authorized to contract with HMOs that meet the
16 requirements of sub-subparagraphs a. through d. prior to the
17 open enrollment period for state employees. The division is
18 not required to renew the contract with the HMOs as set forth
19 in this paragraph more than twice. Thereafter, the HMOs shall
20 be eligible to participate in the state group insurance
21 program only through the request for proposal process
22 described in subparagraph 2.
23 5. All enrollees in the state group health insurance
24 plan or any health maintenance organization plan shall have
25 the option of changing to any other health plan which is
26 offered by the state within any open enrollment period
27 designated by the division. Open enrollment shall be held at
28 least once each calendar year.
29 6. When a contract between a treating provider and the
30 state-contracted health maintenance organization is terminated
31 for any reason other than for cause, each party shall allow
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1 any enrollee for whom treatment was active to continue
2 coverage and care when medically necessary, through completion
3 of treatment of a condition for which the enrollee was
4 receiving care at the time of the termination, until the
5 enrollee selects another treating provider, or until the next
6 open enrollment period offered, whichever is longer, but no
7 longer than 6 months after termination of the contract. Each
8 party to the terminated contract shall allow an enrollee who
9 has initiated a course of prenatal care, regardless of the
10 trimester in which care was initiated, to continue care and
11 coverage until completion of postpartum care. This does not
12 prevent a provider from refusing to continue to provide care
13 to an enrollee who is abusive, noncompliant, or in arrears in
14 payments for services provided. For care continued under this
15 subparagraph, the program and the provider shall continue to
16 be bound by the terms of the terminated contract. Changes made
17 within 30 days before termination of a contract are effective
18 only if agreed to by both parties.
19 7.6. Any HMO participating in the state group
20 insurance program shall, upon the request of the division,
21 submit to the division standardized data for the purpose of
22 comparison of the appropriateness, quality, and efficiency of
23 care provided by the HMO. Such standardized data shall
24 include: membership profiles; inpatient and outpatient
25 utilization by age and sex, type of service, provider type,
26 and facility; and emergency care experience. Requirements and
27 timetables for submission of such standardized data and such
28 other data as the division deems necessary to evaluate the
29 performance of participating HMOs shall be adopted by rule.
30 8.7. The division shall, after consultation with
31 representatives from each of the unions representing state and
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1 university employees, establish a comprehensive package of
2 insurance benefits including, but not limited to, supplemental
3 health and life coverage, dental care, long-term care, and
4 vision care to allow state employees the option to choose the
5 benefit plans which best suit their individual needs.
6 a. Based upon a desired benefit package, the division
7 shall issue a request for proposal for health insurance
8 providers interested in participating in the state group
9 insurance program, and the division shall issue a request for
10 proposal for insurance providers interested in participating
11 in the non-health-related components of the state group
12 insurance program. Upon receipt of all proposals, the
13 division may enter into contract negotiations with insurance
14 providers submitting bids or negotiate a specially designed
15 benefit package. Insurance providers offering or providing
16 supplemental coverage as of May 30, 1991, which qualify for
17 pretax benefit treatment pursuant to s. 125 of the Internal
18 Revenue Code of 1986, with 5,500 or more state employees
19 currently enrolled may be included by the division in the
20 supplemental insurance benefit plan established by the
21 division without participating in a request for proposal,
22 submitting bids, negotiating contracts, or negotiating a
23 specially designed benefit package. These contracts shall
24 provide state employees with the most cost-effective and
25 comprehensive coverage available; however, no state or agency
26 funds shall be contributed toward the cost of any part of the
27 premium of such supplemental benefit plans.
28 b. Pursuant to the applicable provisions of s.
29 110.161, and s. 125 of the Internal Revenue Code of 1986, the
30 division shall enroll in the pretax benefit program those
31 state employees who voluntarily elect coverage in any of the
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1 supplemental insurance benefit plans as provided by
2 sub-subparagraph a.
3 c. Nothing herein contained shall be construed to
4 prohibit insurance providers from continuing to provide or
5 offer supplemental benefit coverage to state employees as
6 provided under existing agency plans.
7 Section 5. Effective July 1, 1999, and applicable to
8 policies and contracts issued or renewed on or after that
9 date, subsections (2) and (3) of section 641.31, Florida
10 Statutes, are amended to read:
11 641.31 Health maintenance contracts.--
12 (2) The rates charged by any health maintenance
13 organization to its subscribers shall not be excessive,
14 inadequate, or unfairly discriminatory or follow a rating
15 methodology that is inconsistent, indeterminate, or ambiguous
16 or encourages misrepresentation or misunderstanding. The
17 department, in accordance with generally accepted actuarial
18 practice as applied to health maintenance organizations, may
19 define by rule what constitutes excessive, inadequate, or
20 unfairly discriminatory rates and may require whatever
21 information it deems necessary to determine that a rate or
22 proposed rate meets the requirements of this subsection.
23 (3)(a) If a health maintenance organization desires to
24 amend any contract with its subscribers or any certificate or
25 member handbook, or desires to change any rate charged for the
26 contract or to change any basic health maintenance contract,
27 certificate, grievance procedure, or member handbook form, or
28 application form where written application is required and is
29 to be made a part of the contract, or printed amendment,
30 addendum, rider, or endorsement form or form of renewal
31 certificate, it may do so, upon filing with the department the
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1 proposed change or, amendment, or change in rates. Any
2 proposed change shall be effective immediately, subject to
3 disapproval by the department. Following receipt of notice of
4 such disapproval or withdrawal of approval, no health
5 maintenance organization shall issue or use any form or rate
6 disapproved by the department or as to which the department
7 has withdrawn approval.
8 (b) Any change in the rate is subject to paragraph (d)
9 and requires at least 30 days' advance written notice to the
10 subscriber. In the case of a group member, there may be a
11 contractual agreement with the health maintenance organization
12 to have the employer provide the required notice to the
13 individual members of the group.
14 (c)(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. Use of the rating
10 methodology must be discontinued immediately upon disapproval
11 unless the health maintenance organization seeks
12 administrative relief. If a new rating methodology is filed
13 with the department, the premiums determined by such newly
14 filed rating methodology may apply prospectively only to new
15 or renewal business written on or after the effective date of
16 the responsive filing made by the health maintenance
17 organization.
18 6.7. Excludes coverage for human immunodeficiency
19 virus infection or acquired immune deficiency syndrome or
20 contains limitations in the benefits payable, or in the terms
21 or conditions of such contract, for human immunodeficiency
22 virus infection or acquired immune deficiency syndrome which
23 are different than those which apply to any other sickness or
24 medical condition.
25 (d) Any change in rates charged for the contract must
26 be filed with the department not less than 30 days in advance
27 of the effective date. At the expiration of such 30 days, the
28 rate filing shall be deemed approved unless prior to such time
29 the filing has been affirmatively approved or disapproved by
30 order of the department. The approval of the filing by the
31 department constitutes a waiver of any unexpired portion of
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1 such waiting period. The department may extend by not more
2 than an additional 15 days the period within which it may so
3 affirmatively approve or disapprove any such filing, by giving
4 notice of such extension before expiration of the initial
5 30-day period. At the expiration of any such period as so
6 extended, and in the absence of such prior affirmative
7 approval or disapproval, any such filing shall be deemed
8 approved.
9 (e)(c) It is not the intent of this subsection to
10 restrict unduly the right to modify rates in the exercise of
11 reasonable business judgment.
12 Section 6. This act shall take effect upon becoming a
13 law and shall apply only to contracts entered into after the
14 effective date.
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