These rules are being amended to update and delete out of date references to government agencies and programs, as well as to incorporate a form for filing a pro forma projection of an anticipated program.

 

DEPARTMENT OF FINANCIAL SERVICES

OIR – Insurance Regulation

RULE NO.:RULE TITLE:

69O-191.074Records Retention

69O-191.076Corrective Action Plans

69O-191.078Subscriber Grievance Procedure

PURPOSE AND EFFECT: These rules are being amended to update and delete out of date references to government agencies and programs, as well as to incorporate a form for filing a pro forma projection of an anticipated program.

SUMMARY: Rule 69O-191.074, FAC, is amended to update and delete out of date references to government agencies and update the manner to retain records. Rule 69O-191.076, F.A.C., is amended to incorporate a form for filing a pro forma projection of an anticipated program. Rule 69O-191.078, F.A.C., is amended to delete references to the Statewide Subscriber Assistance Panel due to the repeal of section 408.7056, FS.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: Agency personnel familiar with the subject matter of the rule amendment have performed an economic analysis of the rule amendment that shows that the rule amendment is unlikely to have an adverse impact on the State economy in excess of the criteria established in paragraph 120.541(2)(a), Florida Statutes.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 641.36 FS.

LAW IMPLEMENTED: 641.22(9), 641.23(3), 641.27, 641.31(5) FS.

IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE SCHEDULED AND ANNOUNCED IN THE FAR.

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Michael Lawrence, Jr., Assistant General Counsel, [e-mail], [phone].

 

THE FULL TEXT OF THE PROPOSED RULE IS:

69O-191.074 Records Retention.

(1) No change.

(2) These records, either in the form of paper or electronic hard documents, microfiche or computer diskettes, shall be maintained for no less than three (3) years, unless otherwise required to be maintained for a longer period of time by the Department of Health, Office of Health and Rehabilitative Services, Internal Revenue Service, Centers for Medicare & Medicaid Services (CMS) Health Care Financing Administration (HCFA) or as otherwise specified by the Office.

Rulemaking Authority 641.36 FS. Law Implemented 641.27 FS. History–New 5-28-92, Formerly 4-191.074, Amended ____________.

 

69O-191.076 Corrective Action Plans.

(1) through (3) No change.

(4) The Office shall approve a corrective action plan complying with subsection 641.23(3), F.S., if the plan meets all of the following criteria in that the plan includes:

(a) through (d) No change.

(e) A pro forma projecting the anticipated program. Pro forma projections must be submitted electronically on Form OIR-A2-2212, Pro Forma Projections, effective 09/18, hereby incorporated by reference and available at www.flrules.org/XXXXX, via the Office’s Regulatory Electronic Filing System (REFS) at https://www.floir.com/iportal.

Rulemaking Authority 641.36 FS. Law Implemented 641.23(3) FS. History–New 5-28-92, Amended 8-15-94, Formerly 4-191.076, Amended ____________.

 

69O-191.078 Subscriber Grievance Procedure.

Every HMO shall have a subscriber grievance procedure. A detailed description of the HMO’s subscriber grievance procedure shall be included in all group and individual contracts as well as in any certificate or member handbook provided to subscribers. This procedure shall be administered at no cost to the subscriber. An HMO subscriber grievance procedure must include the following:

(1) through (5) No change.

(6) The HMO shall process the formal written subscriber grievance in a reasonable length of time not to exceed 60 days, unless the subscriber and HMO mutually agree to extend the time frame set forth by this rule. However, any mutually agreed time frame modification will not preclude the subscriber from appealing to the Statewide Subscriber Assistance Panel within the periods as established by this rule. If the complaint involves the collection of information outside the service area, the HMO will have 30 additional days to process the subscriber complaint through all phases of the grievance procedure. The time limitations prescribed in this paragraph requiring completion of the grievance process within 60 days shall be tolled after the HMO has notified the subscriber, in writing, that additional information is required in order to properly complete review of the complaint. Upon receipt by the HMO of the additional information requested, the time for completion of the grievance process set forth herein shall resume. A grievance which is arbitrated pursuant to chapter 682, F.S., is permitted an additional time limitation not to exceed 210 days from the date the HMO receives a written request for arbitration from the subscriber. Arbitration provisions, if any, shall not preclude the subscriber from filing with the Statewide Subscriber Assistance Panel. At the point of the arbitration process the subscriber shall be deemed to have complied with the full formal grievance procedure for the purpose of appealing to the Statewide Subscriber Assistance Panel. Each HMO shall notify the Office of all arbitrated grievances on the quarterly grievance report required by subsection 69O-191.078 (11) (12) , F.A.C.;

(7) The subscriber grievance procedure shall state that the subscriber always has the right to appeal to the Office or the Department of Health and Rehabilitative Services. The HMO shall provide to the subscriber written notice of the right to appeal upon completion of the full grievance procedure and supply the Office with a copy of the final decision letter;

(7)(8) The HMO shall have physician involvement in reviewing medically related grievances. Physician involvement in the grievance process should not be limited to the subscriber’s primary care physician, but may include at least one other physician;

(8)(9) The HMO shall offer to meet with the subscriber during the formal grievance process. The location of the meeting shall be at the administrative offices of the HMO within the service area or at a location within the service area which is convenient to the subscriber;

(9)(10) The HMO may not establish time limits of less than one year from the date of occurrence for the subscriber to file a formal grievance;

(10)(11) Each HMO shall maintain an accurate record of each formal grievance. Each record shall include the following:

(a) through (d) No change;

(11)(12) Each HMO shall submit a quarterly report to the Office pursuant to section 641.311(1)(b), F.S., listing the number and nature of all formal subscriber grievances which have not been resolved to the satisfaction of the subscriber, after the subscriber has utilized the full grievance procedure of the HMO. This report shall be formatted as outlined in the quarterly report of subscriber grievances form incorporated herein by reference and shall be filed with the Office no later than 45 days after the end of each calendar quarter. Quarterly report of subscriber grievance forms can be obtained from the Office of Insurance Regulation’s website: http://www.floir.com/iportal.

Rulemaking Authority 641.36 FS. Law Implemented 641.22(9), 641.31(5) FS. History–New 7-8-87, Amended 2-22-88, 10-25-89, Formerly 4-31.078, Amended 5-28-92, Formerly 4-191.078, Amended ____________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Michael Lawrence, Jr., Assistant General Counsel

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Financial Services Commission

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: March 12, 2019

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: October 30, 2018