Florida Statutes 641.31076 – Shared savings incentive program
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(2) As used in this section, the term:
(a) “Health care provider” means a hospital or facility licensed under chapter 395; an entity licensed under chapter 400; a health care practitioner as defined in s. 456.001; a blood bank, plasma center, industrial clinic, or renal dialysis facility; or a professional association, partnership, corporation, joint venture, or other association for professional activity by health care providers. The term includes entities and professionals outside this state with an active, unencumbered license for an equivalent facility or practitioner type issued by another state, the District of Columbia, or a possession or territory of the United States.
Terms Used In Florida Statutes 641.31076
- Agency: means the Agency for Health Care Administration. See Florida Statutes 641.19
- Baseline: Projection of the receipts, outlays, and other budget amounts that would ensue in the future without any change in existing policy. Baseline projections are used to gauge the extent to which proposed legislation, if enacted into law, would alter current spending and revenue levels.
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
- Entity: means any legal entity with continuing existence, including, but not limited to, a corporation, association, trust, or partnership. See Florida Statutes 641.19
- Health maintenance organization: means any organization authorized under this part which:(a) Provides, through arrangements with other persons, emergency care, inpatient hospital services, physician care including care provided by physicians licensed under chapters 458, 459, 460, and 461, ambulatory diagnostic treatment, and preventive health care services. See Florida Statutes 641.19
- Partnership: A voluntary contract between two or more persons to pool some or all of their assets into a business, with the agreement that there will be a proportional sharing of profits and losses.
- Subscriber: means an entity or individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract. See Florida Statutes 641.19
(b) “Health maintenance organization” means an authorized health maintenance organization issuing major medical or other comprehensive coverage through an individual or a group contract. The term does not include the state group health insurance program provided under s. 110.123.(c) “Shared savings incentive” means a voluntary and optional financial incentive that a health maintenance organization may provide to a subscriber for choosing certain shoppable health care services under a shared savings incentive program and may include, but is not limited to, the incentives described in s. 641.3903(15).(d) “Shared savings incentive program” means a voluntary and optional incentive program established by a health maintenance organization pursuant to this section.(e) “Shoppable health care service” means a lower-cost, high-quality nonemergency health care service for which a shared savings incentive is available for subscribers under a health maintenance organization’s shared savings incentive program. Shoppable health care services may be provided within or outside this state and include, but are not limited to:1. Clinical laboratory services.2. Infusion therapy.3. Inpatient and outpatient surgical procedures.4. Obstetrical and gynecological services.5. Inpatient and outpatient nonsurgical diagnostic tests and procedures.6. Physical and occupational therapy services.7. Radiology and imaging services.8. Prescription drugs.9. Services provided through telehealth.10. Any additional services published by the Agency for Health Care Administration that have the most significant price variation pursuant to s. 408.05(3)(m).
(3) A health maintenance organization may offer a shared savings incentive program to provide incentives to a subscriber when the subscriber obtains a shoppable health care service from the health maintenance organization’s shared savings list. A subscriber may not be required to participate in a shared savings incentive program. A health maintenance organization that offers a shared savings incentive program must:
(a) Establish the program as a component part of the contract of coverage provided by the health maintenance organization and notify the subscribers and the office at least 30 days before program termination.
(b) File a description of the program on a form prescribed by commission rule. The office must review the filing and determine whether the shared savings incentive program complies with this section.
(c) Notify a subscriber annually and at the time of renewal, and an applicant for coverage at the time of enrollment, of the availability of the shared savings incentive program and the procedure to participate in the program.
(d) Publish on a web page easily accessible to subscribers and to applicants for coverage a list of shoppable health care services and health care providers and the shared savings incentive amount applicable for each service. A shared savings incentive may not be less than 25 percent of the savings generated by the subscriber’s participation in any shared savings incentive offered by the health maintenance organization. The baseline for the savings calculation is the average in-network amount paid for that service in the most recent 12-month period or some other methodology established by the health maintenance organization and approved by the office.
(e) At least quarterly, credit or deposit the shared savings incentive amount to the subscriber’s account as a return or reduction in premium, or credit the shared savings incentive amount to the subscriber’s flexible spending account, health savings account, or health reimbursement account, or reward the subscriber directly with cash or a cash equivalent.
(f) Submit an annual report to the office within 90 business days after the close of each plan year. At a minimum, the report must include the following information:
1. The number of subscribers who participated in the program during the plan year and the number of instances of participation.
2. The total cost of services provided as a part of the program.
3. The total value of the shared savings incentive payments made to subscribers participating in the program and the values distributed as premium reductions, credits to flexible spending accounts, credits to health savings accounts, or credits to health reimbursement accounts.
4. An inventory of the shoppable health care services offered by the health maintenance organization.
(4) A shared savings incentive offered by a health maintenance organization in accordance with this section:
(a) Is not an administrative expense for rate development or rate filing purposes and shall be counted as a medical expense for such purposes.
(b) Does not constitute an unfair method of competition or an unfair or deceptive act or practice under s. 641.3903 and is presumed to be appropriate unless credible data clearly demonstrates otherwise.
(5) The commission may adopt rules necessary to implement and enforce this section.