Senate Bill sb0534

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    Florida Senate - 2005                                   SB 534

    By Senator Campbell





    32-568-05

  1                      A bill to be entitled

  2         An act relating to the provision of health care

  3         services; specifying conditions under which a

  4         health care provider must be permitted to

  5         participate as a service provider under a

  6         health plan offered by a managed care

  7         organization; defining the term "managed care

  8         organization"; requiring that a health care

  9         provider be reimbursed for providing services

10         under specified conditions; providing for civil

11         penalties; amending s. 627.419, F.S.; providing

12         for construction of policies; providing for

13         application; providing an effective date.

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

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17         Section 1.  Health care provider as an authorized

18  service provider; penalties.--

19         (1)  A managed care organization must allow any health

20  care provider to participate as a service provider under a

21  health plan offered by the managed care organization if the

22  health care provider agrees to:

23         (a)  Accept the reimbursement rates negotiated by the

24  managed care organization with other health care providers

25  that provide the same service under the health plan; and

26         (b)  Comply with all guidelines relating to quality of

27  care and utilization criteria which must be met by other

28  employee or nonemployee providers.

29         (2)  A managed care organization must reimburse any

30  health care provider rendering services under the health plan

31  if the health care provider accepts the managed care

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    Florida Senate - 2005                                   SB 534
    32-568-05




 1  organization's reimbursement rates and has complied with the

 2  guidelines for quality of care and utilization criteria.

 3         (3)  As used in this section, the term "managed care

 4  organization" means a health maintenance organization or

 5  prepaid health clinic certified under chapter 641, Florida

 6  Statutes, a health insurer that issues an exclusive provider

 7  organization policy under section 627.6472 or section

 8  627.662(9), Florida Statutes, or a health insurer that issues

 9  a preferred provider organization policy under section

10  627.6471 or section 627.662(8), Florida Statutes.

11         (4)  A managed care organization that violates

12  subsection (1) or subsection (2) is subject to a civil fine in

13  the amount of:

14         (a)  Up to $25,000 for each violation; or

15         (b)  If the Secretary of Health Care Administration

16  determines that the entity has engaged in a pattern of

17  violations of subsection (1) or subsection (2), up to $100,000

18  for each violation.

19         Section 2.  Subsection (10) is added to section

20  627.419, Florida Statutes, to read:

21         627.419  Construction of policies.--

22         (10)(a)  Any health insurance policy, health care

23  services plan, or other contract that provides for payment for

24  medical expense benefits or procedures must allow any health

25  care provider to participate as a service provider under a

26  health plan offered by the health insurance policy, health

27  care services plan, or other contract that provides for

28  payment for medical expense benefits or procedures if the

29  health care provider agrees to:

30         1.  Accept the reimbursement rates negotiated by the

31  health insurance policy, health care services plan, or other

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    Florida Senate - 2005                                   SB 534
    32-568-05




 1  contract that provides for payment for medical expense

 2  benefits or procedures with other health care providers that

 3  provide the same service under the health plan; and

 4         2.  Comply with all guidelines relating to quality of

 5  care and utilization criteria which must be met by other

 6  providers with whom the health insurance policy, health care

 7  services plan, or other contract that provides for payment for

 8  medical expense benefits or procedures has contractual

 9  arrangements for those services.

10         (b)  A provider of a health insurance policy, health

11  care services plan, or other contract to pay for medical

12  expense benefits must reimburse any health care provider

13  rendering services under the health plan if the health care

14  provider accepts the provider's reimbursement rates and the

15  health care provider has complied with the guidelines for

16  quality of care and utilization criteria.

17         (c)  The provider of any health insurance policy,

18  health care services plan, or other contract that violates

19  paragraph (a) or paragraph (b) is subject to a civil fine in

20  the amount of:

21         1.  Up to $25,000 for each violation; or

22         2.  If the Office of Insurance Regulation determines

23  that the provider has engaged in a pattern of violations of

24  paragraph (a) or paragraph (b), up to $100,000 for each

25  violation.

26         Section 3.  Sections 1 and 2 of this act do not apply

27  to any health insurance policy that is in force before October

28  1, 2005, but do apply to such policies at the next renewal

29  period immediately following October 1, 2005.

30         Section 4.  This act shall take effect October 1, 2005.

31  

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    Florida Senate - 2005                                   SB 534
    32-568-05




 1            *****************************************

 2                          SENATE SUMMARY

 3    Requires that a health care provider be permitted by a
      managed care organization to participate as a service
 4    provider if the provider agrees to accept the
      reimbursement rates for the health plan and comply with
 5    certain guidelines. Requires a provider to reimburse a
      health care provider who complies with specified
 6    conditions. Provides civil penalties for failure to
      comply with the act.
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