59A-12.006. Quality of Care

Each HMO or PHC shall:

(1) Make available to each member an appropriate health assessment in accordance with preventive health guidelines and professional standards in the community.

(2) Provide for or arrange the following services as a minimum:

(a) Coordination of all necessary care contracted for with the subscriber;

(b) Acute episodic care, with appropriate ancillary services necessary for proper evaluation and treatment, for example:

1. Laboratory studies;

2. Diagnostic radiology;

3. Treatment plan; and,

4. Specialty consultation referrals.

(c) Chronic disease screening, and follow-up treatment for prevention of complications, for example:

1. Periodic update of history and physical examination;

2. Hypertension follow-up; and,

3. Diabetes follow-up.

(d) Health risk appraisal and prevention measures, for example:

1. Dietary counseling;

2. Smoking cessation education;

3. Stress reduction counseling; and,

4. Substance abuse education.

(e) Family planning services.

(3) Ensure that the health care services it provides or arranges for are accessible to the subscriber with reasonable promptness. Such services shall include, at a minimum:

(a) Establishment of an appointment system;

(b) A method to distinguish among emergency, urgent, and routine cases.

1. Emergencies will be seen immediately;

2. Urgent cases will be seen within 24 hours;

3. Routine symptomatic cases will be seen within two weeks; and,

4. Routine non-symptomatic cases will be seen as soon as possible.

(c) A provision that patients with appointments should have a professional evaluation within one hour of scheduled appointment time. If a delay is unavoidable, patient shall be informed and provided an alternative;

(d) Average travel time from the HMO geographic services area boundary to the nearest primary care delivery site and to the nearest general hospital under arrangement with the HMO to provide health care services of no longer than 30 minutes under normal circumstances. Average travel time from the HMO geographic services area boundary to the nearest provider of specialty physician services, ancillary services, specialty inpatient hospital services and all other health services of no longer than 60 minutes under normal circumstances. AHCA shall waive this requirement if the HMO provides sufficient justification as to why the average travel time requirement is not feasible or necessary in a particular geographic service area;

(e) Provision of accessible hours of operation and after hours emergency services;

(f) Maintenance of staffing patterns within generally accepted HMO or PHC industry norms for meeting projected subscriber needs and for expeditiously satisfying the requirements of the benefit package as offered by the HMO or PHC; and,

(g) Maintenance of a professional staff or arrangements with providers, duly licensed as required to practice in Florida.

(4) Make grievance files available during normal business hours for inspection by the agency. The files shall contain a written summary of the actions taken by the HMO or PHC including actions taken through the review by the quality improvement process, with the exception of protected peer review information.

(5) Coordinate the overall health care of each member, and, when possible, provide this coordination through a single health care professional, who will maintain a unified health record on the member.

(6) Assure that services provided members through referral sources are reported to the HMO or PHC or a designated health care professional in order that all appropriate medical information is filed in the member’s medical record in a timely manner.

(7) Provide a system whereby a member may request and obtain a second medical opinion if the member feels that he is not responding to the current treatment plan in a satisfactory manner after a reasonable lapse of time for the condition being treated. The primary care physician must be so informed by the member, and a request for a consultation initiated. Such a consultation shall be provided upon authorization by the Medical Director.

(8) Inform subscribers of their rights and responsibilities set forth in Section 381.026, F.S., as well as the rights and responsibilities of the managed care organization incorporated in the member’s handbook.

Rulemaking Authority 641.56 FS. Law Implemented 641.49, 641.495(3), 641.515, 641.54 FS. History–New 1-28-88, Amended 3-11-92, Formerly 10D-100.006, Amended 4-10-03.