HB 4131

1	A bill to be entitled
2	An act relating to health care grievances; amending s.
3	641.511, F.S.; retaining the requirement that any
4	health maintenance organization and any prepaid health
5	clinic must have a grievance procedure available to
6	subscribers to address complaints and grievances;
7	deleting provisions that require, specify, or provide
8	for certain reports, procedures, processes,
9	notifications, reviews, deadlines, or administrative
10	penalties relating to such required grievance
11	procedure; repealing s. 408.7056, F.S., relating to
12	the Subscriber Assistance Program; deleting authority
13	for the Subscriber Assistance Program, adopted and
14	implemented by the Agency for Health Care
15	Administration, to provide assistance to subscribers
16	whose grievances are not resolved by a managed care
17	entity to the satisfaction of the subscriber and
18	deleting procedures, processes, and requirements with
19	respect thereto; amending ss. 220.1845, 376.30781,
20	376.86, 409.818, 409.91211, 641.185, 641.3154, 641.51,
21	641.515, and 641.58, F.S.; conforming cross-
22	references; providing an effective date.
23
24	Be It Enacted by the Legislature of the State of Florida:
25
26	Section 1.  Section 641.511, Florida Statutes, is amended
27	to read:
28	641.511  Subscriber grievance procedure reporting and
29	resolution requirements.-
30	(1)  Every organization must have a grievance procedure
31	available to its subscribers for the purpose of addressing
32	complaints and grievances. Every organization must notify its
33	subscribers that a subscriber must submit a grievance within 1
34	year after the date of occurrence of the action that initiated
35	the grievance, and may submit the grievance for review to the
36	Subscriber Assistance Program panel as provided in s. 408.7056
37	after receiving a final disposition of the grievance through the
38	organization's grievance process. An organization shall maintain
39	records of all grievances and shall report annually to the
40	agency the total number of grievances handled, a categorization
41	of the cases underlying the grievances, and the final
42	disposition of the grievances.
43	(2)  When an organization receives an initial complaint
44	from a subscriber, the organization must respond to the
45	complaint within a reasonable time after its submission. At the
46	time of receipt of the initial complaint, the organization shall
47	inform the subscriber that the subscriber has a right to file a
48	written grievance at any time and that assistance in preparing
49	the written grievance shall be provided by the organization.
50	(3)  Each organization's grievance procedure, as required
51	under subsection (1), must include, at a minimum:
52	(a)  An explanation of how to pursue redress of a
53	grievance.
54	(b)  The names of the appropriate employees or a list of
55	grievance departments that are responsible for implementing the
56	organization's grievance procedure. The list must include the
57	address and the toll-free telephone number of each grievance
58	department, the address of the agency and its toll-free
59	telephone hotline number, and the address of the Subscriber
60	Assistance Program and its toll-free telephone number.
61	(c)  The description of the process through which a
62	subscriber may, at any time, contact the toll-free telephone
63	hotline of the agency to inform it of the unresolved grievance.
64	(d)  A procedure for establishing methods for classifying
65	grievances as urgent and for establishing time limits for an
66	expedited review within which such grievances must be resolved.
67	(e)  A notice that a subscriber may voluntarily pursue
68	binding arbitration in accordance with the terms of the contract
69	if offered by the organization, after completing the
70	organization's grievance procedure and as an alternative to the
71	Subscriber Assistance Program. Such notice shall include an
72	explanation that the subscriber may incur some costs if the
73	subscriber pursues binding arbitration, depending upon the terms
74	of the subscriber's contract.
75	(f)  A process whereby the grievance manager acknowledges
76	the grievance and investigates the grievance in order to notify
77	the subscriber of a final decision in writing.
78	(g)  A procedure for providing individuals who are unable
79	to submit a written grievance with access to the grievance
80	process, which shall include assistance by the organization in
81	preparing the grievance and communicating back to the
82	subscriber.
83	(4)(a)  With respect to a grievance concerning an adverse
84	determination, an organization shall make available to the
85	subscriber a review of the grievance by an internal review
86	panel; such review must be requested within 30 days after the
87	organization's transmittal of the final determination notice of
88	an adverse determination. A majority of the panel shall be
89	persons who previously were not involved in the initial adverse
90	determination. A person who previously was involved in the
91	adverse determination may appear before the panel to present
92	information or answer questions. The panel shall have the
93	authority to bind the organization to the panel's decision.
94	(b)  An organization shall ensure that a majority of the
95	persons reviewing a grievance involving an adverse determination
96	are providers who have appropriate expertise. An organization
97	shall issue a copy of the written decision of the review panel
98	to the subscriber and to the provider, if any, who submits a
99	grievance on behalf of a subscriber. In cases where there has
100	been a denial of coverage of service, the reviewing provider
101	shall not be a provider previously involved with the adverse
102	determination.
103	(c)  An organization shall establish written procedures for
104	a review of an adverse determination. Review procedures shall be
105	available to the subscriber and to a provider acting on behalf
106	of a subscriber.
107	(d)  In any case when the review process does not resolve a
108	difference of opinion between the organization and the
109	subscriber or the provider acting on behalf of the subscriber,
110	the subscriber or the provider acting on behalf of the
111	subscriber may submit a written grievance to the Subscriber
112	Assistance Program.
113	(5)  Except as provided in subsection (6), the organization
114	shall resolve a grievance within 60 days after receipt of the
115	grievance, or within a maximum of 90 days if the grievance
116	involves the collection of information outside the service area.
117	These time limitations are tolled if the organization has
118	notified the subscriber, in writing, that additional information
119	is required for proper review of the grievance and that such
120	time limitations are tolled until such information is provided.
121	After the organization receives the requested information, the
122	time allowed for completion of the grievance process resumes.
123	The Employee Retirement Income Security Act of 1974, as
124	implemented by 29 C.F.R. s. 2560.503-1, is adopted and
125	incorporated by reference as applicable to all organizations
126	that administer small and large group health plans that are
127	subject to 29 C.F.R. s. 2560.503-1. The claims procedures of the
128	regulations of the Employee Retirement Income Security Act of
129	1974, as implemented by 29 C.F.R. s. 2560.503-1, shall be the
130	minimum standards for grievance processes for claims for
131	benefits for small and large group health plans that are subject
132	to 29 C.F.R. s. 2560.503-1.
133	(6)(a)  An organization shall establish written procedures
134	for the expedited review of an urgent grievance. A request for
135	an expedited review may be submitted orally or in writing and
136	shall be subject to the review procedures of this section, if it
137	meets the criteria of this section. Unless it is submitted in
138	writing, for purposes of the grievance reporting requirements in
139	subsection (1), the request shall be considered an appeal of a
140	utilization review decision and not a grievance. Expedited
141	review procedures shall be available to a subscriber and to the
142	provider acting on behalf of a subscriber. For purposes of this
143	subsection, "subscriber" includes the legal representative of a
144	subscriber.
145	(b)  Expedited reviews shall be evaluated by an appropriate
146	clinical peer or peers. The clinical peer or peers shall not
147	have been involved in the initial adverse determination.
148	(c)  In an expedited review, all necessary information,
149	including the organization's decision, shall be transmitted
150	between the organization and the subscriber, or the provider
151	acting on behalf of the subscriber, by telephone, facsimile, or
152	the most expeditious method available.
153	(d)  In an expedited review, an organization shall make a
154	decision and notify the subscriber, or the provider acting on
155	behalf of the subscriber, as expeditiously as the subscriber's
156	medical condition requires, but in no event more than 72 hours
157	after receipt of the request for review. If the expedited review
158	is a concurrent review determination, the service shall be
159	continued without liability to the subscriber until the
160	subscriber has been notified of the determination.
161	(e)  An organization shall provide written confirmation of
162	its decision concerning an expedited review within 2 working
163	days after providing notification of that decision, if the
164	initial notification was not in writing.
165	(f)  An organization shall provide reasonable access, not
166	to exceed 24 hours after receiving a request for an expedited
167	review, to a clinical peer who can perform the expedited review.
168	(g)  In any case when the expedited review process does not
169	resolve a difference of opinion between the organization and the
170	subscriber or the provider acting on behalf of the subscriber,
171	the subscriber or the provider acting on behalf of the
172	subscriber may submit a written grievance to the Subscriber
173	Assistance Program.
174	(h)  An organization shall not provide an expedited
175	retrospective review of an adverse determination.
176	(7)  Each organization shall send to the agency a copy of
177	its quarterly grievance reports submitted to the office pursuant
178	to s. 408.7056(12).
179	(8)  The agency shall investigate all reports of unresolved
180	quality of care grievances received from:
181	(a)  Annual and quarterly grievance reports submitted by
182	the organization to the office.
183	(b)  Review requests of subscribers whose grievances remain
184	unresolved after the subscriber has followed the full grievance
185	procedure of the organization.
186	(9)(a)  The agency shall advise subscribers with grievances
187	to follow their organization's formal grievance process for
188	resolution prior to review by the Subscriber Assistance Program.
189	The subscriber may, however, submit a copy of the grievance to
190	the agency at any time during the process.
191	(b)  Requiring completion of the organization's grievance
192	process before the Subscriber Assistance Program panel's review
193	does not preclude the agency from investigating any complaint or
194	grievance before the organization makes its final determination.
195	(10)  Each organization must notify the subscriber in a
196	final decision letter that the subscriber may request review of
197	the organization's decision concerning the grievance by the
198	Subscriber Assistance Program, as provided in s. 408.7056, if
199	the grievance is not resolved to the satisfaction of the
200	subscriber. The final decision letter must inform the subscriber
201	that the request for review must be made within 365 days after
202	receipt of the final decision letter, must explain how to
203	initiate such a review, and must include the addresses and toll-
204	free telephone numbers of the agency and the Subscriber
205	Assistance Program.
206	(11)  Each organization, as part of its contract with any
207	provider, must require the provider to post a consumer
208	assistance notice prominently displayed in the reception area of
209	the provider and clearly noticeable by all patients. The
210	consumer assistance notice must state the addresses and toll-
211	free telephone numbers of the Agency for Health Care
212	Administration, the Subscriber Assistance Program, and the
213	Department of Financial Services. The consumer assistance notice
214	must also clearly state that the address and toll-free telephone
215	number of the organization's grievance department shall be
216	provided upon request. The agency may adopt rules to implement
217	this section.
218	(12)  The agency may impose administrative sanction, in
219	accordance with s. 641.52, against an organization for
220	noncompliance with this section.
221	Section 2.  Section 408.7056, Florida Statutes, is
222	repealed.
223	Section 3.  Paragraph (k) of subsection (2) of section
224	220.1845, Florida Statutes, is amended to read:
225	220.1845  Contaminated site rehabilitation tax credit.-
226	(2)  AUTHORIZATION FOR TAX CREDIT; LIMITATIONS.-
227	(k)  In order to encourage the construction and operation
228	of a new health care facility as defined in s. 408.032 or s.
229	408.07, or a health care provider as defined in s. 408.07 or
230	former s. 408.7056, on a brownfield site, an applicant for a tax
231	credit may claim an additional 25 percent of the total site
232	rehabilitation costs, not to exceed $500,000, if the applicant
233	meets the requirements of this paragraph. In order to receive
234	this additional tax credit, the applicant must provide
235	documentation indicating that the construction of the health
236	care facility or health care provider by the applicant on the
237	brownfield site has received a certificate of occupancy or a
238	license or certificate has been issued for the operation of the
239	health care facility or health care provider.
240	Section 4.  Paragraph (f) of subsection (3) of section
241	376.30781, Florida Statutes, is amended to read:
242	376.30781  Tax credits for rehabilitation of drycleaning-
243	solvent-contaminated sites and brownfield sites in designated
244	brownfield areas; application process; rulemaking authority;
245	revocation authority.-
246	(3)
247	(f)  In order to encourage the construction and operation
248	of a new health care facility or a health care provider, as
249	defined in s. 408.032, s. 408.07, or former s. 408.7056, on a
250	brownfield site, an applicant for a tax credit may claim an
251	additional 25 percent of the total site rehabilitation costs,
252	not to exceed $500,000, if the applicant meets the requirements
253	of this paragraph. In order to receive this additional tax
254	credit, the applicant must provide documentation indicating that
255	the construction of the health care facility or health care
256	provider by the applicant on the brownfield site has received a
257	certificate of occupancy or a license or certificate has been
258	issued for the operation of the health care facility or health
259	care provider.
260	Section 5.  Subsection (1) of section 376.86, Florida
261	Statutes, is amended to read:
262	376.86  Brownfield Areas Loan Guarantee Program.-
263	(1)  The Brownfield Areas Loan Guarantee Council is created
264	to review and approve or deny, by a majority vote of its
265	membership, the situations and circumstances for participation
266	in partnerships by agreements with local governments, financial
267	institutions, and others associated with the redevelopment of
268	brownfield areas pursuant to the Brownfields Redevelopment Act
269	for a limited state guaranty of up to 5 years of loan guarantees
270	or loan loss reserves issued pursuant to law. The limited state
271	loan guaranty applies only to 50 percent of the primary lenders
272	loans for redevelopment projects in brownfield areas. If the
273	redevelopment project is for affordable housing, as defined in
274	s. 420.0004, in a brownfield area, the limited state loan
275	guaranty applies to 75 percent of the primary lender's loan. If
276	the redevelopment project includes the construction and
277	operation of a new health care facility or a health care
278	provider, as defined in s. 408.032, s. 408.07, or former s.
279	408.7056, on a brownfield site and the applicant has obtained
280	documentation in accordance with s. 376.30781 indicating that
281	the construction of the health care facility or health care
282	provider by the applicant on the brownfield site has received a
283	certificate of occupancy or a license or certificate has been
284	issued for the operation of the health care facility or health
285	care provider, the limited state loan guaranty applies to 75
286	percent of the primary lender's loan. A limited state guaranty
287	of private loans or a loan loss reserve is authorized for
288	lenders licensed to operate in the state upon a determination by
289	the council that such an arrangement would be in the public
290	interest and the likelihood of the success of the loan is great.
291	Section 6.  Paragraph (d) of subsection (3) of section
292	409.818, Florida Statutes, is amended to read:
293	409.818  Administration.-In order to implement ss. 409.810-
294	409.821, the following agencies shall have the following duties:
295	(3)  The Agency for Health Care Administration, under the
296	authority granted in s. 409.914(1), shall:
297	(d)  Establish a mechanism for investigating and resolving
298	complaints and grievances from program applicants, enrollees,
299	and health benefits coverage providers, and maintain a record of
300	complaints and confirmed problems. In the case of a child who is
301	enrolled in a health maintenance organization, the agency must
302	use the provisions of s. 641.511 to address grievance reporting
303	and resolution requirements.
304
305	The agency is designated the lead state agency for Title XXI of
306	the Social Security Act for purposes of receipt of federal
307	funds, for reporting purposes, and for ensuring compliance with
308	federal and state regulations and rules.
309	Section 7.  Paragraph (q) of subsection (3) of section
310	409.91211, Florida Statutes, is amended to read:
311	409.91211  Medicaid managed care pilot program.-
312	(3)  The agency shall have the following powers, duties,
313	and responsibilities with respect to the pilot program:
314	(q)  To implement a grievance resolution process for
315	Medicaid recipients enrolled in a capitated managed care network
316	under the pilot program modeled after the subscriber assistance
317	panel, as created in former s. 408.7056. This process shall
318	include a mechanism for an expedited review of no greater than
319	24 hours after notification of a grievance if the life of a
320	Medicaid recipient is in imminent and emergent jeopardy.
321	Section 8.  Paragraph (j) of subsection (1) of section
322	641.185, Florida Statutes, is amended to read:
323	641.185  Health maintenance organization subscriber
324	protections.-
325	(1)  With respect to the provisions of this part and part
326	III, the principles expressed in the following statements shall
327	serve as standards to be followed by the commission, the office,
328	the department, and the Agency for Health Care Administration in
329	exercising their powers and duties, in exercising administrative
330	discretion, in administrative interpretations of the law, in
331	enforcing its provisions, and in adopting rules:
332	(j)  A health maintenance organization should receive
333	timely and, if necessary, urgent review by an independent state
334	external review organization for unresolved grievances and
335	appeals pursuant to s. 408.7056.
336	Section 9.  Paragraph (c) of subsection (4) of section
337	641.3154, Florida Statutes, is amended to read:
338	641.3154  Organization liability; provider billing
339	prohibited.-
340	(4)  A provider or any representative of a provider,
341	regardless of whether the provider is under contract with the
342	health maintenance organization, may not collect or attempt to
343	collect money from, maintain any action at law against, or
344	report to a credit agency a subscriber of an organization for
345	payment of services for which the organization is liable, if the
346	provider in good faith knows or should know that the
347	organization is liable. This prohibition applies during the
348	pendency of any claim for payment made by the provider to the
349	organization for payment of the services and any legal
350	proceedings or dispute resolution process to determine whether
351	the organization is liable for the services if the provider is
352	informed that such proceedings are taking place. It is presumed
353	that a provider does not know and should not know that an
354	organization is liable unless:
355	(c)  The office or agency makes a final determination that
356	the organization is required to pay for such services subsequent
357	to a recommendation made by the Subscriber Assistance Panel
358	pursuant to s. 408.7056; or
359	Section 10.  Paragraph (c) of subsection (5) of section
360	641.51, Florida Statutes, is amended to read:
361	641.51  Quality assurance program; second medical opinion
362	requirement.-
363	(5)
364	(c)  For second opinions provided by contract physicians
365	the organization is prohibited from charging a fee to the
366	subscriber in an amount in excess of the subscriber fees
367	established by contract for referral contract physicians. The
368	organization shall pay the amount of all charges, which are
369	usual, reasonable, and customary in the community, for second
370	opinion services performed by a physician not under contract
371	with the organization, but may require the subscriber to be
372	responsible for up to 40 percent of such amount. The
373	organization may require that any tests deemed necessary by a
374	noncontract physician shall be conducted by the organization.
375	The organization may deny reimbursement rights granted under
376	this section in the event the subscriber seeks in excess of
377	three such referrals per year if such subsequent referral costs
378	are deemed by the organization to be evidence that the
379	subscriber has unreasonably overutilized the second opinion
380	privilege. A subscriber thus denied reimbursement under this
381	section shall have recourse to grievance procedures as specified
382	in ss. 408.7056, 641.495, and 641.511. The organization's
383	physician's professional judgment concerning the treatment of a
384	subscriber derived after review of a second opinion shall be
385	controlling as to the treatment obligations of the health
386	maintenance organization. Treatment not authorized by the health
387	maintenance organization shall be at the subscriber's expense.
388	Section 11.  Subsection (1) of section 641.515, Florida
389	Statutes, is amended to read:
390	641.515  Investigation by the agency.-
391	(1)  The agency shall investigate further any quality of
392	care issue contained in recommendations and reports submitted
393	pursuant to ss. 408.7056 and 641.511. The agency shall also
394	investigate further any information that indicates that the
395	organization does not meet accreditation standards or the
396	standards of the review organization performing the external
397	quality assurance assessment pursuant to reports submitted under
398	s. 641.512. Every organization shall submit its books and
399	records and take other appropriate action as may be necessary to
400	facilitate an examination. The agency shall have access to the
401	organization's medical records of individuals and records of
402	employed and contracted physicians, with the consent of the
403	subscriber or by court order, as necessary to carry out the
404	provisions of this part.
405	Section 12.  Subsection (4) of section 641.58, Florida
406	Statutes, is amended to read:
407	641.58  Regulatory assessment; levy and amount; use of
408	funds; tax returns; penalty for failure to pay.-
409	(4)  The moneys received and deposited into the Health Care
410	Trust Fund shall be used to defray the expenses of the agency in
411	the discharge of its administrative and regulatory powers and
412	duties under this part, including conducting an annual survey of
413	the satisfaction of members of health maintenance organizations;
414	contracting with physician consultants for the Subscriber
415	Assistance Panel; maintaining offices and necessary supplies,
416	essential equipment, and other materials, salaries and expenses
417	of required personnel; and discharging the administrative and
418	regulatory powers and duties imposed under this part.
419	Section 13.  This act shall take effect July 1, 2012.

CODING: Words stricken are deletions; words underlined are additions.