Florida Senate - 2015 SB 7026
By the Committee on Governmental Oversight and Accountability
585-01659-15 20157026__
1 A bill to be entitled
2 An act relating to the state group insurance program;
3 creating s. 110.12303, F.S.; defining terms; requiring
4 the Department of Management Services to ensure that a
5 health maintenance organization under contract with
6 the department provides reasonable access to certain
7 services to persons younger than 21 years of age;
8 specifying provisions that must be included in a
9 contract between the department and a health
10 maintenance organization; providing an effective date.
11
12 Be It Enacted by the Legislature of the State of Florida:
13
14 Section 1. Section 110.12303, Florida Statutes, is created
15 to read:
16 110.12303 Reasonable access to health services for persons
17 under age 21.—
18 (1) As used in this section, the term:
19 (a) “Health maintenance organization” or “HMO” means an
20 entity certified under part I of chapter 641 which is under
21 contract with the department to participate in the state group
22 insurance program or an entity which is under contract with the
23 department to participate in the state group insurance program
24 to administer health services offered in a geographic region of
25 the state.
26 (b) “Health services” means medical services provided to a
27 member which meet early and periodic screening, diagnostic, and
28 treatment requirements under the state Medicaid Plan and are
29 covered under the state group insurance program.
30 (c) “Member” means a health plan member, as defined in s.
31 110.123, who is younger than 21 years of age.
32 (d) “Reasonable access” means health services are initiated
33 within timeframes established as guidelines for national
34 standards of medical care but no later than 3 months after the
35 initial date of the request for health services.
36 (e) “State group insurance program” has the same meaning as
37 provided in s. 110.123.
38 (f) “Subscriber” means the enrollee, as defined in s.
39 110.123, under which a member is eligible to participate in the
40 state group insurance program.
41 (2) In addition to the requirements in s. 110.123, the
42 department must ensure that a health maintenance organization
43 provides a member with reasonable access to health services.
44 (3) A contract between the department and an HMO must:
45 (a) Include standards, relating to health services, for
46 network adequacy, timely referral, and reasonable access.
47 (b) Specify the financial consequences that the department
48 must apply if the HMO fails to meet the standards established
49 for network adequacy, timely referral, and reasonable access.
50 (c) Require the HMO to allow, if reasonable access is
51 denied, a member or subscriber to:
52 1. Submit a complaint or grievance pursuant to the
53 procedures established in s. 641.511; and
54 2. Request an external review, including an expedited
55 external review, pursuant to the procedure provided in s. 1001
56 of the federal Patient Protection and Affordable Care Act, Pub.
57 L. No. 111-148.
58 (d) Require the HMO to report to the department at least
59 quarterly. The report must include the following:
60 1. The number of complaints or grievances initiated in the
61 past quarter regarding reasonable access to health services.
62 2. The types of health services that were the subjects of
63 the complaints and grievances.
64 3. The resolution of such complaints and grievances.
65 (e) Specify a fine to be assessed against an HMO, in
66 addition to any fine imposed under paragraph (b), in each
67 instance that the HMO has failed to provide reasonable access to
68 health services.
69 Section 2. This act shall take effect July 1, 2015.