Florida Senate - 2015                   (PROPOSED BILL) SPB 7026
       
       
        
       FOR CONSIDERATION By the Committee on Governmental Oversight and
       Accountability
       
       
       
       
       585-01514A-15                                         20157026pb
    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.
   23         (b) “Health services” means medical services provided to a
   24  member which meet early and periodic screening, diagnostic, and
   25  treatment requirements under the state Medicaid Plan and are
   26  covered under the state group health insurance plan, as defined
   27  in s. 110.123.
   28         (c) “Member” means a health plan member, as defined in s.
   29  110.123, who is younger than 21 years of age.
   30         (d) “Reasonable access” means health services are initiated
   31  within timeframes established as guidelines for national
   32  standards of medical care but no later than 3 months after the
   33  initial date of the request for health services.
   34         (e) “State group insurance program” has the same meaning as
   35  provided in s. 110.123.
   36         (f) “Subscriber” means the enrollee, as defined in s.
   37  110.123, under which a member is eligible to participate in the
   38  state group insurance program.
   39         (2) In addition to the requirements in s. 110.123, the
   40  department must ensure that a health maintenance organization
   41  provides a member with reasonable access to health services.
   42         (3) A contract between the department and an HMO must:
   43         (a) Include standards, relating to health services, for
   44  network adequacy, timely referral, and reasonable access.
   45         (b) Specify the financial consequences that the department
   46  must apply if the HMO fails to meet the standards established
   47  for network adequacy, timely referral, and reasonable access.
   48         (c) Require the HMO to allow, if reasonable access is
   49  denied, a member or subscriber to:
   50         1. Submit a complaint or grievance pursuant to the
   51  procedures established in s. 641.511; and
   52         2. Request an external review, including an expedited
   53  external review, pursuant to the procedure provided in s. 1001
   54  of the federal Patient Protection and Affordable Care Act, Pub.
   55  L. No. 111-148.
   56         (d) Require the HMO to report to the department at least
   57  quarterly. The report must include the following:
   58         1. The number of complaints or grievances initiated in the
   59  past quarter regarding reasonable access to health services.
   60         2. The types of health services that were the subjects of
   61  the complaints and grievances.
   62         3. The resolution of such complaints and grievances.
   63         (e) Specify a fine to be assessed against an HMO, in
   64  addition to any fine imposed under paragraph (b), in each
   65  instance that the HMO has failed to provide reasonable access to
   66  health services.
   67         Section 2. This act shall take effect July 1, 2015.