The Florida Senate

Faced with the continuation of mounting costs of health care, coupled with the state’s interest in high-quality care, the Legislature has determined that there is a need to explore alternative methods for the delivery of health care services, with a view toward achieving greater efficiency and economy in providing these services.

Health maintenance organizations, consisting of prepaid health care plans, hereinafter referred to as “plans,” are developing rapidly in many communities. Through these organizations, structured in various forms, health care services are provided directly to a group of people who make regular premium payments.

These plans, when properly operated, emphasize effective cost and quality controls.

It shall be the policy of this state to:

Although it is the intent of this act to provide an opportunity for the development of health maintenance organizations, there is no intent to impair the present system for the delivery of health services.

The Legislature has determined that the operation of a health maintenance organization without a subsisting certificate of authority or the renewal, issuance, or delivery of a health maintenance contract without a subsisting certificate of authority constitutes a danger to the citizens of this state and exposes any subscriber to immediate and irreparable injury, loss, or damage.

Report assets acquired prior to June 30, 2001, in accordance with s. 641.35, Florida Statutes (2000), through December 31, 2005. Assets acquired on or after June 30, 2001, shall be accounted for in accordance with the National Association of Insurance Commissioners Accounting Practices and Procedures Manual effective January 1, 2001. A health maintenance organization electing to report assets pursuant to this subsection shall maintain complete and detailed records reflecting such accounting treatment; or

Report all assets in accordance with the NAIC Accounting Practices and Procedures Manual effective January 1, 2001.

With respect to the provisions of this part and part III, the principles expressed in the following statements shall serve as standards to be followed by the commission, the office, the department, and the Agency for Health Care Administration in exercising their powers and duties, in exercising administrative discretion, in administrative interpretations of the law, in enforcing its provisions, and in adopting rules:

This section shall not be construed as creating a civil cause of action by any subscriber or provider against any health maintenance organization.

“Affiliate” means any entity that exercises control over or is controlled by the health maintenance organization, directly or indirectly, through:

“Agency” means the Agency for Health Care Administration.

“Capitation” means the fixed amount paid by an HMO to a health care provider under contract with the health maintenance organization in exchange for the rendering of covered medical services.

“Comprehensive health care services” means services, medical equipment, and supplies furnished by a provider, which may include, but which are not limited to, medical, surgical, and dental care; psychological, optometric, optic, chiropractic, podiatric, nursing, physical therapy, and pharmaceutical services; health education, preventive medical, rehabilitative, and home health services; inpatient and outpatient hospital services; extended care; nursing home care; convalescent institutional care; technical and professional clinical pathology laboratory services; laboratory and ambulance services; appliances, drugs, medicines, and supplies; and any other care, service, or treatment of disease, or correction of defects for human beings.

“Copayment” means a specific dollar amount, except as otherwise provided for by statute, that the subscriber must pay upon receipt of covered health care services. Copayments may not be established in an amount that will prevent a person from receiving a covered service or benefit as specified in the subscriber contract approved by the office.

“Emergency medical condition” means:

“Emergency services and care” means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital.

“Entity” means any legal entity with continuing existence, including, but not limited to, a corporation, association, trust, or partnership.

“Geographic area” means the county or counties, or any portion of a county or counties, within which the health maintenance organization provides or arranges for comprehensive health care services to be available to its subscribers.

“Guaranteeing organization” is an organization that is domiciled in the United States; that has authorized service of process against it; and that has appointed the Chief Financial Officer as its agent for service of process issuing upon any cause of action arising in this state, based upon any guarantee entered into under this part.

“Health maintenance contract” means any contract entered into by a health maintenance organization with a subscriber or group of subscribers to provide coverage for comprehensive health care services in exchange for a prepaid per capita or prepaid aggregate fixed sum.

“Health maintenance organization” means any organization authorized under this part which:

Except in cases in which the health care provider is an employee of the health maintenance organization, the fact that the health maintenance organization arranges for the provision of health care services under this chapter does not create an actual agency, apparent agency, or employer-employee relationship between the health care provider and the health maintenance organization for purposes of vicarious liability for the medical negligence of the health care provider.

“Insolvent” or “insolvency” means that all the statutory assets of the health maintenance organization, if made immediately available, would not be sufficient to discharge all of its liabilities or that the health maintenance organization is unable to pay its debts as they become due in the usual course of business. In the event that all the assets of the health maintenance organization, if made immediately available, would not be sufficient to discharge all of its liabilities, but the organization has a written guarantee of the type and subject to the same provisions as outlined in s. 641.225, the organization shall not be considered insolvent unless it is unable to pay its debts as they become due in the usual course of business.

“Provider” means any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state.

“Reporting period” means the annual calendar year accounting period or any part thereof.

“Schedule of reimbursements” means a schedule of fees to be paid by a health maintenance organization to a physician provider for reimbursement for specific services pursuant to the terms of a contract. The physician provider’s net reimbursement may vary after consideration of other factors, including, but not limited to, bundling codes together into another code and member cost-sharing responsibility, as long as these factors are disclosed and included in the terms of the contract between the health maintenance organization and provider. The reimbursement schedule may be stated as:

Specific nonrelative-value services shall be stated separately from relative-value services, and reimbursement for unclassified services shall be on a reasonable basis.

“Statutory accounting principles” means accounting principles as defined in the National Association of Insurance Commissioners Accounting Practices and Procedures Manual as of 2002.

“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.

“Surplus” means total statutory assets in excess of total liabilities, except that assets pledged to secure debts not reflected on the books of the health maintenance organization shall not be included in surplus. Surplus includes capital stock, capital in excess of par, other contributed capital, retained earnings, and surplus notes.

“Uncovered expenditures” means the cost of health care services that are covered by a health maintenance organization, for which a subscriber would also be liable in the event of the insolvency of the organization.

“Health care risk contract” means a contract under which an individual or entity receives consideration or other compensation in an amount greater than 1 percent of the health maintenance organization’s annual gross written premium in exchange for providing to the health maintenance organization a provider network or other services, which may include administrative services. The 1-percent threshold shall be calculated on a contract-by-contract basis for each such individual or entity and not in the aggregate for all health care risk contracts.

Enter into arrangements whereby the expected cost of health care services provided directly or through arrangements with other persons by the health maintenance organization is self-funded by the person contracting with the health maintenance organization, but the health maintenance organization assumes the risks that costs will exceed that amount on a prepaid per capita or prepaid aggregate fixed-sum basis; or

Enter into arrangements whereby the cost of health care services provided directly or through arrangements with other persons by the health maintenance organization is self-funded by the person contracting with the health maintenance organization.

Notwithstanding other provisions of this chapter, a health maintenance organization may issue a contract that limits coverage to home health care services only. The organization and the contract shall be subject to all of the requirements of this part that do not require or otherwise apply to specific benefits other than home care services. To this extent, all of the requirements of this part apply to any organization or contract that limits coverage to home care services, except the requirements for providing comprehensive health care services as provided in ss. 641.19(4), (11), and (12), and 641.31(1), except ss. 641.31(9), (12), (17), (18), (19), (20), (21), and (24) and 641.31095.

Notwithstanding the other provisions of this chapter, a health maintenance organization may apply for and obtain a certificate of authority from the office pursuant to this part and a health care provider certificate pursuant to part III, which certificate limits the authority of the organization to the issuance of contracts that limit coverage to home health care services pursuant to subsection (1). In addition to all applicable requirements of this part, as specified in subsection (1), all of the requirements of part III apply to an organization applying for such a limited certificate, except to the extent that such requirements directly conflict with the limited nature of the coverage provided.

Any contract that limits coverage to home health care benefits as provided in this section must also meet all of the requirements of ss. 627.9403-627.9408 of the Long-Term Care Insurance Act, except s. 627.9407(3)(c) and (9).

Before any entity may operate a health maintenance organization, it shall obtain a certificate of authority from the office. The office shall accept and shall begin its review of an application for a certificate of authority anytime after an organization has filed an application for a health care provider certificate pursuant to part III of this chapter. However, the office may not issue a certificate of authority to any applicant which does not possess a valid health care provider certificate issued by the agency. Each application for a certificate shall be on such form as the commission shall prescribe, shall be verified by the oath of two officers of the corporation and properly notarized, and shall be accompanied by the following:

After submission of the application for a certificate of authority, the entity may engage in initial group marketing activities solely with respect to employers, representatives of labor unions, professional associations, and trade associations, so long as it does not enter into, issue, deliver, or otherwise effectuate health maintenance contracts, effectuate or bind coverage or benefits, provide health care services, or collect premiums or charges until it has been issued a certificate of authority by the office. Any such activities, oral or written, shall include a statement that the entity does not possess a valid certificate of authority and cannot enter into health maintenance contracts until such time as it has been issued a certificate of authority by the office.

A comprehensive feasibility study, performed by a certified actuary in conjunction with a certified public accountant. The study shall be for the greater of 3 years or until the health maintenance organization has been projected to be profitable for 12 consecutive months. The study must show that the health maintenance organization would not, at the end of any month of the projection period, have less than the minimum surplus as required by s. 641.225.

As a condition precedent to the issuance or maintenance of a certificate of authority, a health maintenance organization insurer must file or have on file with the office:

The commencement of a bankruptcy proceeding either by or against a health maintenance organization shall, by operation of law:

If the proceeding is initiated by a party other than the health maintenance organization, the operation of subsection (2) shall be stayed for a period of 60 days following the date of commencement of the proceeding.

Any entity contracting with the Agency for Health Care Administration to provide health care services to Medicaid recipients or state employees on a prepaid or fixed-sum basis must submit to the Agency for Health Care Administration the entity’s plan for recruitment and retention of health care practitioners who are minorities as defined in s. 288.703(3). The plan must demonstrate an ability to recruit and retain minorities which shall include, but is not limited to, the following efforts:

The Agency for Health Care Administration may not contract with such an entity until the agency has received and approved the entity’s plan required in subsection (1). Failure to implement the plan as approved shall constitute grounds for the suspension or termination of the entity’s contract with the agency.

As a condition precedent to the issuance of any certificate, the entity has obtained a health care provider certificate from the Agency for Health Care Administration pursuant to part III of this chapter.

The health maintenance organization is actuarially sound.

The entity has met the applicable requirements specified in s. 641.225.

The procedures for offering comprehensive health care services and offering and terminating contracts to subscribers will not unfairly discriminate on the basis of age, sex, race, health, or economic status. However, this section does not prohibit reasonable underwriting classifications for the purposes of establishing contract rates, nor does it prohibit experience rating.

The entity furnishes evidence of adequate insurance coverage or an adequate plan for self-insurance to respond to claims for injuries arising out of the furnishing of comprehensive health care.

The ownership, control, and management of the entity is competent and trustworthy and possesses managerial experience that would make the proposed health maintenance organization operation beneficial to the subscribers. The office shall not grant or continue authority to transact the business of a health maintenance organization in this state at any time during which the office has good reason to believe that:

The entity has a blanket fidelity bond in the amount of $100,000, issued by a licensed insurance carrier in this state, that will reimburse the entity in the event that anyone handling the funds of the entity either misappropriates or absconds with the funds. All employees handling the funds shall be covered by the blanket fidelity bond. An agent licensed under the provisions of the Florida Insurance Code may either directly or indirectly represent the health maintenance organization in the solicitation, negotiation, effectuation, procurement, receipt, delivery, or forwarding of any health maintenance organization subscriber’s contract or collect or forward any consideration paid by the subscriber to the health maintenance organization; and the licensed agent shall not be required to post the bond required by this subsection.

The entity has filed with the office, and obtained approval from the office of, all reinsurance contracts as provided in s. 641.285.

The health maintenance organization has a grievance procedure that will facilitate the resolution of subscriber grievances and that includes both formal and informal steps available within the organization.

Each health maintenance organization shall at all times maintain a minimum surplus in an amount that is the greater of $1,500,000, or 10 percent of total liabilities, or 2 percent of total annualized premium.

The office shall not issue a certificate of authority, except as provided in subsection (3), unless the health maintenance organization has a minimum surplus in an amount which is the greater of:

The commission may adopt rules to set uniform standards and criteria for the early warning that the continued operation of any health maintenance organization might be hazardous to its subscribers, creditors, or the general public, and to set standards for evaluating the financial condition of any health maintenance organization.

A surplus note shall not be used to initially capitalize a health maintenance organization.

In lieu of having any minimum surplus, the health maintenance organization may provide a written guarantee to assure payment of covered subscriber claims and all other liabilities of the health maintenance organization, provided that the written guarantee is made by a guaranteeing organization which:

The solvency requirements of ss. 1855 and 1856 of the Balanced Budget Act of 1997 and 42 C.F.R. s. 422.350, subpart H, apply to a health maintenance organization that is a provider-sponsored organization rather than the solvency requirements of this part. However, if the provider-sponsored organization does not meet the solvency requirements of this part, the organization is limited to the issuance of Medicare+Choice plans to eligible individuals. For the purposes of this section, the terms “Medicare+Choice plans,” “provider-sponsored organizations,” and “solvency requirements” have the same meaning as defined in the federal act and federal rules and regulations.

The solvency requirements in 42 C.F.R. s. 422.350, subpart H, and the solvency requirements established in approved federal waivers pursuant to chapter 409 apply to a Medicaid provider service network rather than the solvency requirements of this part.

The office shall not issue or permit to exist a certificate of authority to operate a health maintenance organization in this state unless the organization has deposited with the department $10,000 in cash for use in the Rehabilitation Administrative Expense Fund as established in subsection (2).

The department shall maintain all deposits received under this section and all income from such deposits in trust in an account titled “Rehabilitation Administrative Expense Fund.” The fund shall be administered by the department and shall be used for the purpose of payment of the administrative expenses of the department during any rehabilitation of a health maintenance organization, when rehabilitation is ordered by a court of competent jurisdiction.

Upon successful rehabilitation of a health maintenance organization, the organization shall reimburse the fund for the amount of expenses incurred by the department during the court-ordered rehabilitation period.

If a court of competent jurisdiction orders liquidation of a health maintenance organization, the fund shall be reimbursed for expenses incurred by the department as provided for in chapter 631.

Each deposit made under this section shall be allowed as an asset for purposes of determination of the financial condition of the health maintenance organization. The deposit shall be refunded to the organization only when the organization both ceases operation as a health maintenance organization and no longer holds a subsisting certificate of authority.

The office shall not issue a certificate to any health maintenance organization after July 1, 1989, until the applicant health maintenance organization has paid in full its special assessment as set forth in s. 631.819(2)(a).

No assessment paid to the Florida Health Maintenance Organization Consumer Assistance Plan shall be allowed as an asset of any health maintenance organization.

The office may suspend or revoke the certificate of authority of any health maintenance organization which does not timely pay its assessment to the Florida Health Maintenance Organization Consumer Assistance Plan.

The maintenance of a valid and current health care provider certificate issued pursuant to part III of this chapter is a condition of the maintenance of a valid and current certificate of authority issued by the office to operate a health maintenance organization. Denial or revocation of a health care provider certificate shall be deemed to be an automatic and immediate cancellation of a health maintenance organization’s certificate of authority. At the discretion of the office, nonrenewal of a health care provider certificate may be deemed to be an automatic and immediate cancellation of a health maintenance organization’s certificate of authority if the Agency for Health Care Administration notifies the office, in writing, that the health care provider certificate will not be renewed.

The office may suspend the authority of a health maintenance organization to enroll new subscribers or revoke any certificate issued to a health maintenance organization, or order compliance within 30 days, if it finds that any of the following conditions exists:

Whenever the financial condition of the health maintenance organization is such that, if not modified or corrected, its continued operation would result in impairment or insolvency, the office may order the health maintenance organization to file with the office and implement a corrective action plan designed to do one or more of the following:

If the health maintenance organization fails to submit a plan within 30 days of the office’s order or submits a plan which is insufficient to correct the health maintenance organization’s financial condition, the office may order the health maintenance organization to implement one or more of the corrective actions listed in this subsection.

The office shall, in its order suspending the authority of a health maintenance organization to enroll new subscribers, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the health maintenance organization prior to reinstatement of its authority to enroll new subscribers. The order of suspension is subject to rescission or modification by further order of the office prior to the expiration of the suspension period. Reinstatement shall not be made unless requested by the health maintenance organization; however, the office shall not grant reinstatement if it finds that the circumstances for which the suspension occurred still exist or are likely to recur.

The commission shall adopt rules establishing an actuarially sound medical loss ratio for Medicaid. In determining the appropriate medical loss ratio, the commission shall consider factors, including but not limited to, plan age, plan structure, geographic service area, product mix, provider network, medical inflation, provider services, other professional services, out of network referrals and expenditures, in and out of network emergency room expenditures, inpatient expenditures, other medical expenditures, incentive pool adjustments, copayments, coordination of benefits, subrogation, and any other expenses associated with the delivery of medical benefits. The commission shall utilize assistance from the Agency for Health Care Administration, the State University System, an independent actuary, and representatives from health maintenance organizations in developing the rule for appropriate medical loss ratios.

The office shall calculate and publish at least annually the medical loss ratios of all licensed health maintenance organizations. The publication shall include an explanation of what the medical loss ratio means and shall disclose that the medical loss ratio is not a direct reflection of quality, but must be looked at along with patient satisfaction and other standards that define quality.

The office may require a health maintenance organization to submit any contract for administrative services, contract with a provider other than an individual physician, contract for management services, and contract with an affiliated entity to the office.

After review of a contract the office may order the health maintenance organization to cancel the contract in accordance with the terms of the contract and applicable law if it determines:

All contracts for administrative services, management services, provider services other than individual physician contracts, and with affiliated entities entered into or renewed by a health maintenance organization on or after October 1, 1988, shall contain a provision that the contract shall be canceled upon issuance of an order by the office pursuant to this section.

Every acquisition of a health maintenance organization shall be subject to the provisions of s. 628.4615. However, in the case of a health maintenance organization organized as a for-profit corporation, the provisions of s. 628.451 govern with respect to any merger or consolidation; and, in the case of a health maintenance organization organized as a not-for-profit corporation, the provisions of s. 628.471 govern with respect to any merger or consolidation.

In addition to the requirements set forth in ss. 628.451, 628.4615, and 628.471, each party to any transaction involving any licensee which, as indicated in its most recent quarterly or annual statement, derives income from Medicaid funds shall in the filing made with the office identify:

which in any way relates to the acquisition, merger, or consolidation. The commission may adopt a form to be made part of the application which is to be sworn to by an officer of the entity which made or will make the payment. The form shall include the name of the person or entity paying the fee; the name of the person or entity receiving the fee; the date of payment; and a brief description of the work performed.

Every health maintenance organization shall, annually within 3 months after the end of its fiscal year, or within an extension of time therefor as the office, for good cause, may grant, in a form prescribed by the commission, file a report with the office, verified by the oath of two officers of the organization or, if not a corporation, of two persons who are principal managing directors of the affairs of the organization, properly notarized, showing its condition on the last day of the immediately preceding reporting period. Such report shall include:

The office may require updates of the actuarial certification as to a particular health maintenance organization if the office has reasonable cause to believe that such reserves are understated to the extent of materially misstating the financial position of the health maintenance organization. Workpapers in support of the statement of the updated actuarial certification must be provided to the office upon request.

Every health maintenance organization shall file quarterly, for the first three calendar quarters of each year, an unaudited financial statement of the organization as described in paragraphs (1)(a) and (b). The statement for the quarter ending March 31 shall be filed on or before May 15, the statement for the quarter ending June 30 shall be filed on or before August 15, and the statement for the quarter ending September 30 shall be filed on or before November 15. The quarterly report shall be verified by the oath of two officers of the organization, properly notarized.

Any health maintenance organization that neglects to file an annual report or quarterly report in the form and within the time required by this section shall forfeit up to $1,000 for each day for the first 10 days during which the neglect continues and shall forfeit up to $2,000 for each day after the first 10 days during which the neglect continues; and, upon notice by the office to that effect, the organization’s authority to enroll new subscribers or to do business in this state shall cease while such default continues. The office shall deposit all sums collected by it under this section to the credit of the Insurance Regulatory Trust Fund. The office shall not collect more than $100,000 for each report.

Each authorized health maintenance organization shall retain an independent certified public accountant, referred to in this section as “CPA,” who agrees by written contract with the health maintenance organization to comply with the provisions of this part.

To facilitate uniformity in financial statements and to facilitate office analysis, the commission may by rule adopt the form for financial statements of a health maintenance organization, including supplements as approved by the National Association of Insurance Commissioners in 1995, and may adopt subsequent amendments thereto if the methodology remains substantially consistent, and may by rule require each health maintenance organization to submit to the office all or part of the information contained in the annual statement in a computer-readable form compatible with the electronic data processing system specified by the office.

In addition to information called for and furnished in connection with its annual or quarterly statements, the health maintenance organization shall furnish to the office as soon as reasonably possible such information as to its material transactions which, in the office’s opinion, may have a material adverse effect on the health maintenance organization’s financial condition, as the office requests in writing. All such information furnished pursuant to the office’s request must be verified by the oath of two executive officers of the health maintenance organization.

Each health maintenance organization shall file one copy of its annual statement convention blank in electronic form, along with such additional filings as prescribed by the commission for the preceding calendar year or quarter, with the National Association of Insurance Commissioners. Each health maintenance organization shall pay fees assessed by the National Association of Insurance Commissioners to cover costs associated with the filing and analysis of the documents by the National Association of Insurance Commissioners.

Each authorized health maintenance organization shall provide records and information to the Agency for Health Care Administration pursuant to s. 409.910(20) and (21) for the sole purpose of identifying potential coverage for claims filed with the agency and its fiscal agents for payment of medical services under the Medicaid program.

Any information provided by a health maintenance organization under this section to the agency shall not be considered a violation of any right of confidentiality or contract that the health maintenance organization may have with covered persons. The health maintenance organization is immune from any liability that it may otherwise incur through its release of information to the agency under this section.

The office shall examine the affairs, transactions, accounts, business records, and assets of any health maintenance organization as often as it deems it expedient for the protection of the people of this state, but not less frequently than once every 5 years. However, except when the medical records are requested and copies furnished pursuant to s. 456.057, medical records of individuals and records of physicians providing service under contract to the health maintenance organization shall not be subject to audit, although they may be subject to subpoena by court order upon a showing of good cause. For the purpose of examinations, the office may administer oaths to and examine the officers and agents of a health maintenance organization concerning its business and affairs. The examination of each health maintenance organization by the office shall be subject to the same terms and conditions as apply to insurers under chapter 624. In no event shall expenses of all examinations exceed a maximum of $50,000 for any 1-year period. Any rehabilitation, liquidation, conservation, or dissolution of a health maintenance organization shall be conducted under the supervision of the department, which shall have all power with respect thereto granted to it under the laws governing the rehabilitation, liquidation, reorganization, conservation, or dissolution of life insurance companies.

The office may contract, at reasonable fees for work performed, with qualified, impartial outside sources to perform audits or examinations or portions thereof pertaining to the qualification of an entity for issuance of a certificate of authority or to determine continued compliance with the requirements of this part, in which case the payment must be made directly to the contracted examiner by the health maintenance organization examined, in accordance with the rates and terms agreed to by the office and the examiner. Any contracted assistance shall be under the direct supervision of the office. The results of any contracted assistance shall be subject to the review of, and approval, disapproval, or modification by, the office.

A health maintenance organization is being operated by any person or entity without a subsisting certificate of authority.

Any person, entity, or health maintenance organization has engaged in any activity prohibited by this part or any rule adopted pursuant thereto.

Any health maintenance organization, person, or entity is renewing, issuing, or delivering a health maintenance contract or contracts without a subsisting certificate of authority.

Each health maintenance organization shall deposit with the department cash or securities of the type eligible under s. 625.52, which shall have at all times a market value in the amount set forth in this subsection. The amount of the deposit shall be reviewed annually, or more often, as the office deems necessary. The market value of the deposit shall be a minimum of $300,000.

If securities or assets deposited by a health maintenance organization under this part are subject to material fluctuations in market value, the office may, in its discretion, require the organization to deposit and maintain on deposit additional securities or assets in an amount as may be reasonably necessary to assure that the deposit will at all times have a market value of not less than the amount specified under this section. If for any reason the market value of assets and securities of a health maintenance organization held on deposit in this state under this code falls below the amount required, the organization shall promptly deposit other or additional assets or securities eligible for deposit sufficient to cure the deficiency. If the health maintenance organization has failed to cure the deficiency within 30 days after receipt of notice thereof by registered or certified mail from the office, the office may revoke the certificate of authority of the health maintenance organization.

Whenever the office determines that the financial condition of a health maintenance organization has deteriorated to the point that the policyholders’ or subscribers’ best interests are not being preserved by the activities of a health maintenance organization, the office may require such health maintenance organization to deposit and maintain deposited in trust with the department for the protection of the health maintenance organization’s policyholders, subscribers, and creditors, for such time as the office deems necessary, securities eligible for such deposit under s. 625.52 having a market value of not less than the amount that the office determines is necessary, which amount must not be less than $100,000 or greater than $2 million. The deposit required under this subsection is in addition to any other deposits required of a health maintenance organization pursuant to subsections (1) and (2).

All income from deposits shall belong to the depositing health maintenance organization and shall be paid to it as it becomes available. A health maintenance organization that has made a securities deposit may withdraw that deposit, or any part thereof, after making a substitute deposit of cash or eligible securities or any combination of these or other acceptable measures of equal amount and value.

For filing a copy of its application for a certificate of authority or amendment thereto, a nonrefundable fee in the amount of $1,000.

For filing each annual report, which must be filed by electronic means in a computer-readable form, $150.

Every health maintenance organization shall accept the claim form prescribed pursuant to s. 641.3155.

Except as provided in this part, the Florida Insurance Code does not apply to health maintenance organizations certificated under this part, and health maintenance organizations certificated under this part are not subject to part II of this chapter. Any person, entity, or health maintenance organization operating without a subsisting certificate of authority in violation of this part or rules promulgated thereunder or renewing, issuing, or delivering health maintenance contracts without a subsisting certificate of authority in violation of this part or rules promulgated thereunder, in addition to being subject to the provisions of this part, is subject to the provisions of the Florida Insurance Code as defined in s. 624.01.

The solicitation of subscribers by a health maintenance organization or its representatives shall not be construed to be violative of any provisions of law relating to solicitation or advertising by health professionals if the health maintenance organization is operating pursuant to a subsisting certificate of authority.

The Division of Insurance Fraud of the department is vested with all powers granted to it under the Florida Insurance Code with respect to the investigation of any violation of this part.

Every health maintenance organization must comply with s. 627.4301.

PURPOSE.—The purpose of this section is to prohibit unfair practices in a health maintenance organization contract with respect to exposure to the human immunodeficiency virus infection and related matters, and thereby reduce the possibility that a health maintenance organization subscriber or applicant may suffer unfair discrimination when subscribing to or applying for the contractual services of a health maintenance organization.

SCOPE.—This section applies to all health maintenance contracts which are issued in this state or which are issued outside this state but cover residents of this state. This section shall not prohibit a health maintenance organization from contesting a contract or claim to the extent allowed by law.

DEFINITIONS.—As used in this section:

UTILIZATION OF MEDICAL TESTS.—

RESTRICTIONS ON CONTRACT EXCLUSIONS AND LIMITATIONS.—

The text of all advertisements by a health maintenance organization, if printed or broadcast in a language other than English, also shall be available in English and shall be furnished to the office upon request. As used in this subsection, the term “advertisement” means any advertisement, circular, pamphlet, brochure, or other printed material disclosing or disseminating advertising material or information by a health maintenance organization to prospective or existing subscribers and includes any radio or television transmittal of an advertisement or information.

Every health maintenance organization marketing coverage to Medicare participants or persons eligible for Medicare in this state, directly or through its agents, shall:

In addition to the practices prohibited in s. 641.3903:

Any entity issued a certificate and otherwise in compliance with this part may enter into contracts in this state to provide an agreed-upon set of comprehensive health care services to subscribers in exchange for a prepaid per capita sum or a prepaid aggregate fixed sum. Each subscriber shall be given a copy of the applicable health maintenance contract, certificate, or member handbook. Whichever document is provided to a subscriber shall contain all of the provisions and disclosures required by this section.

The rates charged by any health maintenance organization to its subscribers shall not be excessive, inadequate, or unfairly discriminatory or follow a rating methodology that is inconsistent, indeterminate, or ambiguous or encourages misrepresentation or misunderstanding. A law restricting or limiting deductibles, coinsurance, copayments, or annual or lifetime maximum payments shall not apply to any health maintenance organization contract that provides coverage as described in s. 641.31071(5)(a)2., offered or delivered to an individual or a group of 51 or more persons. The commission, in accordance with generally accepted actuarial practice as applied to health maintenance organizations, may define by rule what constitutes excessive, inadequate, or unfairly discriminatory rates and may require whatever information it deems necessary to determine that a rate or proposed rate meets the requirements of this subsection.

Every health maintenance contract, certificate, or member handbook shall clearly state all of the services to which a subscriber is entitled under the contract and must include a clear and understandable statement of any limitations on the services or kinds of services to be provided, including any copayment feature or schedule of benefits required by the contract or by any insurer or entity which is underwriting any of the services offered by the health maintenance organization. The contract, certificate, or member handbook shall also state where and in what manner the comprehensive health care services may be obtained.

Every subscriber shall receive a clear and understandable description of the method of the health maintenance organization for resolving subscriber grievances, and the method shall be set forth in the contract, certificate, and member handbook. The organization shall also furnish, at the time of initial enrollment and when necessary due to substantial changes to the grievance process a separate and additional communication prepared or approved by the office notifying the contract holder of a group contract or subscriber of an individual contract of their rights and responsibilities under the grievance process.

The rate of payment for a health maintenance contract shall be a part of the contract and shall be stated in individual contracts issued to subscribers.

A health maintenance organization is entitled to coordinate benefits on the same basis as an insurer under s. 627.4235.

A health maintenance organization providing medical benefits or payments to a subscriber who suffers injury, disease, or illness by virtue of the negligent act or omission of a third party is entitled to reimbursement from the subscriber in accordance with s. 768.76(4).

All health maintenance contracts that provide coverage, benefits, or services for a member of the family of the subscriber must, as to such family member’s coverage, benefits, or services, provide also that the coverage, benefits, or services applicable for children must be provided with respect to a newborn child of the subscriber, or covered family member of the subscriber, from the moment of birth. However, with respect to a newborn child of a covered family member other than the spouse of the insured or subscriber, the coverage for the newborn child terminates 18 months after the birth of the newborn child. The coverage, benefits, or services for newborn children must consist of coverage for injury or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and transportation costs of the newborn to and from the nearest appropriate facility appropriately staffed and equipped to treat the newborn’s condition, when such transportation is certified by the attending physician as medically necessary to protect the health and safety of the newborn child.

No alteration of any written application for any health maintenance contract shall be made by any person other than the applicant without his or her written consent, except that insertions may be made by the health maintenance organization, for administrative purposes only, in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant.

No contract shall contain any waiver of rights or benefits provided to or available to subscribers under the provisions of any law or rule applicable to health maintenance organizations.

Each health maintenance contract, certificate, or member handbook shall state that emergency services and care shall be provided to subscribers in emergency situations not permitting treatment through the health maintenance organization’s providers, without prior notification to and approval of the organization. Not less than 75 percent of the reasonable charges for covered services and supplies shall be paid by the organization, up to the subscriber contract benefit limits. Payment also may be subject to additional applicable copayment provisions, not to exceed $100 per claim. The health maintenance contract, certificate, or member handbook shall contain the definitions of “emergency services and care” and “emergency medical condition” as specified in s. 641.19(6) and (7), shall describe procedures for determination by the health maintenance organization of whether the services qualify for reimbursement as emergency services and care, and shall contain specific examples of what does constitute an emergency. In providing for emergency services and care as a covered service, a health maintenance organization shall be governed by s. 641.513.

In addition to the requirements of this section, with respect to a person who is entitled to have payments for health care costs made under Medicare, Title XVIII of the Social Security Act (“Medicare”), parts A and/or B:

Whenever a subscriber of a health maintenance organization is also a Medicaid recipient, the health maintenance organization’s coverage shall be primary to the recipient’s Medicaid benefits and the organization shall be a third party subject to the provisions of s. 409.910(4).

The contracts must clearly disclose the intent of the health maintenance organization as to the applicability or nonapplicability of coverage to preexisting conditions. If coverage of the contract is not to be applicable to preexisting conditions, the contract shall specify, in substance, that coverage pertains solely to accidental bodily injuries resulting from accidents occurring after the effective date of coverage and that sicknesses are limited to those which first manifest themselves subsequent to the effective date of coverage.

All health maintenance contracts that provide coverage for a member of the family of the subscriber, shall, as to such family member’s coverage, provide that coverage, benefits, or services applicable for children shall be provided with respect to an adopted child of the subscriber, which child is placed in compliance with chapter 63, from the moment of placement in the residence of the subscriber. Such contracts may not exclude coverage for any preexisting condition of the child. In the case of a newborn child, coverage shall begin from the moment of birth if a written agreement to adopt such child has been entered into by the subscriber prior to the birth of the child, whether or not such agreement is enforceable. However, coverage for such child shall not be required in the event that the child is not ultimately placed in the residence of the subscriber in compliance with chapter 63.

Notwithstanding any other provision of law, health maintenance policies or contracts which provide coverage, benefits, or services as described in s. 463.002(5), shall offer to the subscriber the services of an optometrist licensed pursuant to chapter 463.

Notwithstanding any other provision of law, health maintenance policies or contracts which provide coverage, benefits, or services which are performed by physicians who are ophthalmologists, licensed pursuant to chapter 458 or chapter 459, shall offer the subscriber the services of an ophthalmologist. For purposes of this subsection, ophthalmologists are physicians specializing in the diagnosis and treatment of diseases and injuries of the eye.

Notwithstanding any other provision of law, health maintenance policies or contracts which provide anesthesia coverage, benefits, or services shall offer to the subscriber, if requested and available, the services of a certified registered nurse anesthetist licensed pursuant to part I of chapter 464.

Each health maintenance organization that offers a group plan within this state must have at least one open enrollment period of not less than 30 days every 18 months. Such open enrollment periods are required for as long as the group exists unless the health maintenance organization and the employer mutually agree to a shorter period of time than 18 months.

The contract shall include the following provision:

“Time limit on certain defenses: Relative to a misstatement in the application, after 2 years from the issue date, only fraudulent misstatements in the application may be used to void the policy or deny any claim for loss incurred or disability starting after the 2-year period.”

Each health maintenance organization that provides for inpatient and outpatient services by allopathic hospitals shall provide as an option of the subscriber similar inpatient and outpatient services by hospitals accredited by the American Osteopathic Association when such services are available in the same service area of the HMO and the osteopathic hospital agrees to provide the services as specified herein. As a condition precedent to providing osteopathic inpatient and outpatient services through an osteopathic hospital that has not entered into a written contract with the HMO, the HMO may require the subscriber or any other person receiving osteopathic services to release the HMO from any liability arising from any act of omission or commission constituting malpractice in the delivery of osteopathic care from that hospital. The osteopathic hospital providing the inpatient and outpatient services for the HMO shall charge rates that do not exceed the osteopathic hospital’s usual and customary rates less the average discount provided by allopathic hospitals providing the HMO services in the same service area of the HMO.

If a subscriber is a resident of a continuing care facility certified under chapter 651 or a retirement facility consisting of a nursing home or assisted living facility and residential apartments, the subscriber’s primary care physician must refer the subscriber to that facility’s skilled nursing unit or assisted living facility if requested by the subscriber and agreed to by the facility; if the primary care physician finds that such care is medically necessary; if the facility agrees to be reimbursed at the health maintenance organization’s contract rate negotiated with similar providers for the same services and supplies; and if the facility meets all guidelines established by the health maintenance organization related to quality of care, utilization, referral authorization, risk assumption, use of the health maintenance organization’s network, and other criteria applicable to providers under contract for the same services and supplies. If a health maintenance organization enrolls a new subscriber who already resides in a continuing care facility or a retirement facility as described in this subsection, the health maintenance organization must provide in writing a disclosure of the subscriber’s rights under this subsection. If a subscriber’s request to be referred to the skilled nursing unit or assisted living facility that is part of the subscriber’s place of residence is not honored, the subscriber may use the grievance process provided in s. 641.511.

Any health maintenance contract that covers a resident of this state and that is issued, amended, delivered, or renewed in this state after October 1, 1996, must provide coverage for the medically necessary diagnosis and treatment of osteoporosis for high-risk individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis. This subsection shall not apply to the state employee health insurance program.

A health maintenance organization may not discriminate against or fail to contract with a hospital, based solely on the fact that the hospital’s medical staff is comprised of physicians licensed under chapter 459. Nothing in this subsection shall mandate that a health maintenance organization contract with a hospital.

If a health maintenance contract provides that coverage of a dependent child of the subscriber will terminate upon attainment of the limiting age for dependent children which is specified in the contract, the contract must also provide in substance that attainment of the limiting age does not terminate the coverage of the child while the child continues to be both:

If the claim is denied under a contract for the stated reason that the child has attained the limiting age for dependent children specified in the contract, the notice or denial must state that the subscriber has the burden of establishing that the child continues to meet the criteria specified in paragraphs (a) and (b).

A health maintenance contract that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy. As used in this subsection, the term “breast reconstructive surgery” means surgery to reestablish symmetry between the two breasts. Such surgery must be in a manner chosen by the treating physician under contract with the health maintenance organization, consistent with prevailing medical standards, and in consultation with the patient. The health maintenance organization may charge an appropriate additional premium for the coverage required by this subsection. The coverage for prosthetic devices and breast reconstructive surgery shall be subject to any deductible and coinsurance conditions.

Notwithstanding any provision of this section to the contrary, a health maintenance organization which offers dermatological services shall provide direct patient access, for office visits and minor procedures and testing, to a dermatologist who is under contract with the health maintenance organization. The term “direct patient access” means the ability of a subscriber to obtain such services without a referral or other authorization before receiving services. The health maintenance organization shall, by July 1, 1997, develop criteria for compliance with the provisions of this subsection which do not impede or inhibit access to dermatological services for policyholders of the health maintenance organization. The criteria may include a maximum of five office visits to a dermatologist without prior authorization for a dermatologic problem within a 12-month period.

For purposes of this subsection, dental treatment or surgery shall be considered necessary when the dental condition is likely to result in a medical condition if left untreated. Any health maintenance organization contract which provides coverage for general anesthesia and hospitalization services to a covered person shall not preclude such coverage in assuring the safe delivery of necessary dental care provided to a covered person who:

As provided herein, all terms and conditions of the covered person’s health maintenance organization contract shall apply to such services, and this section does not require coverage for the diagnosis or treatment of dental disease. A health maintenance organization may require prior authorization for general anesthesia and hospital services required under this section in the same manner the organization requires prior authorization for hospitalization for other covered services. This subsection shall not apply to Medicare supplement, long-term care, disability, limited benefit, accident only, or specified disease policies.

A health maintenance contract that covers a child under the age of 18 must provide coverage for treatment of cleft lip and cleft palate for the child. The coverage must include medical, dental, speech therapy, audiology, and nutrition services only if such services are prescribed by the primary care physician or physician to whom the child is referred and such physician certifies that such services are medically necessary and consequent to treatment of the cleft lip or cleft palate. The coverage required by this section is subject to terms and conditions applicable to other benefits.

A health maintenance organization may increase the copayment for any benefit, or delete, amend, or limit any of the benefits to which a subscriber is entitled under the group contract only, upon written notice to the contract holder at least 45 days in advance of the time of coverage renewal. The health maintenance organization may amend the contract with the contract holder, with such amendment to be effective immediately at the time of coverage renewal. The written notice to the contract holder shall specifically identify any deletions, amendments, or limitations to any of the benefits provided in the group contract during the current contract period which will be included in the group contract upon renewal. This subsection does not apply to any increases in benefits. The 45-day notice requirement shall not apply if benefits are amended, deleted, or limited at the request of the contract holder.

All health maintenance contracts that provide coverage for massage must also cover the services of persons licensed to practice massage pursuant to chapter 480 if the massage is prescribed by a contracted physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461 as medically necessary and the prescription specifies the number of treatments. Such massage services are subject to the same terms, conditions, and limitations as those of other covered services.

A health maintenance organization contract may not prohibit or restrict a subscriber from receiving inpatient services in a contracted hospital from a contracted primary care or admitting physician if such services are determined by the organization to be medically necessary and covered services under the organization’s contract with the contract holder.

All health maintenance contracts providing coverage for a member of the subscriber’s family must comply with the provisions of s. 627.6562.

The contract, certificate, or member handbook must be accompanied by an identification card that contains, at a minimum:

The identification card must present the information in a readily identifiable manner or, alternatively, the information may be embedded on the card and available through magnetic stripe or smart card. The information may also be provided through other electronic technology.

Whenever, in any health maintenance organization claim form, a subscriber specifically authorizes payment of benefits directly to any contracted hospital, ambulance provider, physician, or dentist, the health maintenance organization shall make such payment to the designated provider of such services if any benefits are due to the subscriber under the terms of the agreement between the subscriber and the health maintenance organization. The health maintenance organization contract may not prohibit, and claims forms must provide an option for, the payment of benefits directly to a licensed hospital, ambulance provider, physician, or dentist for covered services provided, for services provided pursuant to s. 395.1041, and for ambulance transport and treatment provided pursuant to part III of chapter 401. The attestation of assignment of benefits may be in written or electronic form. Payment to the provider from the health maintenance organization may not be more than the amount that the insurer would otherwise have paid without the assignment. This subsection does not affect the applicability of ss. 641.3154 and 641.513 with respect to services provided and payment for such services provided pursuant to the subsection.

Necessary, on account of the manner in which the organization is constituted or operated, in order to state the rights and obligations of the parties to the contract; or

Desired by the organization and neither prohibited by law nor in conflict with any provisions required to be included therein.

A health maintenance organization that offers individual health maintenance contracts in this state may not decline to offer coverage to an eligible individual as required in s. 627.6487.

A health maintenance organization shall not expel or refuse to renew the coverage of, or refuse to enroll, any individual member of a subscriber group on the basis of the race, color, creed, marital status, sex, or national origin of the subscriber or individual. A health maintenance organization shall not expel or refuse to renew the coverage of any individual member of a subscriber group on the basis of the age, health status, health care needs, or prospective costs of health care services of the subscriber or individual. Nothing in this section shall prohibit a health maintenance organization from requiring that, as a condition of continued eligibility for membership, dependents of a subscriber, upon reaching a specified age, convert to a converted contract or that individuals entitled to have payments for health costs made under Title XVIII of the United States Social Security Act, as amended, be issued a health maintenance contract for Medicare beneficiaries so long as the health maintenance organization is authorized to issue health maintenance contracts for Medicare beneficiaries.

Every health maintenance contract shall be executed in the name of and on behalf of the health maintenance organization by its officer, attorney in fact, employee, or representative duly authorized by the organization.

A facsimile signature of any executing individual may be used in lieu of an original signature.

No health maintenance contract which is otherwise valid shall be rendered invalid by reason of the apparent execution thereof on behalf of the health maintenance organization by the imprinted facsimile signature of an individual not authorized so to execute as of the date of the contract.

Any health maintenance contract, rider, endorsement, attachment, or addendum otherwise valid which contains any condition or provision not in compliance with the requirements of this part shall not be thereby rendered invalid, but shall be construed and applied in accordance with such conditions and provisions as would have applied had such contract, rider, endorsement, attachment, or addendum been in full compliance with this part. In the event an organization issues or delivers any contract for an amount which exceeds any limitations otherwise provided in this part, such organization shall be liable to the subscriber or her or his beneficiary for the full amount stated in the contract in addition to any other penalties that may be imposed under this part.

Any health maintenance contract delivered or issued for delivery in this state covering a subscriber, which subscriber, pursuant to the provisions of this part, the organization may not lawfully cover under the contract, shall be cancelable at any time by the organization, any provision of the contract to the contrary notwithstanding; and the organization shall promptly cancel the contract in accordance with the request of the office therefor. No such illegality or cancellation shall be deemed to relieve the organization of any liability incurred by it under the contract while in force or to prohibit the organization from retaining the pro rata earned premium or rate thereon. This provision does not relieve the organization from any penalty otherwise incurred by the organization under this part on account of any such violation.

As used in this section, the term:

Subject to the exceptions specified in subsection (4), a health maintenance organization that offers group coverage, may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:

Genetic information shall not be treated as a condition described in paragraph (2)(a) in the absence of a diagnosis of the condition related to such information.

Except as otherwise provided in this subsection, the requirements of paragraph (8)(b) shall apply to events that occur on or after July 1, 1996.

In the case of an individual who seeks to establish creditable coverage for any period for which certification is not required because it relates to an event occurring before July 1, 1996:

For purposes of subsection (10), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement of this section may not be treated as a termination of such collective bargaining agreement.

A health maintenance organization that issues a group health insurance policy shall permit an employee who is eligible, but not enrolled, for coverage under the terms of the contract, or a dependent of such an employee if the dependent is eligible but not enrolled for coverage under such terms, to enroll for coverage under the terms of the contract if each of the following conditions is met:

For dependent beneficiaries, if:

the health maintenance organization shall provide for a dependent special enrollment period described in subsection (3) during which the person, or, if not otherwise enrolled, the individual, may be enrolled under the plan as a dependent of the individual, and in the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a dependent of the individual if such spouse is otherwise eligible for coverage.

A dependent special enrollment period under subsection (2) shall be a period of not less than 30 days and shall begin on the later of:

If an individual seeks to enroll a dependent during the first 30 days of such a dependent special enrollment period, the coverage of the dependent shall become effective:

Subject to subsection (2), a health maintenance organization that offers group health insurance coverage may not establish rules for eligibility, including continued eligibility, of an individual to enroll under the terms of the contract based on any of the following health-status-related factors in relation to the individual or a dependent of the individual:

Subsection (1) does not:

For purposes of subsection (1), rules for eligibility to enroll under a contract include rules for defining any applicable affiliation or waiting periods of enrollment.

Except as otherwise provided in this section, a health maintenance organization that issues a group health insurance contract must renew or continue in force such coverage at the option of the contract holder.

A health maintenance organization may nonrenew or discontinue a contract based only on one or more of the following conditions:

At the time of coverage renewal, a health maintenance organization may modify the coverage for a product offered:

In applying this section in the case of health insurance coverage that is made available by a health maintenance organization in the small group market or large group market to employers only through one or more associations, a reference to “contract holder” is deemed, with respect to coverage provided to an employer member of the association, to include a reference to such employer.

Except for nonpayment of premium or termination of eligibility, no health maintenance organization may cancel or otherwise terminate or fail to renew a health maintenance contract without giving the subscriber at least 45 days’ notice in writing of the cancellation, termination, or nonrenewal of the contract. The written notice shall state the reason or reasons for the cancellation, termination, or nonrenewal. All health maintenance contracts shall contain a clause which requires that this notice be given.

If cancellation is due to nonpayment of premium, the health maintenance organization may not retroactively cancel the contract to a date prior to the date that notice of cancellation was provided to the subscriber unless the organization mails notice of cancellation to the subscriber prior to 45 days after the date the premium was due. Such notice must be mailed to the subscriber’s last address as shown by the records of the organization and may provide for a retroactive date of cancellation no earlier than midnight of the date that the premium was due.

In the case of a health maintenance contract issued to an employer or person holding the contract on behalf of the subscriber group, the health maintenance organization may make the notification through the employer or group contract holder, and, if the health maintenance organization elects to take this action through the employer or group contract holder, the organization shall be deemed to have complied with the provisions of this section upon notifying the employer or group contract holder of the requirements of this section and requesting the employer or group contract holder to forward to all subscribers the notice required herein.

Every health maintenance contract issued or renewed on or after January 1, 1996, shall provide coverage for at least the following:

The coverage required by this section is subject to the deductible and copayment provisions applicable to outpatient visits, and is also subject to all other terms and conditions applicable to other benefits. A health maintenance organization shall make available to the subscriber as part of the application, for an appropriate additional premium, the coverage required in this section without such coverage being subject to any deductible or copayment provisions in the contract.

The Legislature finds and declares it to be of vital importance that emergency services and care be provided by hospitals and physicians to every person in need of such care, but with the double-digit increases in health insurance premiums, health care providers and insurers should encourage patients and the insured to assume responsibility for their treatment, including emergency care. The Legislature finds that inappropriate utilization of emergency department services increases the overall cost of providing health care and these costs are ultimately borne by the hospital, by the insured patients, and, many times, by the taxpayers of this state. Finally, the Legislature declares that the providers and insurers must share the responsibility of providing alternative treatment options to urgent care patients outside of the emergency department. Therefore, it is the intent of the Legislature to place the obligation for educating consumers and creating mechanisms for delivery of care that will decrease the overutilization of emergency service on health maintenance organizations and providers.

Health maintenance organizations shall provide on their Internet websites information regarding appropriate utilization of emergency care services, which shall include, but not be limited to, a list of alternative urgent care contracted providers, the types of services offered by these providers, and what to do in the event of a true emergency.

Health maintenance organizations shall develop community emergency department diversion programs. Such programs may include at the discretion of the health maintenance organization, but not be limited to, enlisting providers to be on call to subscribers after hours, coordinating care through local community resources, and providing incentives to providers for case management.

As a disincentive for subscribers to inappropriately use emergency department services for nonemergency care, health maintenance organizations may require higher copayments for urgent care or primary care provided in an emergency department and higher copayments for use of out-of-network emergency departments. Higher copayments may not be charged for the utilization of the emergency department for emergency care. For the purposes of this section, the term “emergency care” has the same meaning as provided in s. 395.002 and shall include services provided to rule out an emergency medical condition.

This section and s. 627.6686 may be cited as the “Steven A. Geller Autism Coverage Act.”

As used in this section, the term:

A health maintenance contract issued or renewed on or after April 1, 2009, shall provide coverage to an eligible individual for:

The coverage required pursuant to subsection (3) is subject to the following requirements:

The coverage required pursuant to subsection (3) may not be subject to dollar limits, deductibles, or coinsurance provisions that are less favorable to a subscriber than the dollar limits, deductibles, or coinsurance provisions that apply to physical illnesses that are generally covered under the subscriber’s contract, except as otherwise provided in subsection (3).

A health maintenance organization may not deny or refuse to issue coverage for medically necessary services, refuse to contract with, or refuse to renew or reissue or otherwise terminate or restrict coverage for an individual solely because the individual is diagnosed as having a developmental disability.

The treatment plan required pursuant to subsection (4) shall include, but is not limited to, a diagnosis, the proposed treatment by type, the frequency and duration of treatment, the anticipated outcomes stated as goals, the frequency with which the treatment plan will be updated, and the signature of the treating physician.

Beginning January 1, 2011, the maximum benefit under paragraph (4)(b) shall be adjusted annually on January 1 of each calendar year to reflect any change from the previous year in the medical component of the then current Consumer Price Index for all urban consumers, published by the Bureau of Labor Statistics of the United States Department of Labor.

The Office of Insurance Regulation may not enforce this section against a health maintenance organization that is a signatory no later than April 1, 2009, to the developmental disabilities compact established under s. 624.916. The Office of Insurance Regulation shall enforce this section against a health maintenance organization that is a signatory to the compact established under s. 624.916 if the health maintenance organization has not complied with the terms of the compact for all health maintenance contracts by April 1, 2010.

Every group health maintenance contract shall provide that termination of the contract shall be without prejudice to any continuous loss which commenced while the contract was in force, but any extension of benefits beyond the period the contract was in force may be predicated upon the continuous total disability of the subscriber and may be limited to payment for the treatment of a specific accident or illness incurred while the subscriber was a member. Such extension of benefits may be limited to the occurrence of the earliest of the following events:

For the purposes of this section, an individual is totally disabled if the individual has a condition resulting from an illness or injury which prevents an individual from engaging in any employment or occupation for which the individual is or may become qualified by reason of education, training, or experience, and the individual is under the regular care of a physician.

In the case of maternity coverage, when not covered by the succeeding carrier, a reasonable extension of benefits or accrued liability provision is required, which provision provides for continuation of the contract benefits in connection with maternity expenses for a pregnancy that commenced while the policy was in effect. The extension shall be for the period of that pregnancy and shall not be based upon total disability.

Except as provided in subsection (1), no subscriber is entitled to an extension of benefits if the termination of the contract by the health maintenance organization is based upon any event referred to in s. 641.3922(7)(a), (b), or (e).

Each contract between a health maintenance organization and a provider of health care services must be in writing and must contain a provision that the subscriber is not liable to the provider for any services for which the health maintenance organization is liable as specified in s. 641.3154.

Upon receipt by the health maintenance organization of a 60-day cancellation notice, the health maintenance organization may, if requested by the provider, terminate the contract in less than 60 days if the health maintenance organization is not financially impaired or insolvent.

Whenever a contract exists between a health maintenance organization and a provider, the health maintenance organization shall disclose to the provider:

A health maintenance organization shall provide to its contracted providers no less than 30 calendar days’ prior written notice of any changes in the information required in this subsection.

A contract between a health maintenance organization and a provider of health care services shall not contain any provision restricting the provider’s ability to communicate information to the provider’s patient regarding medical care or treatment options for the patient when the provider deems knowledge of such information by the patient to be in the best interest of the health of the patient.

A contract between a health maintenance organization and a provider of health care services may not contain any provision that in any way prohibits or restricts:

A health maintenance organization or health care provider may not terminate a contract with a health care provider or health maintenance organization unless the party terminating the contract provides the terminated party with a written reason for the contract termination, which may include termination for business reasons of the terminating party. The reason provided in the notice required in this section or any other information relating to the reason for termination does not create any new administrative or civil action and may not be used as substantive evidence in any such action, but may be used for impeachment purposes. As used in this subsection, the term “health care provider” means a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461, or a dentist licensed under chapter 466.

The health maintenance organization must establish written procedures for a contract provider to request and the health maintenance organization to grant authorization for utilization of health care services. The health maintenance organization must give written notice to the contract provider prior to any change in these procedures.

A contract between a health maintenance organization and a contracted primary care or admitting physician may not contain any provision that prohibits such physician from providing inpatient services in a contracted hospital to a subscriber if such services are determined by the organization to be medically necessary and covered services under the organization’s contract with the contract holder.

A health maintenance organization shall not require a contracted health care practitioner as defined in s. 456.001(4) to accept the terms of other health care practitioner contracts with the health maintenance organization or any insurer, or other health maintenance organization, under common management and control with the health maintenance organization, including Medicare and Medicaid practitioner contracts and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or this section, except for a practitioner in a group practice as defined in s. 456.053 who must accept the terms of a contract negotiated for the practitioner by the group, as a condition of continuation or renewal of the contract. Any contract provision that violates this section is void. A violation of this section is not subject to the criminal penalty specified in s. 624.15.

If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to the provider.

For purposes of this section, a health maintenance organization is liable for services rendered to an eligible subscriber by a provider if the provider follows the health maintenance organization’s authorization procedures and receives authorization for a covered service for an eligible subscriber, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.

The liability of an organization for payment of fees for services is not affected by any contract the organization has with a third party for the functions of authorizing, processing, or paying claims.

A provider or any representative of a provider, regardless of whether the provider is under contract with the health maintenance organization, may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency a subscriber of an organization for payment of services for which the organization is liable, if the provider in good faith knows or should know that the organization is liable. This prohibition applies during the pendency of any claim for payment made by the provider to the organization for payment of the services and any legal proceedings or dispute resolution process to determine whether the organization is liable for the services if the provider is informed that such proceedings are taking place. It is presumed that a provider does not know and should not know that an organization is liable unless:

An organization, the office, and the department shall report any suspected violation of this section by a health care practitioner to the Department of Health and by a facility to the agency, which shall take such action as authorized by law.

As used in this section, the term “claim” for a noninstitutional provider means a paper or electronic billing instrument submitted to the health maintenance organization’s designated location that consists of the HCFA 1500 data set, or its successor, that has all mandatory entries for a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 463, or psychologists licensed under chapter 490 or any appropriate billing instrument that has all mandatory entries for any other noninstitutional provider. For institutional providers, “claim” means a paper or electronic billing instrument submitted to the health maintenance organization’s designated location that consists of the UB-92 data set or its successor with entries stated as mandatory by the National Uniform Billing Committee.

All claims for payment or overpayment, whether electronic or nonelectronic:

For all electronically submitted claims, a health maintenance organization shall:

For all nonelectronically submitted claims, a health maintenance organization shall:

If a health maintenance organization determines that it has made an overpayment to a provider for services rendered to a subscriber, the health maintenance organization must make a claim for such overpayment to the provider’s designated location. A health maintenance organization that makes a claim for overpayment to a provider under this section shall give the provider a written or electronic statement specifying the basis for the retroactive denial or payment adjustment. The health maintenance organization must identify the claim or claims, or overpayment claim portion thereof, for which a claim for overpayment is submitted.

Payment of a claim is considered made on the date the payment was mailed or electronically transferred. An overdue payment of a claim bears simple interest of 12 percent per year. Interest on an overdue payment for a claim or for any portion of a claim begins to accrue when the claim should have been paid, denied, or contested. The interest is payable with the payment of the claim.

A provider or any representative of a provider, regardless of whether the provider is under contract with the health maintenance organization, may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency a subscriber for payment of covered services for which the health maintenance organization contested or denied the provider’s claim. This prohibition applies during the pendency of any claim for payment made by the provider to the health maintenance organization for payment of the services or internal dispute resolution process to determine whether the health maintenance organization is liable for the services. For a claim, this pendency applies from the date the claim or a portion of the claim is denied to the date of the completion of the health maintenance organization’s internal dispute resolution process, not to exceed 60 days. This subsection does not prohibit collection by the provider of copayments, coinsurance, or deductible amounts due the provider.

The provisions of this section may not be waived, voided, or nullified by contract.

A health maintenance organization may not retroactively deny a claim because of subscriber ineligibility more than 1 year after the date of payment of the claim.

A health maintenance organization shall pay a contracted primary care or admitting physician, pursuant to such physician’s contract, for providing inpatient services in a contracted hospital to a subscriber if such services are determined by the health maintenance organization to be medically necessary and covered services under the health maintenance organization’s contract with the contract holder.

A permissible error ratio of 5 percent is established for health maintenance organizations’ claims payment violations of paragraphs (3)(a), (b), (c), and (e) and (4)(a), (b), (c), and (e). If the error ratio of a particular insurer does not exceed the permissible error ratio of 5 percent for an audit period, no fine shall be assessed for the noted claims violations for the audit period. The error ratio shall be determined by dividing the number of claims with violations found on a statistically valid sample of claims for the audit period by the total number of claims in the sample. If the error ratio exceeds the permissible error ratio of 5 percent, a fine may be assessed according to s. 624.4211 for those claims payment violations which exceed the error ratio. Notwithstanding the provisions of this section, the office may fine a health maintenance organization for claims payment violations of paragraphs (3)(e) and (4)(e) which create an uncontestable obligation to pay the claim. The office shall not fine organizations for violations which the office determines were due to circumstances beyond the organization’s control.

This section shall apply to all claims or any portion of a claim submitted by a health maintenance organization subscriber under a health maintenance organization subscriber contract to the organization for payment.

Notwithstanding paragraph (3)(b), where an electronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health maintenance organization, the pharmacy benefits manager shall, within 30 days of receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the organization’s action on the claim and payment of the claim is considered to be made on the date the notice or payment was mailed or electronically transferred.

Notwithstanding paragraph (4)(a), effective November 1, 2003, where a nonelectronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health maintenance organization, the pharmacy benefits manager shall provide acknowledgment of receipt of the claim within 30 days after receipt of the claim to the provider or provide a provider within 30 days after receipt with electronic access to the status of a submitted claim.

Notwithstanding the 30-month period provided in subsection (5), all claims for overpayment submitted to a provider licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 466 must be submitted to the provider within 12 months after the health maintenance organization’s payment of the claim. A claim for overpayment may not be permitted beyond 12 months after the health maintenance organization’s payment of a claim, except that claims for overpayment may be sought beyond that time from providers convicted of fraud pursuant to s. 817.234.

Notwithstanding any other provision of this section, all claims for underpayment from a provider licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 466 must be submitted to the health maintenance organization within 12 months after the health maintenance organization’s payment of the claim. A claim for underpayment may not be permitted beyond 12 months after the health maintenance organization’s payment of a claim.

A health maintenance organization must pay any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized by a provider empowered by contract with the health maintenance organization to authorize or direct the patient’s utilization of health care services and which was also authorized in accordance with the health maintenance organization’s current and communicated procedures, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.

A claim for treatment may not be denied if a provider follows the health maintenance organization’s authorization procedures and receives authorization for a covered service for an eligible subscriber, unless the provider provided information to the health maintenance organization with the willful intention to misinform the health maintenance organization.

Emergency services are subject to the provisions of s. 641.513 and are not subject to the provisions of this section.

It is the intent of the Legislature, through the adoption of this section, to ensure the financial soundness of fiscal intermediary services organizations established to develop, manage, and administer the business affairs of health care professional providers such as medical doctors, doctors of osteopathy, doctors of chiropractic medicine, doctors of podiatric medicine, doctors of dentistry, or other health professionals regulated by the Department of Health.

A fiscal intermediary services organization that is operated for the purpose of acquiring and administering provider contracts with managed care plans for professional health care services, including, but not limited to, medical, surgical, chiropractic, dental, and podiatric care, and which performs fiduciary or fiscal intermediary services shall be required to secure and maintain a fidelity bond in the minimum amount of 10 percent of the funds handled by the intermediary in connection with its fiscal and fiduciary services during the prior year or $1 million, whichever is less. The minimum bond amount shall be $50,000. The fidelity bond shall protect the fiscal intermediary from loss caused by the dishonesty of its employees and must remain unimpaired for as long as the intermediary continues in business in the state.

A fiscal intermediary services organization, as described in subsection (3), shall secure and maintain a surety bond on file with the office, naming the intermediary as principal. The bond must be obtained from a company authorized to write surety insurance in the state, and the office shall be obligee on behalf of itself and third parties. The penal sum of the bond may not be less than 5 percent of the funds handled by the intermediary in connection with its fiscal and fiduciary services during the prior year or $250,000, whichever is less. The minimum bond amount must be $10,000. The condition of the bond must be that the intermediary shall register with the office and shall not misappropriate funds within its control or custody as a fiscal intermediary or fiduciary. The aggregate liability of the surety for any and all breaches of the conditions of the bond may not exceed the penal sum of the bond. The bond must be continuous in form, must be renewed annually by a continuation certificate, and may be terminated by the surety upon its giving 30 days’ written notice of termination to the office. This subsection does not apply to a fiscal intermediary services organization that is owned, operated, or controlled by a third-party administrator holding a certificate of authority under part VII of chapter 626.

A fiscal intermediary services organization may not collect from the subscriber any payment other than the copayment or deductible specified in the subscriber agreement.

Any fiscal intermediary services organization, other than a hospital licensed under chapter 395, an insurer licensed under chapter 624, a third-party administrator licensed under chapter 626, a prepaid limited health service organization licensed under chapter 636, a health maintenance organization licensed under this chapter, a not-for-profit corporation that provides health care services directly to patients through employed, salaried physicians and that is affiliated with an accredited hospital licensed in this state, or a physician group practice as defined in s. 456.053(3)(h) which provides services under the scope of licenses of the members of the group practice, must register with the office and meet the requirements of this section. In order to register as a fiscal intermediary services organization, the organization must comply with ss. 641.21(1)(c), (d), and (j), 641.22(6), and 641.27. The fiscal intermediary services organization must also comply with the provisions of ss. 641.3155, 641.3156, and 641.51(4). Should the office determine that the fiscal intermediary services organization does not meet the requirements of this section, the registration shall be denied. If the registrant fails to maintain compliance with this section, the office may revoke or suspend the registration. In lieu of revocation or suspension of the registration, the office may levy an administrative penalty in accordance with s. 641.25.

The commission shall adopt rules necessary to administer this section.

No entity certificated as a health maintenance organization, other than a licensed insurer insofar as its name is concerned, shall use in its name, contracts, or literature any of the words “insurance,” “casualty,” “surety,” “mutual,” or any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in the state.

No person, entity, or health care plan not certificated under the provisions of this part shall use in its name, logo, contracts, or literature the phrase “health maintenance organization” or the initials “HMO”; imply, directly or indirectly, that it is a health maintenance organization; or hold itself out to be a health maintenance organization.

ASSETS.—In any determination of the financial condition of a health maintenance organization, there shall be allowed as “assets” only those assets that are owned by the health maintenance organization and that consist of:

The office, upon determining that a health maintenance organization’s asset has not been evaluated according to applicable law or that it does not qualify as an asset, shall require the health maintenance organization to properly reevaluate the asset or replace the asset with an asset suitable to the office within 30 days of receipt of written notification by the office of this determination, if the removal of the asset from the organization’s assets would impair the organization’s solvency.

ASSETS NOT ALLOWED.—In addition to assets impliedly excluded by the provisions of subsection (1), the following assets expressly shall not be allowed as assets in any determination of the financial condition of a health maintenance organization:

LIABILITIES.—In any determination of the financial condition of a health maintenance organization, liabilities to be charged against its assets shall include:

The office, upon determining that a health maintenance organization has failed to report liabilities that should have been reported, shall require a corrected report which reflects the proper liabilities to be submitted by the organization to the office within 10 working days of receipt of written notification.

INVESTMENTS GENERALLY.—Health maintenance organizations may invest their funds only in accordance with the provisions of this part. Notwithstanding the provisions of this part, however, the office may, after notice and hearing, order a health maintenance organization to limit or withdraw from certain investments or to discontinue certain investment practices, to the extent that the office finds the investment practices hazardous to the financial condition of the organization. At any such hearing, the office shall have the burden of presenting a prima facie case that the investment or investment practices are hazardous to the financial condition of the organization. If the office presents such a prima facie case, then it shall be the organization’s burden to demonstrate that the investment or investment practices are not hazardous to the financial condition of the organization.

ELIGIBLE INVESTMENTS.—

GENERAL QUALIFICATIONS.—

DIRECTORS MUST AUTHORIZE OR RATIFY INVESTMENTS.—No investment or loan shall be made or engaged in by any health maintenance organization unless the same has been authorized or ratified by the organization’s board of directors or by a committee, department, or section of the organization charged with the duty of supervising investments and loans. The minutes or records of any such committee, department, or section shall be maintained and regular reports of such committee, department, or section shall be submitted to the board of directors. No health maintenance organization shall subscribe to or participate in any underwriting of the purchase or sale of securities or property or enter into any agreement to withhold from sale any of its property, but the disposition of its property shall be at all times within the control of the board of directors. Nothing contained in this section shall prevent the board of directors of any health maintenance organization from depositing any of its securities with a committee appointed for the purpose of protecting the interest of security holders or with the authorities of any state or county where it is necessary to do so in order to secure permission to transact its appropriate business therein, and nothing contained in this section shall prevent the board of directors of the organization from depositing any securities as collateral for the securing of any bond required for the business of the organization.

EXCESSIVE COMMISSIONS AND CERTAIN INTERESTS PROHIBITED.—

SURPLUS AND DEPOSIT RESTRICTIONS.—Every health maintenance organization must maintain an amount equal to its required minimum surplus in coin or currency of the United States on hand or on deposit in any solvent national or state bank, savings and loan association, or trust company or in eligible securities or obligations as follows:

PROPERTY USED IN THE HEALTH MAINTENANCE ORGANIZATION’S BUSINESS.—Real estate, including leasehold estates, for the convenient accommodation of the organization’s business operations, including home office, branch administrative offices, hospitals, medical clinics, medical professional buildings, and any other facility to be used in the provision of health care services, or real estate for rental to any health care provider under contract with the organization to provide health care services which shall be used in the provision of health care services to members of the organization by that provider, is acceptable as an investment on the following conditions:

INVESTMENTS IN ADMINISTRATIVE AND MANAGEMENT SERVICE ENTITIES AND OTHER HEALTH CARE PROVIDERS.—A health maintenance organization may invest directly or indirectly in real estate, common and preferred stocks, bonds or debentures, including convertible debentures, or other evidences of debts of or equity in an entity if the entity is owned by or, with the approval of the office, under contract to the organization to provide management services, administrative services, or health care services for the organization, on the following conditions:

EXCHANGES OF FACILITIES OR ASSETS.—Health care or administrative service entities, if subsidiaries of or under contract to the health maintenance organization to provide administrative or health care services to the organization’s members, may exchange facilities or similar assets to be used in the organization’s business for stock of the organization. However, any exchange involving an entity under contract with the health maintenance organization must have the approval of the office prior to the exchange. These facilities or assets shall be valued in accordance with statutory accounting principles.

OTHER INVESTMENTS.—After satisfying the requirements of subsections (9), (10), (11), and (12), any funds of the health maintenance organization in excess of the minimum surplus required to be maintained under this part may be invested in any investment listed in this subsection or in subsections (9) and (14).

SPECIAL LIMITATION INVESTMENTS.—

INVESTMENT OF EXCESS FUNDS.—

PROHIBITED INVESTMENTS AND INVESTMENT UNDERWRITING.—

TIME LIMIT FOR DISPOSAL OF INELIGIBLE PROPERTY AND SECURITIES; EFFECT OF FAILURE TO DISPOSE.—

The provisions of this section supersede any inconsistent provision of s. 106 of the Secondary Mortgage Market Enhancement Act of 1984 (15 U.S.C. s. 77r).

The office shall not approve a dividend or distribution in excess of the maximum amount allowed in subsection (1) unless it determines that the distribution or dividend would not jeopardize the financial condition of the health maintenance organization, considering:

Any director of a health maintenance organization who knowingly votes for or concurs in declaration or payment of a dividend to stockholders when such declaration is in violation of this section is guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083, and shall be jointly and severally liable, together with other such directors likewise voting for or concurring, for any loss thereby sustained by creditors of the health maintenance organization to the extent of such dividend.

Any stockholder receiving such an illegal dividend shall be liable in the amount thereof to the health maintenance organization.

The office may revoke or suspend the certificate of authority of a health maintenance organization which has declared or paid such an illegal dividend.

Any person or entity which knowingly renews, issues, or delivers any health maintenance contract without first obtaining and thereafter maintaining a certificate of authority is guilty of a felony of the third degree, punishable as provided in s. 775.082 or s. 775.083.

Except as provided in subsection (1), any person, entity, or health maintenance organization which knowingly violates the provisions of this part is guilty of a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.

Any agent or representative, examining physician, applicant, or other person who knowingly makes any false and fraudulent statements or representation in, or with reference to, any application or negotiation for health maintenance organization coverage is, in addition to any other penalty provided by law, guilty of a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.

Any agent, representative, collector, or other person who, while acting on behalf of a health maintenance organization, receives or collects its funds or premium payments and fails to satisfactorily account for or turn over, when required, all such funds or payments is, in addition to the other penalties provided for by law, guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.

Any person who, without authority granted by a health maintenance organization, collects or secures cash advances, premium payments, or other funds owing to the health maintenance organization or otherwise conducts the business of a health maintenance organization without its authority is, in addition to the other penalties provided for by law, guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.

With respect to a health maintenance contract, no person shall, unless licensed and appointed as a health insurance agent in accordance with the applicable provisions of the Florida Insurance Code:

All qualifications, disciplinary provisions, licensing and appointment procedures, fees, and related matters contained in the Florida Insurance Code which apply to the licensing and appointment of health insurance agents by insurers shall apply to health maintenance organizations and to persons licensed or appointed by the health maintenance organization as their agents.

An examination, license, or appointment is not required of any regular salaried officer or employee of a health maintenance organization who devotes substantially all of his or her services to activities other than the solicitation of health maintenance organization contracts from the public and who receives no commission or other compensation directly dependent upon the solicitation of such contracts. This exemption does not apply to the solicitation of Medicaid eligible subscribers.

All agents and health maintenance organizations shall comply with and be subject to the applicable provisions of ss. 641.309 and 409.912(21), and all companies and entities appointing agents shall comply with s. 626.451, when marketing for any health maintenance organization licensed pursuant to this part, including those organizations under contract with the Agency for Health Care Administration to provide health care services to Medicaid recipients or any private entity providing health care services to Medicaid recipients pursuant to a prepaid health plan contract with the Agency for Health Care Administration.

Whether or not delinquency proceedings as to a health maintenance organization have been or are to be initiated, a director or officer of a health maintenance organization, except with the written permission of the office, may not authorize or permit the health maintenance organization to solicit or accept new or renewal health maintenance contracts or provider contracts in this state after the director or officer knew, or reasonably should have known, that the health maintenance organization was insolvent or impaired. As used in this section, the term “impaired” means that the health maintenance organization does not meet the requirements of s. 641.225.

Any director or officer who violates this section is guilty of a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

MISREPRESENTATION AND FALSE ADVERTISING OF HEALTH MAINTENANCE CONTRACTS.—Knowingly making, issuing, or circulating, or causing to be made, issued, or circulated, any estimate, illustration, circular, statement, sales presentation, omission, or comparison which:

FALSE INFORMATION AND ADVERTISING GENERALLY.—Knowingly making, publishing, disseminating, circulating, or placing before the public, or causing, directly or indirectly, to be made, published, disseminated, circulated, or placed before the public:

an advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of the health maintenance organization which is untrue, deceptive, or misleading.

DEFAMATION.—Knowingly making, publishing, disseminating, or circulating, directly or indirectly, or aiding, abetting, or encouraging the making, publishing, disseminating, or circulating of, any oral or written statement, or any pamphlet, circular, article, or literature, which is false or maliciously critical of any person and which is calculated to injure such person.

FALSE STATEMENTS AND ENTRIES.—

UNFAIR CLAIM SETTLEMENT PRACTICES.—

FAILURE TO MAINTAIN COMPLAINT-HANDLING PROCEDURES.—Failure of any person to maintain a complete record of all the complaints received since the date of the most recent examination of the health maintenance organization by the office. For the purposes of this subsection, the term “complaint” means any written communication primarily expressing a grievance and requesting a remedy to the grievance.

OPERATION WITHOUT A SUBSISTING CERTIFICATE OF AUTHORITY.—Operation of a health maintenance organization by any person or entity without a subsisting certificate of authority therefor or renewal, issuance, or delivery of any health maintenance contract by a health maintenance organization, person, or entity without a subsisting certificate of authority.

MISREPRESENTATION IN HEALTH MAINTENANCE ORGANIZATION APPLICATIONS.—Knowingly making false or fraudulent statements or representations on, or relative to, an application for a health maintenance contract for the purpose of obtaining a fee, commission, money, or other benefits from any health maintenance organization; agent; or representative, broker, or individual.

TWISTING.—Knowingly making any misleading representations or incomplete or fraudulent comparisons of any health maintenance contracts or health maintenance organizations or of any insurance policies or insurers for the purpose of inducing, or intending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or health maintenance contract or to take out a health maintenance contract or policy of insurance in another health maintenance organization or insurer.

ILLEGAL DEALINGS IN PREMIUMS; EXCESS OR REDUCED CHARGES FOR HEALTH MAINTENANCE COVERAGE.—

FALSE CLAIMS; OBTAINING OR RETAINING MONEY DISHONESTLY.—Any agent or representative, physician, claimant, or other person who causes to be presented to any health maintenance organization a false claim for payment knowing the same to be false.

PROHIBITED DISCRIMINATORY PRACTICES.—A health maintenance organization may not:

MISREPRESENTATION IN HEALTH MAINTENANCE ORGANIZATION; AVAILABILITY OF PROVIDERS.—Knowingly misleading potential enrollees as to the availability of providers.

ADVERSE ACTION AGAINST A PROVIDER.—Any retaliatory action by a health maintenance organization against a contracted provider, including, but not limited to, termination of a contract with the provider, on the basis that the provider communicated information to the provider’s patient regarding medical care or treatment options for the patient when the provider deems knowledge of such information by the patient to be in the best interest of the patient.

Whenever the department or office has reason to believe that any person, entity, or health maintenance organization has engaged, or is engaging, in this state in any unfair method of competition or any unfair or deceptive act or practice as defined in s. 641.3903 or is operating a health maintenance organization without a certificate of authority as required by this part and that a proceeding by it in respect thereto would be to the interest of the public, the department or office shall conduct or cause to have conducted a hearing in accordance with chapter 120.

The department or office, a duly empowered hearing officer, or an administrative law judge shall, during the conduct of such hearing, have those powers enumerated in s. 120.569; however, the penalties for failure to comply with a subpoena or with an order directing discovery shall be limited to a fine not to exceed $1,000 per violation.

Statements of charges, notices, and orders under this part may be served by anyone duly authorized by the department or office, either in the manner provided by law for service of process in civil actions or by certifying and mailing a copy thereof to the person, entity, or health maintenance organization affected by the statement, notice, order, or other process at her or his or its residence or principal office or place of business. The verified return by the person so serving such statement, notice, order, or other process, setting forth the manner of the service, shall be proof of the same, and the return postcard receipt for such statement, notice, order, or other process, certified and mailed as aforesaid, shall be proof of service of the same.

Suspension or revocation of the health maintenance organization’s certificate of authority if it knew, or reasonably should have known, it was in violation of this part.

If it is determined that the person or entity charged has engaged in the business of operating a health maintenance organization without a certificate of authority, an administrative penalty not to exceed $1,000 for each health maintenance contract offered or effectuated.

A monetary penalty of not more than $200,000 as to all matters determined in such hearing.

Suspension or revocation of the health maintenance organization’s certificate of authority.

Failure to pay any required premium or contribution unless such nonpayment of premium was due to acts of an employer or person other than the individual;

Replacement of any discontinued group coverage by similar group coverage within 31 days;

Fraud or material misrepresentation in applying for any benefits under the health maintenance contract;

Disenrollment for cause. When the requirements of paragraphs (a), (b), and (c) have been met, a health maintenance organization may disenroll a subscriber for cause if the subscriber’s behavior is disruptive, unruly, abusive, or uncooperative to the extent that his or her continuing membership in the organization seriously impairs the organization’s ability to furnish services to either the subscriber or other subscribers.

Willful and knowing misuse of the health maintenance organization identification membership card by the subscriber;

Willful and knowing furnishing to the organization by the subscriber of incorrect or incomplete information for the purpose of fraudulently obtaining coverage or benefits from the organization; or

The subscriber has left the geographic area of the health maintenance organization with the intent to relocate or establish a new residence outside the organization’s geographic area.

TIME LIMIT.—Written application for the converted contract shall be made and the first premium paid to the health maintenance organization not later than 63 days after such termination. However, if termination was the result of failure to pay any required premium or contribution and such nonpayment of premium was due to acts of an employer or group contract holder other than the employee or individual subscriber, written application for the contract must be made and the first premium must be paid not later than 63 days after notice of termination is mailed by the organization or the employer, whichever is earlier, to the employee’s or individual’s last address as shown by the record of the organization or the employer, whichever is applicable. In such case of termination due to nonpayment of premium by the employer or group contract holder, the premium for the converted contract may not exceed the rate for the prior group coverage for the period of coverage under the converted contract prior to the date notice of termination is mailed to the employee or individual subscriber. For the period of coverage after such date, the premium for the converted contract is subject to the requirements of subsection (3).

EVIDENCE OF INSURABILITY.—The converted contract shall be issued without evidence of insurability.

CONVERSION PREMIUM.—The premium for the converted contract shall be determined in accordance with premium rates applicable to the age and class of risk of each person to be covered under the converted contract and to the type and amount of coverage provided. However, the premium for the converted contract may not exceed 200 percent of the standard risk rate, as established by the office under s. 627.6675(3). The mode of payment for the converted contract shall be quarterly or more frequently at the option of the organization, unless otherwise mutually agreed upon between the subscriber and the organization.

EFFECTIVE DATE OF COVERAGE.—The effective date of the converted contract shall be the day following the termination of coverage under the group health maintenance contract. However, until application is made and the first premium is paid, the health maintenance organization may charge the subscriber, on a fee-for-service basis, for any services rendered to the subscriber after the date in which the subscriber ceases to be eligible under the group health maintenance contract. When application is made and the first premium is paid, the organization shall reimburse the subscriber for any payment made by the subscriber for covered services under the converted contract.

SCOPE OF COVERAGE.—The converted contract shall cover the subscriber or dependents who were covered by the group health maintenance contract on the date of termination of coverage. At the option of the health maintenance organization, a separate converted contract may be issued to cover any dependent.

OPTIONAL COVERAGE.—The health maintenance organization shall not be required to issue a converted contract covering any person if such person is or could be covered by Medicare, Title XVIII of the Social Security Act, as added by the Social Security Amendments of 1965, or as later amended or superseded. Furthermore, the health maintenance organization shall not be required to issue a converted health maintenance contract covering any person if:

REASONS FOR CANCELLATION; TERMINATION.—The converted health maintenance contract must contain a cancellation or nonrenewability clause providing that the health maintenance organization may refuse to renew the contract of any person covered thereunder, but cancellation or nonrenewal must be limited to one or more of the following reasons:

BENEFITS OFFERED.—A health maintenance organization shall not be required to issue a converted contract which provides benefits in excess of those provided under the group health maintenance contract from which conversion is made. The converted health maintenance contract shall meet the requirements of law pertaining to health maintenance contracts and shall include a level of benefits for minimum services which is substantially similar to the level of benefits for these services included in the group health maintenance organization contract from which the termination is made.

PREEXISTING CONDITION PROVISION.—The converted health maintenance contract shall not exclude a preexisting condition not excluded by the group contract. However, the converted health maintenance contract may provide that any coverage benefits thereunder may be reduced by the amount of any coverage or benefits under the group health maintenance contract after the termination of the person’s coverage or benefits thereunder. The converted health maintenance contract may also include provisions so that during the first coverage year the coverage or benefits under the converted contract, together with the coverage or benefits under the group health maintenance contract, shall not exceed those that would have been provided had the individual’s coverage or benefits under the group contract remained in force and effect.

ALTERNATE PLANS.—The health maintenance organization shall offer a standard health benefit plan as established pursuant to s. 627.6699(12). The health maintenance organization may, at its option, also offer alternative plans for group health conversion in addition to those required by this section, provided any alternative plan is approved by the office or is a converted policy, approved under s. 627.6675 and issued by an insurance company authorized to transact insurance in this state. Approval by the office of an alternative plan shall be based on compliance by the alternative plan with the provisions of this part and the rules promulgated thereunder, applicable provisions of the Florida Insurance Code and rules promulgated thereunder, and any other applicable law.

RETIREMENT COVERAGE.—In the event that coverage would be continued under the group health maintenance contract on an employee following the employee’s retirement prior to the time she or he is or could be covered by Medicare, the employee may elect, in lieu of such continuation of group coverage, to have the same conversion rights as would apply had her or his coverage terminated at retirement by reason of termination of employment or membership.

CONVERSION PRIVILEGE ALLOWED.—Subject to the conditions set forth above, the conversion privilege shall also be available:

GROUP COVERAGE IN LIEU OF INDIVIDUAL COVERAGE.—The health maintenance organization may elect to provide group health maintenance organization coverage through a group converted contract in lieu of the issuance of an individual converted contract.

NOTIFICATION.—A notification of the conversion privilege shall be included in each health maintenance contract and in any certificate or member’s handbook. The organization shall mail an election and premium notice form, including an outline of coverage, on a form approved by the office, within 14 days after any individual who is eligible for a converted health maintenance contract gives notice to the organization that the individual is considering applying for the converted contract or otherwise requests such information. The outline of coverage must contain a description of the principal benefits and coverage provided by the contract and its principal exclusions and limitations, including, but not limited to, deductibles and coinsurance.

Faced with the continuation of mounting health care costs, coupled with the interest of the state in high-quality care, the Legislature has determined that there is a need to explore intermediate or limited levels of delivery of prepaid health care services, with a view toward achieving greater efficiency and economy in the provision of these services.

Prepaid health clinics, referred to in this part as “clinics,” are developing rapidly in communities in the state. Through these organizations, structured in various forms, basic services are provided directly to groups of people who make regular premium payments as a condition upon their participation. These plans, when properly operated, emphasize effective cost and quality controls.

It is the purpose of this part to:

Although it is the intent of this part to provide an opportunity for the development of prepaid health clinics, there is no intent to impair the present system for the delivery of health services.

The Legislature has determined that the operation of a prepaid health clinic, or the issuance, delivery, or renewal of a prepaid health clinic contract, without a subsisting certificate of authority constitutes a danger to the citizens of this state and exposes a subscriber to immediate and irreparable injury, loss, or damage.

“Basic services” includes any of the following: emergency care, physician care other than hospital inpatient physician services, ambulatory diagnostic treatment, and preventive health care services.

“Guaranteeing organization” means an organization that is domiciled in the United States; that has authorized service of process against it; and that has appointed the Chief Financial Officer as its agent for service of process in connection with any cause of action arising in this state, based upon any guarantee entered into under this part.

“Insolvent” or “insolvency” means the inability of a prepaid health clinic to discharge its liabilities as they become due in the normal course of business.

“Prepaid health clinic” means any organization authorized under this part which provides, either directly or through arrangements with other persons, basic services to persons enrolled with such organization, on a prepaid per capita or prepaid aggregate fixed-sum basis, including those basic services which subscribers might reasonably require to maintain good health. However, no clinic that provides or contracts for, either directly or indirectly, inpatient hospital services, hospital inpatient physician services, or indemnity against the cost of such services shall be a prepaid health clinic.

“Prepaid health clinic contract” means any contract entered into by a prepaid health clinic with a subscriber or group of subscribers to provide any of the basic services in exchange for a prepaid per capita or prepaid aggregate fixed sum.

“Provider” means any physician or person other than a hospital that furnishes health care services and is licensed or authorized to practice in this state.

“Reporting period” means the particular span of time by or for which accounts are redeemed on an annualized basis.

“Subscriber” means an individual who has contracted, or on whose behalf a contract has been entered into, with a prepaid health clinic for health care services.

“Surplus” means total unencumbered assets in excess of total liabilities. Surplus includes capital stock, capital in excess of par, and retained earnings and may include surplus notes.

“Surplus notes” means debt that has been guaranteed by the United States Government or its agencies or debt that has been subordinated to all claims of subscribers and general creditors of the prepaid health clinic.

No person may operate a prepaid health clinic without first obtaining a certificate of authority from the office. The office shall not issue a certificate of authority to any applicant which does not possess a valid Health Care Provider Certificate issued by the Agency for Health Care Administration.

Each application for a certificate of authority shall be on such form as the commission prescribes, and such application shall be accompanied by:

As a condition precedent to the issuance of any certificate, the applicant has obtained a Health Care Provider Certificate from the Agency for Health Care Administration pursuant to part III of this chapter.

The proposed rates are actuarially sound for the benefits provided, including administrative costs.

The applicant has met the minimum surplus requirements of s. 641.407.

The procedures for offering basic services and offering and terminating contracts to subscribers will not unfairly discriminate on the basis of age, health, or economic status. However, this subsection does not prohibit reasonable underwriting classifications for the purposes of establishing contract rates, nor does it prohibit experience rating.

The procedures for offering basic services and offering and terminating contracts to subscribers will not discriminate on the basis of sex, race, or national origin.

The applicant furnishes evidence of adequate insurance coverage or an adequate plan for self-insurance to respond to claims for injuries arising out of the furnishing of basic services.

The ownership, control, or management of the applicant is competent and trustworthy and possesses managerial experience that would make the proposed clinic operation beneficial to the subscribers. The office shall not grant or continue authority to transact the business of a prepaid health clinic in this state at any time during which the office has good reason to believe that the ownership, control, or management of the clinic is under the control of any person whose business operations are or have been marked by business practices or conduct that is to the detriment of the public, stockholders, investors, or creditors; by the improper manipulation of assets or of accounts; or by bad faith.

The application and the applicant are in conformity with all requirements of this part.

Each prepaid health clinic shall have and maintain minimum surplus in accordance with the following schedule: On January 1, 1996, $150,000 or 10 percent of total liabilities, whichever is greater.

In lieu of having any minimum surplus, the prepaid health clinic may provide a written guaranty to assure payment of covered subscriber claims if the guaranteeing organization has been in operation for at least 3 years and has a surplus, not including land, buildings, and equipment, equal to the product of 2 times the amount of the required statutory surplus. Such guaranteeing organization and such written guaranty must be acceptable to, and approved by, the office. The office shall consider the likelihood of the payment of subscriber claims in granting or withholding such approval.

No person issued a certificate of authority as a prepaid health clinic, other than a licensed insurer, insofar as its name is concerned, shall use in its name, contracts, or literature any of the words “health maintenance organization,” “HMO,” “insurance,” “casualty,” “surety,” or “mutual”; any other word descriptive of the health maintenance organization, insurance, casualty, or surety business; or any other word deceptively similar to the name or description of a health maintenance organization, insurance corporation, or surety corporation doing business in this state.

A person that has not been issued a certificate of authority under the provisions of this part shall not use in its name, logo, contracts, or literature the phrase “prepaid health clinic” or the initials “PHC”; nor imply, directly or indirectly, that it is a prepaid health clinic; nor hold itself out to be a prepaid health clinic.

Every prepaid health clinic shall comply with one of the following paragraphs:

In determining the sufficiency of the insurance required under paragraph (1)(a) or the surety bond required under paragraph (1)(b), the office may consider the number of subscribers, the basic services included in subscriber contracts, and the cost of providing such basic services to subscribers in the geographic area served.

Every prepaid health clinic shall deposit with the department a cash deposit in the amount of $30,000 to guarantee that the obligations to the subscribers will be performed.

Each prepaid health clinic shall file a report with the office, annually on or before March 1, or within 3 months of the end of the reporting period of the clinic, or within such extension of time for the filing of the report as the office, for good cause, may grant. The report of the prepaid health clinic must be filed on forms prescribed by the commission and must be verified under oath by two executive officers of the clinic or, if the clinic is not a corporation, verified under oath by two persons who are principal managing directors of the affairs of the clinic. The report of the clinic shall show the condition of the clinic on the last day of the immediately preceding reporting period. Such report shall include:

Any clinic which neglects to file the annual report in the form and within the time required by this section is subject to an administrative penalty, not to exceed $100 for each day during which the neglect continues; and, upon notice by the office to that effect, the authority of the clinic to do business in this state shall cease while such default continues.

Each prepaid health clinic shall provide records and information to the Agency for Health Care Administration pursuant to s. 409.910(20) and (21) for the sole purpose of identifying potential coverage for claims filed with the agency and its fiscal agents for payment of medical services under the Medicaid program.

Any information provided by a prepaid health clinic under this section to the agency shall not be considered a violation of any right of confidentiality or contract that the prepaid health clinic may have with covered persons. The prepaid health clinic is immune from any liability that it may otherwise incur through its release of information to the agency under this section.

Every prepaid health clinic shall pay to the office the following fees:

The fees charged under this section shall be distributed as follows:

Any applicant that has been issued a certificate of authority for a prepaid health clinic, which certificate of authority is subsisting and otherwise in compliance with this part, may enter into prepaid health clinic contracts in this state.

The rates charged by any clinic to its subscribers shall not be excessive, inadequate, or unfairly discriminatory. The commission, in accordance with generally accepted actuarial practice, may define by rule what constitutes excessive, inadequate, or unfairly discriminatory rates and may require whatever information the commission deems necessary to determine that a rate or proposed rate meets the requirements of this subsection.

No clinic shall issue or agree to issue any prepaid health clinic contract to a subscriber unless the contract has first been filed with, and approved by, the office.

Every contract must clearly state all of the services, including basic services, to which a subscriber is entitled under the contract and must include a clear and understandable statement of any limitations on the services or kinds of services to be provided, including any exclusion of any copayment feature or any schedule of benefits required by the contract or by any insurer or entity which is underwriting any of the services offered by the clinic. The contract shall also state where and in what manner the basic services may be obtained.

Every subscriber shall receive a clear and understandable description of the method of the clinic for resolving subscriber grievances; such method shall be set forth in the contract and shall be approved by the office on the basis of its underlying fairness.

The consideration paid for a prepaid health clinic contract shall be a part of the contract and shall be stated in the individual contract issued to a subscriber. Regardless of the duration or term of the prepaid health clinic contract, the consideration shall be payable monthly, prorated based upon the contract duration or term.

All advertisements by a prepaid health clinic, if printed or broadcast in a language other than English, also shall be available in English and shall be furnished to the office upon request. As used in this subsection, the term “advertisement” means any advertisement, circular, pamphlet, brochure, or other printed material disclosing or disseminating advertising material or information by a clinic to prospective or existing subscribers and includes any radio or television transmittal of an advertisement or information.

Every prepaid health clinic contract shall be executed in the name of, and on behalf of, the clinic by an officer or employee of the clinic, the attorney in fact of the clinic, or a representative of the clinic duly authorized by the clinic.

A facsimile signature of any such individual executing the contract on behalf of the clinic may be used in lieu of his or her original signature.

No contract which is otherwise valid shall be rendered invalid by reason of the apparent execution of the contract on behalf of the clinic by the imprinted facsimile signature of an individual who was not authorized, as of the date of the contract, to execute the contract on behalf of the clinic.

Any prepaid health clinic contract, or contract rider, endorsement, attachment, or addendum, that contains any condition or provision not in compliance with the requirements of this part but is otherwise valid shall not be rendered invalid by such condition or provision, except as provided in s. 641.421, but shall be construed and applied in accordance with such conditions and provisions as would have applied had such contract, rider, endorsement, attachment, or addendum been in full compliance with this contract. In the event a clinic issues or delivers any contract for an amount which exceeds any limitation otherwise provided for in this part, such clinic is liable to the subscriber or his or her beneficiary for the full amount stated in the contract in addition to any other penalties that may be imposed under this part.

Any contract delivered or issued for delivery in this state covering a subscriber resident, located, or to be performed in this state, which subscriber, pursuant to the provisions of this part, the clinic may not lawfully provide under such a contract, is cancelable at any time by the clinic, any provision of the contract to the contrary notwithstanding; and the clinic shall promptly cancel the contract in accordance with the request of the office for such cancellation. No such illegality or cancellation shall be deemed to relieve the clinic of any liability incurred by the clinic under the contract while the contract was in force or to prohibit the clinic from retaining the pro rata earned premium on the contract. This provision does not relieve the clinic from any penalty otherwise incurred by the clinic under this part on account of any such violation.

Every prepaid health clinic contract shall be construed according to the entirety of its terms and conditions as set forth in the contract and as amplified, extended, or modified by any application therefor or any rider, endorsement, attachment, or addendum to the contract.

The term “physician” or “medical doctor,” when used in any contract providing for the payment of surgical procedures which are specified in the contract or performed in an accredited hospital in consultation with a licensed physician and are within the scope of a dentist’s professional license, shall be construed to include a dentist who performs such specified procedures.

Notwithstanding any other provision of law, when any contract provides for the payment for procedures which are specified in the contract and are within the scope of an optometrist’s or podiatric physician’s professional license, such contract shall be construed to include payment to an optometrist or podiatric physician who performs such procedures. In the case of podiatric medicine services, payments shall be made in accordance with the coverage now provided for medical and surgical benefits.

Any prepaid health clinic which utilizes the services of a provider who is not licensed or otherwise authorized by law to provide such services is guilty of a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

Every prepaid health clinic or provider shall display, in a prominent place in the clinic’s or provider’s waiting area at which the provider treats subscribers, a true and correct copy of the current and valid license or legal authorization of each provider.

The professional judgment of a physician licensed under chapter 458 or chapter 459 concerning the proper course of treatment of a subscriber shall not be subject to modification by the prepaid health clinic or its board of directors, officers, or administrators. However, this subsection does not prohibit a utilization management program established by a prepaid health clinic.

MISREPRESENTATION AND FALSE ADVERTISING OF PREPAID HEALTH CLINIC CONTRACTS.—Knowingly making, issuing, circulating, or causing to be made, issued, or circulated, any estimate, illustration, circular, statement, sales presentation, omission, or comparison which:

FALSE INFORMATION AND ADVERTISING, GENERALLY.—Knowingly making, publishing, disseminating, circulating, or placing before the public, or causing, directly or indirectly, there to be made, published, disseminated, circulated, or placed before the public:

an advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of the prepaid health clinic which is untrue, deceptive, or misleading.

DEFAMATION.—Knowingly making, publishing, disseminating, or circulating, directly or indirectly, or aiding, abetting, or encouraging the making, publishing, disseminating, or circulating of, any oral or written statement, or any pamphlet, circular, article, or literature, which is false or maliciously critical of, or derogatory to, any person and which is calculated to injure such person.

FALSE STATEMENTS AND ENTRIES.—

UNFAIR CLAIM SETTLEMENT PRACTICES.—

FAILURE TO MAINTAIN COMPLAINT-HANDLING PROCEDURES.—Failure of a person to maintain a record of each complaint received for a 3-year period after the date of the receipt of the written complaint.

REFUSAL TO ISSUE A CONTRACT.—The refusal to issue a prepaid health clinic contract solely because of an individual’s race, color, national origin, sex, marital status, or creed.

OPERATION WITHOUT A SUBSISTING CERTIFICATE OF AUTHORITY.—Operation of a prepaid health clinic by any person or entity without a subsisting certificate of authority, or the issuance, delivery, or renewal of any prepaid health clinic contract by a prepaid health clinic, person, or entity without a subsisting certificate of authority.

The office is vested with the power to seek a temporary restraining order:

The office and the Agency for Health Care Administration are each vested with the power to seek a temporary restraining order on their behalf or on behalf of a subscriber or subscribers of a prepaid health clinic that is being operated in violation of any provision of this part or any rule promulgated under this part, or any other applicable law or rule.

Whenever the office has reason to believe that a person, entity, or prepaid health clinic has engaged, or is engaging, in this state in any unfair method of competition or any unfair or deceptive act or practice as defined in s. 641.441, or is operating a prepaid health clinic without a certificate of authority as required by this part or otherwise operating in violation of any provision of this part or rule adopted pursuant to this part, and that a proceeding by the office in respect thereto would be in the interest of the public, the office shall conduct, or cause to have conducted, a hearing in accordance with chapter 120.

The office, a duly empowered hearing officer, or an administrative law judge shall, during the conduct of such hearing, have those powers enumerated in s. 120.569; however, the penalty for the failure to comply with a subpoena or with an order directing discovery is limited to a fine not to exceed $1,000 per violation.

A statement of charges, notice, or order under this part may be served by anyone duly authorized by the office, either in the manner provided by law for service of process in civil actions or by certifying and mailing a copy of the statement of charges, notice, or order to the person, entity, or prepaid health clinic affected by the statement, notice, or order or other process at his or her or its residence or principal office or place of business. The verified return by the person so serving such statement, notice, or order or other process, setting forth the manner of the service, is proof of such service; and the return postcard receipt for such statement, notice, or order or other process, certified and mailed as provided in this subsection, is proof of the service of the statement, notice, or order or other process.

The suspension or revocation of the certificate of authority of the prepaid health clinic if it knew, or reasonably should have known, that it was in violation of this part.

If it is determined that the person or entity charged has engaged in the business of operating a prepaid health clinic without a certificate of authority, an administrative penalty not to exceed $1,000 for each prepaid health clinic contract offered or effectuated.

A monetary penalty of not more than $50,000 as to all matters determined in such hearing.

The suspension or revocation of the certificate of authority of the prepaid health clinic.

The maintenance of a valid and current Health Care Provider Certificate issued pursuant to part III of this chapter is a condition of the maintenance of a valid and current certificate of authority issued by the office to operate a prepaid health clinic. Revocation or nonrenewal of a Health Care Provider Certificate shall be deemed to be an automatic and immediate cancellation of a prepaid health clinic’s certificate of authority.

The office may suspend the authority of a clinic to enroll new subscribers or revoke any certificate of authority issued to a prepaid health clinic, or order compliance within 60 days, if the office finds that any of the following conditions exist:

The office shall, in its order suspending the authority of a clinic to enroll new subscribers, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the clinic prior to reinstatement of its authority to enroll new subscribers. The order of suspension is subject to rescission or modification by further order of the office prior to the expiration of the suspension period. Reinstatement shall not be made unless requested by the clinic; however, the office shall not grant reinstatement if it finds that the circumstances for which the suspension occurred still exist or are likely to recur.

Except as provided in this part, the Florida Insurance Code, as defined in s. 624.01, does not apply to prepaid health clinics certificated under this part; and prepaid health clinics certificated under this part are not subject to part I of this chapter.

The solicitation of subscribers by a prepaid health clinic or its representative shall not be construed to be violative of any provision of law relating to solicitation or advertising by health professionals if the prepaid health clinic is operating pursuant to a subsisting certificate of authority.

“Adverse determination” means a coverage determination by an organization that an admission, availability of care, continued stay, or other health care service has been reviewed and, based upon the information provided, does not meet the organization’s requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness, and coverage for the requested service is therefore denied, reduced, or terminated.

“Agency” means the Agency for Health Care Administration.

“Clinical peer” means a health care professional in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review.

“Clinical review criteria” means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by the organization to determine, for coverage purposes, the necessity and appropriateness of health care services.

“Complaint” means any expression of dissatisfaction by a subscriber, including dissatisfaction with the administration, claims practices, or provision of services, which relates to the quality of care provided by a provider pursuant to the organization’s contract and which is submitted to the organization or to a state agency. A complaint is part of the informal steps of a grievance procedure and is not part of the formal steps of a grievance procedure unless it is a grievance as defined in subsection (10).

“Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.

“Emergency medical condition” means:

“Emergency services and care” means medical screening, examination, and evaluation by a physician or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists, and if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition within the service capability of a hospital.

“Geographic area” means the county or counties, or any portion of a county or counties, within which the health maintenance organization provides or arranges for comprehensive health care services to be available to its subscribers.

“Grievance” means a written complaint submitted by or on behalf of a subscriber to an organization or a state agency regarding the:

A grievance does not include a written complaint submitted by or on behalf of a subscriber eligible for a grievance and appeals procedure provided by an organization pursuant to contract with the Federal Government under Title XVIII of the Social Security Act.

“Health care services” means comprehensive health care services, as defined in s. 641.19, when applicable to a health maintenance organization, and means basic services, as defined in s. 641.402, when applicable to a prepaid health clinic.

“Minimum services” includes any of the following: emergency care, inpatient hospital services, physician care, ambulatory diagnostic treatment, and preventive health care services.

“Organization” means any health maintenance organization as defined in s. 641.19 and any prepaid health clinic as defined in s. 641.402.

“Provider” means any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state. To submit or pursue a grievance on behalf of a subscriber, a provider must previously have been directly involved in the treatment or diagnosis of the subscriber.

“Retrospective review” means a review, for coverage purposes, of medical necessity conducted after services have been provided to a patient.

“Subscriber” means an individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care services.

“Urgent grievance” means an adverse determination when the standard timeframe of the grievance procedure would seriously jeopardize the life or health of a subscriber or would jeopardize the subscriber’s ability to regain maximum function.

No person or governmental unit shall establish, conduct, or maintain a health maintenance organization or a prepaid health clinic in this state without first obtaining a health care provider certificate under this part.

The office shall not issue a certificate of authority under part I or part II of this chapter to any applicant which does not possess a valid health care provider certificate issued by the agency under this part.

Each application for a health care provider certificate shall be on a form prescribed by the agency. The following information and documents shall be submitted by an applicant and maintained, after certification under this part, by each organization and shall be available for inspection or examination by the agency at the offices of an organization at any time during regular business hours. The agency shall give reasonable notice to an organization prior to any onsite inspection or examination of its records or premises conducted under this section. The agency may require that the following information or documents be submitted with the application:

The agency shall issue a health care provider certificate to an applicant filing a completed application in conformity with ss. 641.48 and 641.49, upon payment of the prescribed fee, and upon the agency’s being satisfied that the applicant has the ability to provide quality of care consistent with the prevailing professional standards of care and which applicant otherwise meets the requirements of this part.

A certificate, unless sooner suspended or revoked, shall automatically expire 2 years from the date of issuance, or at any time accreditation is withdrawn, unless renewed by the organization. The certificate shall be renewed upon application for renewal and payment of a renewal fee of $1,000, provided that the organization is in compliance with the requirements of this part and all rules adopted under this part. An application for renewal of a certificate shall be made 90 days prior to expiration of the certificate, on forms provided by the agency. The renewal application shall not require the resubmission of any documents previously filed with the agency if such documents have remained valid and unchanged since their original filing.

The organization shall demonstrate its capability to provide health care services in the geographic area that it proposes to service. In addition, each health maintenance organization shall notify the agency of its intent to expand its geographic area at least 60 days prior to the date it plans to begin providing health care services in the new area. Prior to the date the health maintenance organization begins enrolling members in the new area, it must submit a notarized affidavit, signed by two officers of the organization who have the authority to legally bind the organization, to the agency describing and affirming its existing and projected capability to provide health care services to its projected number of subscribers in the new area. The notarized affidavit shall further assure that, 15 days prior to providing health care services in the new area, the health maintenance organization shall be able, through documentation or otherwise, to demonstrate that it shall be capable of providing services to its projected subscribers for at least the first 60 days of operation. If the agency determines that the organization is not capable of providing health care services to its projected number of subscribers in the new area, the agency may issue an order as required under chapter 120 prohibiting the organization from expanding into the new area. In any proceeding under chapter 120, the agency shall have the burden of establishing that the organization is not capable of providing health care services to its projected number of subscribers in the new area.

The organization shall ensure that the health care services it provides to subscribers, including physician services as required by s. 641.19(12)(d) and (e), are accessible to the subscribers, with reasonable promptness, with respect to geographic location, hours of operation, provision of after-hours service, and staffing patterns within generally accepted industry norms for meeting the projected subscriber needs. The health maintenance organization must provide treatment authorization 24 hours a day, 7 days a week. Requests for treatment authorization may not be held pending unless the requesting provider contractually agrees to take a pending or tracking number.

The organization shall exercise reasonable care in assuring that delivered health care services are performed by appropriately licensed providers.

The organization shall have a system for verification and examination of the credentials of each of its providers. The organization shall maintain in a central file the credentials, including a copy of the current Florida license, of each of its physicians.

Every organization shall establish standards and procedures reasonably necessary to provide for the maintenance of a readily accessible medical records system which is adequate to accommodate necessary information including an accurate documentation of all services provided for every enrolled subscriber.

Each organization’s contracts, certificates, and subscriber handbooks shall contain a provision, if applicable, disclosing that, for certain types of described medical procedures, services may be provided by physician assistants, nurse practitioners, or other individuals who are not licensed physicians.

Every organization shall have a subscriber grievance procedure, including, as appropriate, a procedure for disenrolling for cause, which is outlined in all master group and individual contracts as well as in any certificate or handbook provided to subscribers.

The organization shall provide, through contract or otherwise, for periodic review of its medical facilities and services, as required under s. 641.512.

The organization shall designate a medical director who is a physician licensed under chapter 458 or chapter 459.

The provisions of part I of chapter 395 do not apply to a health maintenance organization that, on or before January 1, 1991, provides not more than 10 outpatient holding beds for short-term and hospice-type patients in an ambulatory care facility for its members, provided that such health maintenance organization maintains current accreditation by the Joint Commission on Accreditation of Health Care Organizations, the Accreditation Association for Ambulatory Health Care, or the National Committee for Quality Assurance.

The organization shall ensure that the health care services provided to subscribers shall be rendered under reasonable standards of quality of care consistent with the prevailing standards of medical practice in the community.

Each organization shall have an ongoing internal quality assurance program for its health care services. The program shall include, but not be limited to, the following:

The health maintenance organization shall not have the right to control the professional judgment of a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461 concerning the proper course of treatment of a subscriber. However, this subsection shall not be considered to restrict a utilization management program established by an organization or to affect an organization’s decision as to payment for covered services. Except in cases in which the health care provider is an employee of the health maintenance organization, the health maintenance organization shall not be vicariously liable for the medical negligence of the health care provider, whether such claim is alleged under a theory of actual agency, apparent agency, or employer-employee relationship.

The organization shall ensure that only a physician holding an active, unencumbered license issued under chapter 458 or chapter 459 may render an adverse determination regarding a service provided by a physician licensed in this state. The organization shall submit to the treating provider and the subscriber written notification regarding the organization’s adverse determination within 2 working days after the subscriber or provider is notified of the adverse determination. The written notification must include the utilization review criteria or benefits provisions used in the adverse determination, identify the physician who rendered the adverse determination, and be signed by an authorized representative of the organization or the physician who rendered the adverse determination. The organization must include with the notification of an adverse determination information concerning the appeal process for adverse determinations. This ¹provision does not create authority for the Board of Medicine or the Board of Osteopathic Medicine to regulate the organization; however, the Board of Medicine and the Board of Osteopathic Medicine each continue to have jurisdiction over licensees of their respective boards.

Each organization shall develop and maintain a policy to determine when exceptional referrals to out-of-network specially qualified providers should be provided to address the unique medical needs of a subscriber. All financial arrangements for the provision of these services shall be agreed to prior to the services being rendered.

Each organization shall develop and maintain written policies and procedures for the provision of standing referrals to subscribers with chronic and disabling conditions which require ongoing specialty care.

When a contract between an organization and a treating provider is terminated for any reason other than for cause, each party shall allow subscribers for whom treatment was active to continue coverage and care when medically necessary, through completion of treatment of a condition for which the subscriber was receiving care at the time of the termination, until the subscriber selects another treating provider, or during the next open enrollment period offered by the organization, whichever is longer, but not longer than 6 months after termination of the contract. Each party to the terminated contract shall allow a subscriber who has initiated a course of prenatal care, regardless of the trimester in which care was initiated, to continue care and coverage until completion of postpartum care. This does not prevent a provider from refusing to continue to provide care to a subscriber who is abusive, noncompliant, or in arrears in payments for services provided. For care continued under this subsection, the organization and the provider shall continue to be bound by the terms of the terminated contract. Changes made within 30 days before termination of a contract are effective only if agreed to by both parties.

Each organization shall release to the agency data that are indicators of access and quality of care. The agency shall develop rules specifying data-reporting requirements for these indicators. The indicators shall include the following characteristics:

The agency shall develop by rule a uniform format for publication of the data for the public which shall contain explanations of the data collected and the relevance of such data. The agency shall publish such data no less frequently than every 2 years.

Each organization shall adopt recommendations for preventive pediatric health care which are consistent with the requirements for health checkups for children developed for the Medicaid program. Each organization shall establish goals to achieve 90-percent compliance by July 1, 1999, for their enrolled pediatric population.

Each organization shall allow, without prior authorization, a female subscriber, to visit a contracted obstetrician/gynecologist for one annual visit and for medically necessary followup care detected at that visit. Nothing in this subsection shall prevent an organization from requiring that an obstetrician/gynecologist treating a covered patient coordinate the medical care through the patient’s primary care physician, if applicable.

If a contracted primary care physician, licensed under chapter 458 or chapter 459, determines that a subscriber requires examination by a licensed ophthalmologist for medically necessary, contractually covered services, then the organization shall authorize the contracted primary care physician to send the subscriber to a contracted licensed ophthalmologist.

Every organization must have a grievance procedure available to its subscribers for the purpose of addressing complaints and grievances. Every organization must notify its subscribers that a subscriber must submit a grievance within 1 year after the date of occurrence of the action that initiated the grievance, and may submit the grievance for review to the Subscriber Assistance Program panel as provided in s. 408.7056 after receiving a final disposition of the grievance through the organization’s grievance process. An organization shall maintain records of all grievances and shall report annually to the agency the total number of grievances handled, a categorization of the cases underlying the grievances, and the final disposition of the grievances.

When an organization receives an initial complaint from a subscriber, the organization must respond to the complaint within a reasonable time after its submission. At the time of receipt of the initial complaint, the organization shall inform the subscriber that the subscriber has a right to file a written grievance at any time and that assistance in preparing the written grievance shall be provided by the organization.

Each organization’s grievance procedure, as required under subsection (1), must include, at a minimum:

Except as provided in subsection (6), the organization shall resolve a grievance within 60 days after receipt of the grievance, or within a maximum of 90 days if the grievance involves the collection of information outside the service area. These time limitations are tolled if the organization has notified the subscriber, in writing, that additional information is required for proper review of the grievance and that such time limitations are tolled until such information is provided. After the organization receives the requested information, the time allowed for completion of the grievance process resumes. The Employee Retirement Income Security Act of 1974, as implemented by 29 C.F.R. s. 2560.503-1, is adopted and incorporated by reference as applicable to all organizations that administer small and large group health plans that are subject to 29 C.F.R. s. 2560.503-1. The claims procedures of the regulations of the Employee Retirement Income Security Act of 1974, as implemented by 29 C.F.R. s. 2560.503-1, shall be the minimum standards for grievance processes for claims for benefits for small and large group health plans that are subject to 29 C.F.R. s. 2560.503-1.

Each organization shall send to the agency a copy of its quarterly grievance reports submitted to the office pursuant to s. 408.7056(12).

The agency shall investigate all reports of unresolved quality of care grievances received from:

Each organization must notify the subscriber in a final decision letter that the subscriber may request review of the organization’s decision concerning the grievance by the Subscriber Assistance Program, as provided in s. 408.7056, if the grievance is not resolved to the satisfaction of the subscriber. The final decision letter must inform the subscriber that the request for review must be made within 365 days after receipt of the final decision letter, must explain how to initiate such a review, and must include the addresses and toll-free telephone numbers of the agency and the Subscriber Assistance Program.

Each organization, as part of its contract with any provider, must require the provider to post a consumer assistance notice prominently displayed in the reception area of the provider and clearly noticeable by all patients. The consumer assistance notice must state the addresses and toll-free telephone numbers of the Agency for Health Care Administration, the Subscriber Assistance Program, and the Department of Financial Services. The consumer assistance notice must also clearly state that the address and toll-free telephone number of the organization’s grievance department shall be provided upon request. The agency may adopt rules to implement this section.

The agency may impose administrative sanction, in accordance with s. 641.52, against an organization for noncompliance with this section.

The accreditation or review organization must have nationally recognized experience in health maintenance organization activities and in the appraisal of medical practice and quality assurance in a health maintenance organization setting. The accreditation or review organization shall not currently be involved in the operation of the health maintenance organization or prepaid health clinic, nor in the delivery of health care services to its subscribers. The accreditation or review organization shall not have contracted or conducted consultations within the last 2 years for other than accreditation purposes of the health maintenance organization or prepaid health clinic seeking accreditation or under quality assurance assessment.

A representative of the office shall accompany the accreditation or review organization throughout the accreditation or assessment process, but shall not participate in the final accreditation or assessment determination. The accreditation or review organization shall monitor and evaluate the quality and appropriateness of patient care, the organization’s pursuance of opportunities to improve patient care and resolve identified problems, and the effectiveness of the internal quality assurance program required for health maintenance organization and prepaid health clinic certification pursuant to s. 641.49(3)(p).

The accreditation or assessment process shall include a review of:

Every organization shall submit its books, documentations, and medical records and take appropriate action as may be necessary to facilitate the accreditation or assessment process.

The accreditation or review organization shall issue a written report of its findings to the health maintenance organization’s or prepaid health clinic’s board of directors. A copy of the report shall be submitted to the office by the organization within 30 business days of its receipt by the health maintenance organization or prepaid health clinic.

The expenses of the accreditation or assessment process of each organization, including any expenses incurred pursuant to this section, shall be paid by the organization.

In providing for emergency services and care as a covered service, a health maintenance organization may not:

Prehospital and hospital-based trauma services and emergency services and care must be provided to a subscriber of a health maintenance organization as required under ss. 395.1041, 395.4045, and 401.45.

A subscriber may be charged a reasonable copayment, as provided in s. 641.31(12), for the use of an emergency room.

Reimbursement for services pursuant to this section by a provider who does not have a contract with the health maintenance organization shall be the lesser of:

Such reimbursement shall be net of any applicable copayment authorized pursuant to subsection (4).

Reimbursement for services under this section provided to subscribers who are Medicaid recipients by a provider for whom no contract exists between the provider and the health maintenance organization shall be the lesser of:

The agency shall investigate further any quality of care issue contained in recommendations and reports submitted pursuant to ss. 408.7056 and 641.511. The agency shall also investigate further any information that indicates that the organization does not meet accreditation standards or the standards of the review organization performing the external quality assurance assessment pursuant to reports submitted under s. 641.512. Every organization shall submit its books and records and take other appropriate action as may be necessary to facilitate an examination. The agency shall have access to the organization’s medical records of individuals and records of employed and contracted physicians, with the consent of the subscriber or by court order, as necessary to carry out the provisions of this part.

The reports and the records prepared or obtained under this section or s. 641.512 by the agency or by an outside source may be used by the agency in enforcing the requirements of this part and in disciplinary proceedings. Except as otherwise provided in this section, any patient-identifying information contained in these records and reports is confidential and exempt from s. 119.07(1).

If the agency, through its examination or through any investigation, has a reasonable belief that conduct by a staff member or any other employee of an organization may constitute grounds for disciplinary action by the appropriate regulatory board, the agency shall report this fact to such regulatory board.

The agency shall promulgate rules imposing upon physicians and hospitals performing services for a health maintenance organization standards of care generally applicable to physicians and hospitals.

The agency may suspend the authority of an organization to enroll new subscribers or revoke the health care provider certificate of any organization, or order compliance within a time certain, if it finds that any of the following conditions exist:

Revocation of an organization’s certificate shall be for a period of 2 years. After 2 years, the organization may apply for a new certificate by compliance with all application requirements applicable to first-time applicants.

Suspension of an organization’s authority to enroll new subscribers shall be for such period, not to exceed 1 year, as is fixed by the agency. The agency shall, in its order suspending the authority of an organization to enroll new subscribers, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the organization prior to reinstatement of its authority to enroll new subscribers. The order of suspension is subject to rescission or modification by further order of the agency prior to the expiration of the suspension period. Authority to enroll new subscribers shall not be reinstated unless requested by the organization; however, the agency may not grant reinstatement if it finds that the circumstances for which the suspension of authority to enroll new subscribers occurred still exist or are likely to recur.

The agency may suspend the health care provider certificate issued to an organization. The agency shall, in its order suspending the health care provider certificate, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the organization for reinstatement. Upon expiration of the suspension period, the organization’s certificate automatically reinstates unless the agency finds that the causes of the suspension have not been removed or that the organization is otherwise not in compliance with this part. If the agency makes such a finding, the health care provider certificate shall not be reinstated and is considered to have expired as of the end of the suspension period.

If the agency finds that one or more grounds exist for the revocation or suspension of a certificate issued under this part, the agency may, in lieu of such revocation or suspension, impose a fine upon the organization. With respect to any nonwillful violation, the fine may not exceed $2,500 per violation. Such fines may not exceed an aggregate amount of $25,000 for all nonwillful violations arising out of the same action. With respect to any knowing and willful violation of a lawful order or rule of the agency or a provision of this part, the agency may impose a fine upon the organization in an amount not to exceed $20,000 for each such violation. Such fines may not exceed an aggregate amount of $250,000 for all knowing and willful violations arising out of the same action. The agency shall, by January 1, 1997, adopt by rule penalty categories that specify varying ranges of fines for willful violations and for nonwillful violations.

The agency shall immediately notify the office whenever it issues an administrative complaint or an order or otherwise initiates legal proceedings resulting in or which may result in suspension or revocation of an organization’s health care provider certificate or suspension of new enrollment.

Any organization that knowingly utilizes the services of a provider who is not licensed or otherwise authorized by law to provide such services is guilty of a felony of the third degree, punishable as provided in s. 775.082, s. 775.083, or s. 775.084.

Every health maintenance organization shall maintain a current list, by geographic area, of all hospitals which are routinely and regularly used by the organization, indicating to which hospitals the organization may refer particular subscribers for nonemergency services. The list shall also include all physicians under the organization’s direct employ or who are under contract or other arrangement with the organization to provide health care services to subscribers. The list shall contain the following information for each physician:

The list shall be made available, upon request, to the office. The list shall also be made available, upon request:

The organization shall make available to subscribers, upon request, a detailed description of the authorization and referral process for health care services. Any changes in the organization’s authorization and referral process shall be reported to the agency immediately.

The organization shall make available to subscribers, upon request, a detailed description of the process used to determine whether health care services are “medically necessary.” Any change in the organization’s definition of “medically necessary” or the process used to determine medical necessity shall be reported to the agency immediately.

Each organization shall provide to subscribers, upon request, the following:

Each health maintenance organization shall make available to its subscribers the estimated copay, coinsurance percentage, or deductible, whichever is applicable, for any covered services, the status of the subscriber’s maximum annual out-of-pocket payments for a covered individual or family, and the status of the subscriber’s maximum lifetime benefit. Such estimate shall not preclude the actual copay, coinsurance percentage, or deductible, whichever is applicable, from exceeding the estimate.

Each health maintenance organization shall make available on its Internet website a link to the performance outcome and financial data that is published by the Agency for Health Care Administration pursuant to s. 408.05(3)(k) and shall include in every policy delivered or issued for delivery to any person in the state or any materials provided as required by s. 627.64725 notice that such information is available electronically and the address of its Internet website.

Every organization certified under this part shall, as a part of its administrative functions, establish an internal risk management program which shall include the following components:

The risk management program shall be the responsibility of the governing authority or board of the organization. Every organization which has an annual premium volume of $10 million or more and which directly provides health care in a building owned or leased by the organization shall hire a risk manager, certified under ss. 395.10971-395.10975, who shall be responsible for implementation of the organization’s risk management program required by this section. A part-time risk manager shall not be responsible for risk management programs in more than four organizations or facilities. Every organization which does not directly provide health care in a building owned or leased by the organization and every organization with an annual premium volume of less than $10 million shall designate an officer or employee of the organization to serve as the risk manager.

In addition to the programs mandated by this section, other innovative approaches intended to reduce the frequency and severity of medical malpractice and patient injury claims shall be encouraged and their implementation and operation facilitated. Additional approaches may include extending risk management programs to provider offices or facilities.

The Agency for Health Care Administration shall adopt rules necessary to carry out the provisions of this section, including rules governing the establishment of required internal risk management programs to meet the needs of individual organizations and each specific organization type governed by this part. The office shall assist the agency in preparing these rules. Each internal risk management program shall include the use of incident reports to be filed with the risk manager. The risk manager shall have free access to all organization or provider medical records. The incident reports shall be considered to be a part of the workpapers of the attorney defending the organization in litigation relating thereto and shall be subject to discovery, but not be admissible as evidence in court, nor shall any person filing an incident report be subject to civil suit by virtue of the incident report and the matters it contains. As a part of each internal risk management program, the incident reports shall be utilized to develop categories of incidents which identify problem areas. Once identified, procedures must be adjusted to correct these problem areas.

If an adverse or untoward incident, whether occurring in the facilities of the organization or arising from health care prior to enrollment by the organization or admission to the facilities of the organization or in a facility of one of its providers, results in:

the organization must report this incident to the agency within 3 working days after its occurrence. A more detailed followup report must be submitted to the agency within 10 days after the first report. The agency may require an additional, final report. Reports under this subsection must be sent immediately by the agency to the appropriate regulatory board whenever they contain references to a provider licensed under chapter 458, chapter 459, chapter 461, or chapter 466. These reports are confidential and are exempt from s. 119.07(1). This information is not available to the public as part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the agency or the appropriate regulatory board. However, the agency shall make available, upon written request by a practitioner against whom probable cause has been found, any such information contained in the records that form the basis of the determination of probable cause under s. 456.073. The agency may investigate, as it deems appropriate, any such incident and prescribe measures that must or may be taken by the organization in response to the incident. The agency shall review each incident and determine whether it potentially involved conduct by the licensee which is subject to disciplinary action, in which case s. 456.073 applies.

In addition to any penalty imposed under s. 641.52, the agency may impose an administrative fine, not to exceed $5,000, for any violation of the reporting requirements of subsection (5) or subsection (6).

The agency and, upon subpoena issued under s. 456.071, the appropriate regulatory board must be given access to all organization records necessary to carry out the provisions of this section. Any identifying information contained in the records obtained under this section is confidential and exempt from s. 119.07(1). The identifying information contained in records obtained under s. 456.071 is exempt from s. 119.07(1) to the extent that it is part of the record of investigation for and prosecution in disciplinary proceedings made available to the public by the agency or the appropriate regulatory board. However, the agency must make available, upon written request by a practitioner against whom probable cause has been found, any such information contained in the records that form the basis of the determination of probable cause under s. 456.073, except that, with respect to medical review committee records, s. 766.101 controls.

The agency shall review, no less frequently than annually, the risk management program of each organization regulated by this section to determine whether the program meets standards established in statutes and rules, whether the program is being conducted in a manner designed to reduce adverse incidents, and whether the program is appropriately reporting incidents under subsections (5) and (6).

There shall be no monetary liability on the part of, and no cause of action for damages shall arise against, any risk manager certified under part IX of chapter 626 for the implementation and oversight of the risk management program in an organization authorized under this chapter for any act or proceeding undertaken or performed within the scope of the function of such risk management program if the risk manager acts without intentional fraud.

If the agency, through its receipt of the annual reports prescribed in subsection (5) or through any investigation, has a reasonable belief that conduct by a provider, staff member, or employee of an organization may constitute grounds for disciplinary action by the appropriate regulatory board, the agency shall report this fact to the regulatory board.

The agency shall send information bulletins to all organizations as necessary to disseminate trends and preventive data derived from its actions under this section or under s. 395.0197.

In addition to any other license or excise tax now or hereafter imposed, and such taxes as may be imposed under other statutes, there is hereby assessed and imposed upon every organization authorized to engage in business in this state, an annual regulatory assessment not to exceed 0.1 percent of the gross amount of premiums collected by each organization on contracts or certificates issued to subscribers in this state. For the purpose of this section, “premium” shall include all prepaid per capita fees and prepaid aggregate fees, by whatever name called. The assessment shall be payable annually on or before April 1 to the Agency for Health Care Administration by each organization on such premiums collected during the preceding calendar year, and shall be deposited into the Health Care Trust Fund.

The office shall determine the amount of gross premiums for the purposes of the regulatory assessment, and then the agency shall determine on or before December 1 of each year the regulatory assessment percentage necessary to be imposed for that calendar year, payable on or before the following April 1, as herein prescribed, to provide the funds appropriated to the agency to carry out the provisions of subsection (4).

The agency shall make and issue its order setting the regulatory assessment percentage for that calendar year, payable on or before April 1 of the following year, and shall mail a copy of such order to each organization.

The moneys received and deposited into the Health Care Trust Fund shall be used to defray the expenses of the agency in the discharge of its administrative and regulatory powers and duties under this part, including conducting an annual survey of the satisfaction of members of health maintenance organizations; contracting with physician consultants for the Subscriber Assistance Panel; maintaining offices and necessary supplies, essential equipment, and other materials, salaries and expenses of required personnel; and discharging the administrative and regulatory powers and duties imposed under this part.

If, at the end of any fiscal year, an unencumbered balance of funds received from the regulatory assessment imposed by this section remains in the Health Care Trust Fund, such balance shall not revert to the General Revenue Fund of the state, but shall be retained in the Health Care Trust Fund to be used for the purposes set forth above. The agency shall take into account the amount of any such remaining funds when determining the regulatory assessment percentage for each calendar year.

Tax returns with respect to the regulatory assessment prescribed by this section shall be made by each organization liable for payment of such tax on forms to be prescribed by the agency and sworn to by one or more of the executive officers or other persons charged under the law with the management of the organization. In the event of an overpayment on account of the assessment, a refund of the overpayment may be made to the remitter.

If an organization fails to pay the assessment required by this section on or before April 1 of each year, the agency may suspend or revoke its health care provider certificate or impose other reasonable administrative sanctions or penalties.

As used in ss. 641.60-641.75:

There is created within the Agency for Health Care Administration a Statewide Managed Care Ombudsman Committee. The statewide committee shall act as a consumer protection and advocacy organization on behalf of all health care consumers receiving services through managed care programs in the state. The statewide committee shall work in conjunction with the agency in protecting the public health, safety, and welfare, as provided under this section and ss. 641.65, 641.70, and 641.75. The statewide committee shall have administrative authority over the district committees established in s. 641.65.

The statewide committee shall consist of the chairpersons of the district committees.

The members of the statewide committee shall elect a chairperson to a term of 1 year. A person may not serve as chairperson for more than two consecutive terms.

The statewide committee or a member of the committee:

Assessing subscriber satisfaction with providers, particularly primary care physicians;

Sharing subscriber-satisfaction indicators and scores with providers;

Publicly acknowledging providers with high positive subscriber-satisfaction scores;

Addressing behaviors of providers with low subscriber-satisfaction scores; and

Assessing subscriber access and physician availability.

Annually study its subscriber population to determine the most prevalent chronic diseases of its subscribers, design intervention strategies to reduce the morbidities and mortalities associated with at least two prevalent chronic diseases, measure the outcomes of the interventions implemented, and modify the interventions, if necessary, to improve their effectiveness;

Request the input and assistance of its providers and share the information developed under subsection (1) with its providers; and

Share the information developed under subsections (1) and (2) with subscribers identified as having these chronic diseases.

A district managed care ombudsman committee is created in each district of the agency that has staff assigned for the regulation of managed care programs. Each district committee is subject to direction from and the supervision of the statewide committee.

Each district committee shall have no fewer than 9 members and no more than 16 members, including at least: one physician licensed under chapter 458, one physician licensed under chapter 459, one physician licensed under chapter 460, and one physician licensed under chapter 461, one psychologist, one registered nurse, one clinical social worker, one attorney, and one consumer. For the consumer member, preference shall be given to members of organized consumer or advocacy groups with national or statewide membership. No member may be employed by or affiliated with a managed care program.

Each district committee shall elect a chairperson for a term of 1 year. A person may not serve as chairperson for more than two consecutive terms.

If a district committee member misses, without cause, two-thirds of the regular district committee meetings in a calendar year, the member is automatically removed, and the district committee shall select a replacement.

Each district committee or member of the committee:

Patient records held by a district managed care ombudsman committee created under s. 641.65.

The name or identity of a complainant who files a complaint with a district managed care ombudsman committee, unless the complainant provides written consent that authorizes the release of his or her name or unless a court of competent jurisdiction orders that the name or identity of a complainant be disclosed.

Any problem identified by a district managed care ombudsman committee as a result of an investigation.

The agency shall adopt rules that specify:

The Agency for Health Care Administration shall provide a meeting place for district committees in agency offices and shall provide the necessary administrative support to assist the statewide committee and district committees, within available resources.

The secretary of the agency shall ensure the full cooperation and assistance of agency employees with members of the statewide committee and district committees.

Any member of the statewide committee or a district committee who receives or investigates a complaint of an enrollee of a managed care program in accordance with the procedures and guidelines of the agency shall be immune from liability for good faith action on behalf of such an enrollee.

Except as otherwise provided by law, all other matters before the statewide committee or district committees shall be open to the public and subject to chapter 119 and s. 286.011.

Members of any state or district ombudsman committee shall not be required to testify in any court with respect to matters held to be confidential except as may be necessary to enforce ss. 641.60-641.75.