Quick Links
- General Laws Conversion Table (2024) [PDF]
- Florida Statutes Definitions Index (2024) [PDF]
- Table of Section Changes (2024) [PDF]
- Preface to the Florida Statutes (2024) [PDF]
- Table Tracing Session Laws to Florida Statutes (2024) [PDF]
- Index to Special and Local Laws (1971-2024) [PDF]
- Index to Special and Local Laws (1845-1970) [PDF]
- Statute Search Tips
2018 Florida Statutes
Chapter 641
HEALTH CARE SERVICE PROGRAMS
HEALTH CARE SERVICE PROGRAMS
CHAPTER 641
HEALTH CARE SERVICE PROGRAMS
PART I
HEALTH MAINTENANCE ORGANIZATIONS(ss. 641.17-641.3923)
PART II
PREPAID HEALTH CLINICS(ss. 641.40-641.459)
PART III
HEALTH CARE SERVICES(ss. 641.47-641.62)
PART I
HEALTH MAINTENANCE ORGANIZATIONS641.17 Short title.
641.18 Declaration of legislative intent, findings, and purposes.
641.183 Statutory accounting procedures; transition provisions.
641.185 Health maintenance organization subscriber protections.
641.19 Definitions.
641.201 Applicability of other laws.
641.2011 Insurance holding companies.
641.2015 Incorporation required.
641.2017 Insurance business not authorized.
641.2018 Limited coverage for home health care authorized.
641.20185 High-deductible contracts for medical savings accounts.
641.2019 Provider service network certificate of authority.
641.21 Application for certificate.
641.215 Conditions precedent to issuance or maintenance of certificate of authority; effect of bankruptcy proceedings.
641.217 Minority recruitment and retention plans required.
641.22 Issuance of certificate of authority.
641.221 Continued eligibility for certificate of authority.
641.225 Surplus requirements.
641.2261 Application of solvency requirements to provider-sponsored organizations and Medicaid provider service networks.
641.227 Rehabilitation Administrative Expense Fund.
641.228 Florida Health Maintenance Organization Consumer Assistance Plan.
641.23 Revocation or cancellation of certificate of authority; suspension of enrollment of new subscribers; terms of suspension.
641.234 Administrative, provider, and management contracts.
641.2342 Contract providers.
641.25 Administrative penalty in lieu of suspension or revocation.
641.255 Acquisition, merger, or consolidation.
641.26 Annual and quarterly reports.
641.261 Other reporting requirements.
641.27 Examination by the department.
641.28 Civil remedy.
641.281 Injunction.
641.282 Payment of judgment by health maintenance organization.
641.284 Liquidation, rehabilitation, reorganization, and conservation; exclusive methods of remedy.
641.285 Insolvency protection.
641.286 Levy upon deposit limited.
641.29 Fees.
641.30 Construction and relationship to other laws.
641.3005 Application of ch. 85-177.
641.3007 HIV infection and AIDS for contract purposes.
641.305 Language used in contracts and advertisements; translations.
641.309 Standards for marketing to persons eligible for Medicare.
641.31 Health maintenance contracts.
641.3101 Additional contract contents.
641.31015 Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.
641.3102 Restrictions upon expulsion or refusal to issue or renew contract.
641.3103 Charter, bylaw provisions.
641.3104 Execution of contracts.
641.3105 Validity of noncomplying contracts.
641.3106 Construction of contracts.
641.3107 Delivery of contract; definitions.
641.31071 Preexisting conditions.
641.31072 Special enrollment periods.
641.31073 Prohibiting discrimination against individual participants and beneficiaries based on health status.
641.31074 Guaranteed renewability of coverage.
641.3108 Notice of cancellation of contract.
641.31094 Nondiscrimination of coverage for certain surgical procedures involving bones or joints.
641.31095 Coverage for mammograms.
641.31096 Requirements with respect to breast cancer and routine followup care.
641.31097 Decreasing inappropriate utilization of emergency care.
641.31098 Coverage for individuals with developmental disabilities.
641.31099 Restrictions on use of state and federal funds for state exchanges.
641.3111 Extension of benefits.
641.312 Scope.
641.313 Health maintenance contracts; cancer treatment parity; orally administered cancer treatment medications.
641.314 Pharmacy benefit manager contracts.
641.315 Provider contracts.
641.3154 Organization liability; provider billing prohibited.
641.3155 Prompt payment of claims.
641.3156 Treatment authorization; payment of claims.
641.316 Fiscal intermediary services.
641.32 Acceptable payments.
641.33 Certain words prohibited in name of organization.
641.35 Assets, liabilities, and investments.
641.36 Adoption of rules; penalty for violation.
641.365 Dividends.
641.37 Prohibited activities; penalties.
641.38 Operational health maintenance organizations; issuance of certificate.
641.385 Order to discontinue certain advertising.
641.386 Agent licensing and appointment required; exceptions.
641.39001 Soliciting or accepting new or renewal health maintenance contracts by insolvent or impaired health maintenance organization prohibited; penalty.
641.3901 Unfair methods of competition and unfair or deceptive acts or practices prohibited.
641.3903 Unfair methods of competition and unfair or deceptive acts or practices defined.
641.3905 General powers and duties of the department and office.
641.3907 Defined unfair practices; hearings, witnesses, appearances, production of books, and service of process.
641.3909 Cease and desist and penalty orders.
641.3911 Appeals from the department or office.
641.3913 Penalty for violation of cease and desist orders.
641.3915 Health maintenance organization anti-fraud plans and investigative units.
641.3917 Civil liability.
641.3921 Conversion on termination of eligibility.
641.3922 Conversion contracts; conditions.
641.3923 Discrimination against providers prohibited.
641.17 Short title.—This part shall be known and may be cited as the “Health Maintenance Organization Act.”
History.—s. 1, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 778, 804, 809(1st), ch. 82-243; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.18 Declaration of legislative intent, findings, and purposes.—
(1) 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.
(2) 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.
(3) These plans, when properly operated, emphasize effective cost and quality controls.
(4) It shall be the policy of this state to:
(a) Eliminate legal barriers to the organization, promotion, and expansion of comprehensive prepaid health care plans.
(b) Recognize that prepaid comprehensive health care plans shall be exempt from operation of the insurance laws of this state except in the manner and to the extent set forth in this part.
(c) Ensure that comprehensive prepaid health care plans deliver high-quality health care.
(5) 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.
(6) 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.
History.—s. 2, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 779, 804, 809(1st), ch. 82-243; s. 5, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.183 Statutory accounting procedures; transition provisions.—All health maintenance organizations, authorized to do business under this chapter on January 1, 2001, shall elect a transition method for compliance with statutory accounting principles as follows:
(1) 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
(2) Report all assets in accordance with the NAIC Accounting Practices and Procedures Manual effective January 1, 2001.
History.—s. 21, ch. 2001-213.
641.185 Health maintenance organization subscriber protections.—
(1) With respect to the provisions of this part and part III, the principles expressed in the following statements 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:
(a) A health maintenance organization shall ensure that the health care services provided to its subscribers shall be rendered under reasonable standards of quality of care which are at a minimum consistent with the prevailing standards of medical practice in the community pursuant to ss. 641.495(1) and 641.51.
(b) A health maintenance organization subscriber should receive quality health care from a broad panel of providers, including referrals, preventive care pursuant to s. 641.402(1), emergency screening and services pursuant to ss. 641.31(12) and 641.513, and second opinions pursuant to s. 641.51.
(c) A health maintenance organization subscriber should receive assurance that the health maintenance organization has been independently accredited by a national review organization pursuant to s. 641.512, and is financially secure as determined by the state pursuant to ss. 641.221, 641.225, and 641.228.
(d) A health maintenance organization subscriber should receive continuity of health care, even after the provider is no longer with the health maintenance organization pursuant to s. 641.51(8).
(e) A health maintenance organization subscriber should receive timely, concise information regarding the health maintenance organization’s reimbursement to providers and services pursuant to ss. 641.31 and 641.31015 and should receive prompt payment from the organization pursuant to s. 641.3155.
(f) A health maintenance organization subscriber should receive the flexibility to transfer to another Florida health maintenance organization, regardless of health status, pursuant to ss. 641.228, 641.3104, 641.3107, 641.3111, 641.3921, and 641.3922.
(g) A health maintenance organization subscriber should be eligible for coverage without discrimination against individual participants and beneficiaries of group plans based on health status pursuant to s. 641.31073.
(h) A health maintenance organization that issues a group health contract must: provide coverage for preexisting conditions pursuant to s. 641.31071; guarantee renewability of coverage pursuant to s. 641.31074; provide notice of cancellation pursuant to s. 641.3108; provide extension of benefits pursuant to s. 641.3111; provide for conversion on termination of eligibility pursuant to s. 641.3921; and provide for conversion contracts and conditions pursuant to s. 641.3922.
(i) A health maintenance organization subscriber should receive timely and, if necessary, urgent grievances and appeals within the health maintenance organization pursuant to ss. 641.228, 641.31(5), 641.47, and 641.511.
(j) A health maintenance organization subscriber shall be given written notice at least 30 days in advance of a rate change pursuant to s. 641.31(3)(b). In the case of a group member, there may be a contractual agreement with the health maintenance organization to have the employer provide the required notice to the individual members of the group pursuant to s. 641.31(3)(b).
(k) A health maintenance organization subscriber shall be given a copy of the applicable health maintenance contract, certificate, or member handbook specifying: all the provisions, disclosure, and limitations required pursuant to s. 641.31(1) and (4); the covered services, including those services, medical conditions, and provider types specified in ss. 641.31, 641.31094, 641.31095, 641.31096, 641.51(11), and 641.513; and where and in what manner services may be obtained pursuant to s. 641.31(4).
(2) This section shall not be construed as creating a civil cause of action by any subscriber or provider against any health maintenance organization.
History.—s. 44, ch. 2000-256; s. 6, ch. 2001-64; s. 8, ch. 2002-389; s. 1554, ch. 2003-261; s. 110, ch. 2018-24.
641.19 Definitions.—As used in this part, the term:
(1) “Affiliate” means any entity that exercises control over or is controlled by the health maintenance organization, directly or indirectly, through:
(a) Equity ownership of voting securities;
(b) Common managerial control; or
(c) Collusive participation by the management of the health maintenance organization and affiliate in the management of the health maintenance organization or the affiliate.
(2) “Agency” means the Agency for Health Care Administration.
(3) “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.
(4) “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.
(5) “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.
(6) “Emergency medical condition” means:
(a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
1. Serious jeopardy to the health of a patient, including a pregnant woman or a fetus.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
(b) With respect to a pregnant woman:
1. That there is inadequate time to effect safe transfer to another hospital prior to delivery;
2. That a transfer may pose a threat to the health and safety of the patient or fetus; or
3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.
(7) “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.
(8) “Entity” means any legal entity with continuing existence, including, but not limited to, a corporation, association, trust, or partnership.
(9) “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.
(10) “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.
(11) “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.
(12) “Health maintenance organization” means any organization authorized under this part which:
(a) Provides, through arrangements with other persons, emergency care, inpatient hospital services, physician care including care provided by physicians licensed under chapters 458, 459, 460, and 461, ambulatory diagnostic treatment, and preventive health care services.
(b) Provides, either directly or through arrangements with other persons, health care services to persons enrolled with such organization, on a prepaid per capita or prepaid aggregate fixed-sum basis.
(c) Provides, either directly or through arrangements with other persons, comprehensive health care services which subscribers are entitled to receive pursuant to a contract.
(d) Provides physician services, by physicians licensed under chapters 458, 459, 460, and 461, directly through physicians who are either employees or partners of such organization or under arrangements with a physician or any group of physicians.
(e) If offering services through a managed care system, has a system in which a primary physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461 is designated for each subscriber upon request of a subscriber requesting service by a physician licensed under any of those chapters, and is responsible for coordinating the health care of the subscriber of the respectively requested service and for referring the subscriber to other providers of the same discipline when necessary. Each female subscriber may select as her primary physician an obstetrician/gynecologist who has agreed to serve as a primary physician and is in the health maintenance organization’s provider network.
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.
(13) “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.
(14) “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.
(15) “Reporting period” means the annual calendar year accounting period or any part thereof.
(16) “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:
(a) A percentage of the Medicare fee schedule for specific relative-value services;
(b) A listing of the reimbursements to be paid by Current Procedural Terminology codes for physicians that pertain to each physician’s practice; or
(c) Any other method agreed upon by the parties.
Specific nonrelative-value services shall be stated separately from relative-value services, and reimbursement for unclassified services shall be on a reasonable basis.
(17) “Statutory accounting principles” means accounting principles as defined in the National Association of Insurance Commissioners Accounting Practices and Procedures Manual as of 2002.
(18) “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.
(19) “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.
(20) “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.
(21) “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.
(22) “Provider service network” means a network authorized under s. 409.912(1), reimbursed on a prepaid basis, operated by a health care provider or group of affiliated health care providers, and which directly provides health care services under a Medicare, Medicaid, or Healthy Kids contract.
History.—s. 3, ch. 72-264; s. 1, ch. 76-33; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 780, 804, 809(1st), ch. 82-243; s. 1, ch. 83-198; s. 137, ch. 83-216; s. 2, ch. 84-313; s. 6, ch. 85-177; s. 1, ch. 87-236; s. 1, ch. 87-273; s. 2, ch. 88-126; s. 2, ch. 88-388; s. 2, ch. 89-357; s. 74, ch. 89-360; ss. 111, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 2, ch. 95-281; s. 13, ch. 96-199; s. 3, ch. 96-223; s. 22, ch. 2001-213; s. 10, ch. 2002-247; s. 1555, ch. 2003-261; s. 46, ch. 2003-416; s. 1, ch. 2004-321; s. 33, ch. 2011-135; s. 30, ch. 2015-3; s. 18, ch. 2017-4.
641.201 Applicability of other laws.—Except as provided in this part, health maintenance organizations shall be governed by the provisions of this part and part III of this chapter and shall be exempt from all other provisions of the Florida Insurance Code except those provisions of the Florida Insurance Code that are explicitly made applicable to health maintenance organizations.
History.—ss. 25, 50, ch. 85-321; s. 3, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 40, ch. 95-211; s. 71, ch. 2000-318.
641.2011 Insurance holding companies.—Part IV of chapter 628 applies to health maintenance organizations licensed under this part.
History.—s. 76, ch. 2000-318.
641.2015 Incorporation required.—On or after October 1, 1985, any entity that has not yet obtained a certificate of authority to operate a health maintenance organization in this state shall be incorporated or shall be a division of a corporation formed under the provisions of either part I of chapter 607 or chapter 617 or shall be a public entity that is organized as a political subdivision. In the case of a division of a corporation, the financial requirements of this part shall apply to the entire corporation. Incorporation shall not be required of any entity which has already been issued an initial certificate of authority prior to this date and which is not a corporation on October 1, 1985, or which is incorporated in any other state on October 1, 1985; nor shall incorporation be required on renewal of any certificate of authority by such an organization or be required of a public entity that is organized as a political subdivision.
History.—ss. 7, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 14, ch. 96-199; s. 58, ch. 2014-209.
641.2017 Insurance business not authorized.—Nothing in the Florida Insurance Code or this part shall be deemed to authorize any health maintenance organization to transact any insurance business other than that of health maintenance organization type insurance or otherwise to engage in any other type of insurance unless it is authorized under a certificate of authority issued by the office under the provisions of the Florida Insurance Code. However, a health maintenance organization may by contract:
(1) 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
(2) 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.
History.—ss. 26, 50, ch. 85-321; s. 9, ch. 90-248; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1556, ch. 2003-261.
641.2018 Limited coverage for home health care authorized.—
(1) 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.
(2) 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.
(3) 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).
History.—s. 6, ch. 96-275; s. 51, ch. 99-3; s. 1557, ch. 2003-261; s. 10, ch. 2006-254.
641.20185 High-deductible contracts for medical savings accounts.—Notwithstanding the provisions of this part and part III related to the requirement for providing comprehensive coverage, a health maintenance organization may offer a high-deductible contract to employers that establish medical savings accounts, as defined in s. 220(d) of the Internal Revenue Code.
History.—s. 22, ch. 97-179; s. 52, ch. 99-3.
641.2019 Provider service network certificate of authority.—A prepaid provider service network that applies for and obtains a health care provider certificate pursuant to part III of this chapter, meets the surplus requirements of s. 641.225, and meets all other applicable requirements of this part may obtain a certificate of authority under s. 641.21. A certified provider service network has the same rights and responsibilities as a health maintenance organization certified under this part.
History.—s. 34, ch. 2011-135.
641.21 Application for certificate.—
(1) 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:
(a) A copy of the articles of incorporation and all amendments thereto;
(b) A copy of the bylaws, rules and regulations, or similar form of document, if any, regulating the conduct of the affairs of the applicant;
(c) A list of the names, addresses, and official capacities with the organization of the persons who are to be responsible for the conduct of the affairs of the health maintenance organization, including all officers, directors, and owners of in excess of 5 percent of the common stock of the corporation. Such persons shall fully disclose to the office and the directors of the health maintenance organization the extent and nature of any contracts or arrangements between them and the health maintenance organization, including any possible conflicts of interest;
(d) A complete biographical statement on forms prescribed by the commission, and an independent investigation report and fingerprints obtained pursuant to chapter 624, of all of the individuals referred to in paragraph (c);
(e) A statement generally describing the health maintenance organization, its operations, and its grievance procedures;
(f) Forms of all health maintenance contracts, certificates, and member handbooks the applicant proposes to offer the subscribers, showing the benefits to which they are entitled, together with a table of the rates charged, or proposed to be charged, for each form of such contract. A certified actuary shall:
1. Certify that the rates are neither inadequate nor excessive nor unfairly discriminatory;
2. Certify that the rates are appropriate for the classes of risks for which they have been computed; and
3. File an adequate description of the rating methodology showing that such methodology follows consistent and equitable actuarial principles;
(g) A statement describing with reasonable certainty the geographic area or areas to be served by the health maintenance organization;
(h) As to any applicant whose business plan indicates that it will receive Medicaid funds, a list of all contracts and agreements and any information relative to any payment or agreement to pay, directly or indirectly, a consultant fee, a broker fee, a commission, or other fee or charge related in any way to the application for a certificate of authority or the issuance of a certificate of authority, including, but not limited to, 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. The contract, agreement, and related information shall, if requested, be provided to the office.
(i) An audited financial statement prepared on the basis of statutory accounting principles and certified by an independent certified public accountant, except that surplus notes acceptable to the office and meeting the requirements of this act shall be included in the calculation of surplus; and
(j) Such additional reasonable data, financial statements, and other pertinent information as the commission or office requires with respect to the determination that the applicant can provide the services to be offered.
(2) 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.
(3) 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.
History.—s. 5, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 782, 804, 809(1st), ch. 82-243; s. 2, ch. 83-198; s. 8, ch. 85-177; s. 4, ch. 87-236; s. 3, ch. 88-388; ss. 112, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 41, ch. 95-211; s. 15, ch. 96-199; s. 1558, ch. 2003-261; s. 133, ch. 2004-5.
641.215 Conditions precedent to issuance or maintenance of certificate of authority; effect of bankruptcy proceedings.—
(1) 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:
(a) An acknowledgment that a delinquency proceeding pursuant to part I of chapter 631, or supervision by the department pursuant to ss. 624.80-624.87, constitutes the sole and exclusive method for the liquidation, rehabilitation, reorganization, or conservation of a health maintenance organization.
(b) A waiver of any right to file or be subject to a bankruptcy proceeding.
(2) The commencement of a bankruptcy proceeding either by or against a health maintenance organization shall, by operation of law:
(a) Terminate the health maintenance organization’s certificate of authority.
(b) Vest in the office for the use and benefit of the subscribers of the health maintenance organization the title to any deposits of the insurer held by the department.
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.
History.—ss. 113, 188, ch. 91-108; s. 4, ch. 91-429; s. 1559, ch. 2003-261.
641.217 Minority recruitment and retention plans required.—
(1) 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 minority persons as defined in s. 288.703. The plan must demonstrate an ability to recruit and retain minority persons which shall include, but is not limited to, the following efforts:
(a) Establishing and maintaining contacts with various organizations representing the interests and concerns of minority constituencies to seek advice and assistance.
(b) Identifying and recruiting at colleges and universities which primarily serve minority students.
(c) Reviewing and analyzing the organization’s workforce as to minority representation.
(d) Other factors identified by the Agency for Health Care Administration by rule.
(2) 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.
History.—s. 16, ch. 96-199; s. 434, ch. 2011-142.
641.22 Issuance of certificate of authority.—The office shall issue a certificate of authority to any entity filing a completed application in conformity with s. 641.21, upon payment of the prescribed fees and upon the office’s being satisfied that:
(1) 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.
(2) The health maintenance organization is actuarially sound.
(3) The entity has met the applicable requirements specified in s. 641.225.
(4) 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.
(5) 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.
(6) 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:
(a) The ownership, control, or management of the organization includes any person:
1. Who is incompetent or untrustworthy;
2. Who is so lacking in health maintenance organization expertise as to make the operation of the health maintenance organization hazardous to potential and existing subscribers;
3. Who is so lacking in health maintenance organization experience, ability, and standing as to jeopardize the reasonable promise of successful operation;
4. Who is affiliated, directly or indirectly, through ownership, control, reinsurance transactions, or other business relations, with 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; or
5. 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;
(b) Any person, including any stock subscriber, stockholder, or incorporator, who exercises or has the ability to exercise effective control of the organization, or who influences or has the ability to influence the transaction of the business of the health maintenance organization, does not possess the financial standing and business experience for the successful operation of the health maintenance organization;
(c) Any person, including any stock subscriber, stockholder, or incorporator, who exercises or has the ability to exercise effective control of the organization, or who influences or has the ability to influence the transaction of the business of the health maintenance organization, has been found guilty of, or has pled guilty or no contest to, any felony or crime punishable by imprisonment of 1 year or more under the laws of the United States or any state thereof or under the laws of any other country, which involves moral turpitude, without regard to whether a judgment or conviction has been entered by the court having jurisdiction in such case. However, in the case of a health maintenance organization operating under a subsisting certificate of authority, the health maintenance organization shall remove any such person immediately upon discovery of the conditions set forth in this paragraph when applicable to such person or under the order of the office, and the failure to so act by the organization is grounds for revocation or suspension of the health maintenance organization’s certificate of authority; or
(d) Any person, including any stock subscriber, stockholder, or incorporator, who exercises or has the ability to exercise effective control of the organization, or who influences or has the ability to influence the transaction of the business of the health maintenance organization, is now or was in the past affiliated, directly or indirectly, through ownership interest of 10 percent or more, control, or reinsurance transactions, with any business, corporation, or other entity that has been found guilty of or has pleaded guilty or nolo contendere to any felony or crime punishable by imprisonment for 1 year or more under the laws of the United States, any state, or any other country, regardless of adjudication. In the case of a health maintenance organization operating under a subsisting certificate of authority, the health maintenance organization shall immediately remove such person or immediately notify the office of such person upon discovery of the conditions set forth in this paragraph, either when applicable to such person or upon order of the office. The failure to remove such person, provide such notice, or comply with such order constitutes grounds for suspension or revocation of the health maintenance organization’s certificate of authority.
(7) 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.
(8) The entity has filed with the office, and obtained approval from the office of, all reinsurance contracts as provided in s. 641.285.
(9) 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.
History.—s. 6, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 783, 804, 809(1st), ch. 82-243; s. 3, ch. 83-198; s. 3, ch. 84-313; s. 9, ch. 85-177; s. 5, ch. 87-236; s. 4, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 42, ch. 95-211; s. 17, ch. 96-199; s. 21, ch. 97-93; s. 264, ch. 99-8; s. 1560, ch. 2003-261.
641.221 Continued eligibility for certificate of authority.—
(1) In order to maintain its eligibility for a certificate of authority, a health maintenance organization shall continue to meet all conditions required to be met under this part and the rules promulgated thereunder for the initial application for and issuance of its certificate of authority under s. 641.22.
(2) In order to maintain eligibility for a certificate of authority, a health maintenance organization authorized under the Florida Insurance Code to exclusively market, sell, or offer to sell Medicare Advantage plans in this state shall be actively engaged in managed care within 24 months after licensure, shall designate and maintain at least one primary anti-fraud employee, and shall adopt an anti-fraud plan. The Office of Insurance Regulation may extend the period of eligibility upon written request.
History.—ss. 10, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 3, ch. 2017-178.
641.225 Surplus requirements.—
(1) 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.
(2) The office shall not issue a certificate of authority unless the health maintenance organization has a minimum surplus in an amount which is the greater of:
(a) Ten percent of their total liabilities based on their startup projection as set forth in this part;
(b) Two percent of their total projected premiums based on their startup projection as set forth in this part; or
(c) $1,500,000, plus all startup losses, excluding profits, projected to be incurred on their startup projection until the projection reflects statutory net profits for 12 consecutive months.
(3) 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.
(4) A surplus note shall not be used to initially capitalize a health maintenance organization.
(5) 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:
(a) Has been in operation for 5 years or more and has a surplus, not including land, buildings, and equipment, of the greater of $2 million or 2 times the minimum surplus requirements of the health maintenance organization. In any determination of the financial condition of the guaranteeing organization, the definitions of assets, liabilities, and surplus set forth in this part shall apply, except that investments in or loans to any organizations guaranteed by the guaranteeing organization shall be excluded from surplus. If the guaranteeing organization is sponsoring more than one organization, the surplus requirement shall be increased by a multiple equal to the number of such organizations.
(b) Submits a guarantee that is approved by the office as meeting the requirements of this part, provided that the written guarantee contains a provision which requires that the guarantee be irrevocable unless the guaranteeing organization can demonstrate to the office that the cancellation of the guarantee will not result in the insolvency of the health maintenance organization and the office approves cancellation of the guarantee.
(c) Initially submits its audited financial statements, certified by an independent certified public accountant, prepared in accordance with generally accepted accounting principles, covering its two most current annual accounting periods.
(d) Submits annually, within 3 months after the end of its fiscal year, an audited financial statement certified by an independent certified public accountant, prepared in accordance with generally accepted accounting principles. The office may, as it deems necessary, require quarterly financial statements from the guaranteeing organization.
(6) A health maintenance organization that is authorized in this state and one or more other states, jurisdictions, or countries is subject to ss. 624.4085 and 624.40851.
History.—s. 4, ch. 83-198; s. 4, ch. 84-313; s. 28, ch. 85-62; s. 11, ch. 85-177; s. 1, ch. 86-286; s. 5, ch. 88-388; s. 24, ch. 90-295; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 18, ch. 96-199; s. 20, ch. 98-159; s. 7, ch. 2001-64; s. 1561, ch. 2003-261; s. 134, ch. 2004-5; s. 27, ch. 2004-344; s. 16, ch. 2014-101; s. 31, ch. 2015-3; s. 81, ch. 2016-10.
641.2261 Application of solvency requirements to provider-sponsored organizations and Medicaid provider service networks.—
(1) 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.
(2) Except for a provider service network seeking to obtain a certificate of authority under s. 641.2019, 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.
History.—s. 74, ch. 2000-318; s. 5, ch. 2005-358; s. 35, ch. 2011-135.
641.227 Rehabilitation Administrative Expense Fund.—
(1) 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).
(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.
(3) 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.
(4) 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.
(5) 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.
History.—ss. 12, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1562, ch. 2003-261.
641.228 Florida Health Maintenance Organization Consumer Assistance Plan.—
(1) 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).
(2) No assessment paid to the Florida Health Maintenance Organization Consumer Assistance Plan shall be allowed as an asset of any health maintenance organization.
(3) 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.
History.—ss. 6, 24, ch. 88-388; ss. 114, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1563, ch. 2003-261.
641.23 Revocation or cancellation of certificate of authority; suspension of enrollment of new subscribers; terms of suspension.—
(1) 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.
(2) 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:
(a) The organization is not operating in compliance with this part;
(b) The plan is no longer actuarially sound or the organization does not have the minimum surplus as required by this part;
(c) The existing contract rates are excessive, inadequate, or unfairly discriminatory;
(d) The organization has advertised, merchandised, or attempted to merchandise its services in such a manner as to misrepresent its services or capacity for service or has engaged in deceptive, misleading, or unfair practices with respect to advertising or merchandising; or
(e) The organization is insolvent.
(3) 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:
(a) Reduce the total amount of present potential liability for benefits by reinsurance or other means.
(b) Reduce the volume of new business being accepted.
(c) Reduce the expenses of the health maintenance organization by specified methods.
(d) Suspend or limit the writing of new business for a period of time.
(e) Require an increase in the health maintenance organization’s net worth.
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.
(4) 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.
(5) 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.
(6) 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.
History.—s. 7, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 784, 804, 809(1st), ch. 82-243; s. 5, ch. 83-198; s. 6, ch. 84-313; s. 6, ch. 87-236; s. 7, ch. 88-388; ss. 115, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 43, ch. 95-211; s. 19, ch. 96-199; s. 265, ch. 99-8; s. 2, ch. 2000-155; s. 1564, ch. 2003-261.
641.234 Administrative, provider, and management contracts.—
(1) 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.
(2) 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:
(a) That the fees to be paid by the health maintenance organization under the contract are so unreasonably high as compared with similar contracts entered into by the health maintenance organization or as compared with similar contracts entered into by other health maintenance organizations in similar circumstances that the contract is detrimental to the subscribers, stockholders, investors, or creditors of the health maintenance organization; or
(b) That the contract is with an entity that is not licensed under state statutes, if such license is required, or is not in good standing with the applicable regulatory agency.
(3) 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.
(4)(a) If a health maintenance organization, through a health care risk contract, transfers to any entity the obligations to pay any provider for any claims arising from services provided to or for the benefit of any subscriber of the organization, the health maintenance organization shall remain responsible for any violations of ss. 641.3155, 641.3156, and 641.51(4). The provisions of ss. 624.418-624.4211 and 641.52 shall apply to any such violations.
(b) As used in this subsection:
1. The term “health care risk contract” means a contract under which an entity receives compensation in exchange for providing to the health maintenance organization a provider network or other services, which may include administrative services.
2. The term “entity” means a person licensed as an administrator under s. 626.88 and does not include any provider or group practice, as defined in s. 456.053, providing services under the scope of the license of the provider or the members of the group practice. The term does not include a hospital providing billing, claims, and collection services solely on its own and its physicians’ behalf and providing services under the scope of its license.
History.—ss. 8, 24, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 20, ch. 96-199; s. 72, ch. 2000-318; s. 9, ch. 2002-389; s. 1565, ch. 2003-261.
641.2342 Contract providers.—Each health maintenance organization shall file, upon the request of the office, financial statements for all contract providers of comprehensive health care services who have assumed, through capitation or other means, more than 10 percent of the health care risks of the health maintenance organization. However, this provision shall not apply to any individual physician.
History.—ss. 9, 24, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1566, ch. 2003-261.
641.25 Administrative penalty in lieu of suspension or revocation.—If the office finds that one or more grounds exist for the revocation or suspension of a certificate issued under this part, the office may, in lieu of revocation or suspension, impose a fine upon the health maintenance organization. With respect to any nonwillful violation, the fine must 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 office or commission or a provision of this part, the office may impose upon the organization a fine 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 commission must adopt by rule penalty categories that specify varying ranges of monetary fines for willful violations and for nonwillful violations.
History.—s. 9, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 786, 804, 809(1st), ch. 82-243; s. 6, ch. 83-198; s. 7, ch. 87-236; s. 10, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 21, ch. 96-199; s. 1567, ch. 2003-261.
641.255 Acquisition, merger, or consolidation.—
(1) 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.
(2) 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:
(a) Any person who has received any payment from either party or any person on that party’s behalf; or
(b) The existence of any agreement entered into by either party or by any person on that party’s behalf to pay a consultant fee, a broker fee, a commission, or other fee or charge,
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.
(3) A health maintenance organization that is a member of a holding company system is subject to s. 628.461 but not s. 628.4615.
History.—ss. 787, 809(1st), ch. 82-243; ss. 13, 17, ch. 86-250; s. 4, ch. 87-50; s. 10, ch. 90-248; ss. 184, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 22, ch. 96-199; s. 1568, ch. 2003-261; s. 17, ch. 2014-101.
641.26 Annual and quarterly reports.—
(1) 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:
(a) A financial statement of the health maintenance organization filed by electronic means in a computer-readable form using a format acceptable to the office.
(b) A financial statement of the health maintenance organization filed on forms acceptable to the office.
(c) An audited financial statement of the health maintenance organization, including its balance sheet and a statement of operations for the preceding year certified by an independent certified public accountant, prepared in accordance with statutory accounting principles.
(d) The number of health maintenance contracts issued and outstanding and the number of health maintenance contracts terminated.
(e) The number and amount of damage claims for medical injury initiated against the health maintenance organization and any of the providers engaged by it during the reporting year, broken down into claims with and without formal legal process, and the disposition, if any, of each such claim.
(f) An actuarial certification that:
1. The health maintenance organization is actuarially sound, which certification shall consider the rates, benefits, and expenses of, and any other funds available for the payment of obligations of, the organization.
2. The rates being charged or to be charged are actuarially adequate to the end of the period for which rates have been guaranteed.
3. Incurred but not reported claims and claims reported but not fully paid have been adequately provided for.
4. The health maintenance organization has adequately provided for all obligations required by s. 641.35(3)(a).
(g) A report prepared by the certified public accountant and filed with the office describing material weaknesses in the health maintenance organization’s internal control structure as noted by the certified public accountant during the audit. The report must be filed with the annual audited financial report as required in paragraph (c). The health maintenance organization shall provide a description of remedial actions taken or proposed to correct material weaknesses, if the actions are not described in the independent certified public accountant’s report.
(h) Such other information relating to the performance of health maintenance organizations as is required by the commission or office.
(2) 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.
(3) 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.
(4) 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.
(5) 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.
(a) The CPA shall provide to the HMO audited financial statements consistent with this part.
(b) Any determination by the CPA that the health maintenance organization does not meet minimum surplus requirements as set forth in this part shall be stated by the CPA, in writing, in the audited financial statement.
(c) The completed work papers and any written communications between the CPA firm and the health maintenance organization relating to the audit of the health maintenance organization shall be made available for review on a visual-inspection-only basis by the office at the offices of the health maintenance organization, at the office, or at any other reasonable place as mutually agreed between the office and the health maintenance organization. The CPA must retain for review the work papers and written communications for a period of not less than 6 years.
(d) The CPA shall provide to the office a written report describing material weaknesses in the health maintenance organization’s internal control structure as noted during the audit.
(6) 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.
(7) 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.
(8) 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.
History.—s. 10, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 788, 804, 809(1st), ch. 82-243; s. 7, ch. 83-198; s. 13, ch. 85-177; s. 8, ch. 87-236; s. 11, ch. 88-388; s. 75, ch. 89-360; ss. 116, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 23, ch. 96-199; s. 22, ch. 98-159; s. 7, ch. 2002-247; s. 1569, ch. 2003-261.
641.261 Other reporting requirements.—
(1) 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.
(2) 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.
History.—s. 6, ch. 87-377; s. 1, ch. 88-303; s. 8, ch. 90-232; s. 37, ch. 90-295; ss. 187, 188, ch. 91-108; s. 68, ch. 91-282; s. 4, ch. 91-429; s. 44, ch. 95-211; s. 266, ch. 99-8; s. 189, ch. 99-397.
641.27 Examination by the department.—
(1) 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.
(2) 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.
History.—s. 11, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 789, 804, 809(1st), ch. 82-243; s. 8, ch. 83-198; s. 14, ch. 85-177; s. 9, ch. 87-236; s. 12, ch. 88-388; ss. 117, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 161, ch. 98-166; s. 222, ch. 2000-160; s. 73, ch. 2000-318; s. 1570, ch. 2003-261; s. 9, ch. 2005-231.
641.28 Civil remedy.—In any civil action brought to enforce the terms and conditions of a health maintenance organization contract, the prevailing party is entitled to recover reasonable attorney’s fees and court costs. This section shall not be construed to authorize a civil action against the commission, office, or department, their employees, or the Chief Financial Officer or against the Agency for Health Care Administration, its employees, or the director of the agency.
History.—s. 12, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 790, 804, 809(1st), ch. 82-243; s. 9, ch. 83-198; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 24, ch. 96-199; s. 1571, ch. 2003-261.
641.281 Injunction.—In addition to the penalties and other enforcement provisions of this part, the office and department, within the scope of their regulatory jurisdictions, are vested with the power to seek both temporary and permanent injunctive relief when:
(1) A health maintenance organization is being operated by any person or entity without a subsisting certificate of authority.
(2) Any person, entity, or health maintenance organization has engaged in any activity prohibited by this part or any rule adopted pursuant thereto.
(3) Any health maintenance organization, person, or entity is renewing, issuing, or delivering a health maintenance contract or contracts without a subsisting certificate of authority.
The office’s and department’s authority to seek injunctive relief shall not be conditioned on having conducted any proceeding pursuant to chapter 120.
History.—ss. 15, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1572, ch. 2003-261.
641.282 Payment of judgment by health maintenance organization.—Except as otherwise ordered by the court or mutually agreed upon by the parties, every judgment or decree entered in any of the courts of this state against any health maintenance organization for the recovery of money shall be fully satisfied within 60 days from and after the entry thereof or, in the case of an appeal from such judgment or decree, within 60 days from and after the affirmance of the same by the appellate court.
History.—ss. 16, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.284 Liquidation, rehabilitation, reorganization, and conservation; exclusive methods of remedy.—A delinquency proceeding under part I of chapter 631, or supervision by the office under ss. 624.80-624.87, constitute the sole and exclusive means of liquidating, reorganizing, rehabilitating, or conserving a health maintenance organization.
History.—ss. 118, 188, ch. 91-108; s. 4, ch. 91-429; s. 1573, ch. 2003-261.
641.285 Insolvency protection.—
(1) 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.
(2) 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.
(3) 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).
(4) 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.
History.—ss. 791, 809(1st), ch. 82-243; s. 10, ch. 83-198; s. 17, ch. 85-177; ss. 184, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 21, ch. 98-159; s. 1574, ch. 2003-261.
641.286 Levy upon deposit limited.—No judgment creditor or other claimant of a health maintenance organization shall have the right to levy upon any of the assets or securities held in this state as a deposit under s. 641.285.
History.—ss. 18, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.29 Fees.—Every health maintenance organization shall pay to the office the following fees:
(1) For filing a copy of its application for a certificate of authority or amendment thereto, a nonrefundable fee in the amount of $1,000.
(2) For filing each annual report, which must be filed by electronic means in a computer-readable form, $150.
History.—s. 13, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 792, 804, 809(1st), ch. 82-243; s. 19, ch. 85-177; s. 10, ch. 87-236; s. 13, ch. 88-388; ss. 119, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1575, ch. 2003-261.
641.30 Construction and relationship to other laws.—
(1) Every health maintenance organization shall accept the claim form prescribed pursuant to s. 641.3155.
(2) 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.
(3) 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.
(4) The Division of Investigative and Forensic Services 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.
(5) Every health maintenance organization must comply with s. 627.4301.
History.—s. 14, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 793, 804, 809(1st), ch. 82-243; s. 7, ch. 84-313; s. 20, ch. 85-177; s. 11, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 5, ch. 97-182; s. 53, ch. 99-3; s. 10, ch. 2002-389; s. 26, ch. 2016-165.
641.3005 Application of ch. 85-177.—This act shall take effect October 1, 1985, and shall apply to all health maintenance organizations that have obtained certificates of authority before, on, or after this date, unless otherwise provided in this act. Any provision of this act necessitating a change in a health maintenance contract shall apply to contracts issued or renewed after October 1, 1985.
History.—s. 48, ch. 85-177; s. 1, ch. 86-286; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.3007 HIV infection and AIDS for contract purposes.—
(1) 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.
(2) 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.
(3) DEFINITIONS.—As used in this section:
(a) “AIDS” means acquired immune deficiency syndrome.
(b) “ARC” means AIDS-related complex.
(c) “HIV” means human immunodeficiency virus identified as the causative agent of AIDS.
(4) UTILIZATION OF MEDICAL TESTS.—
(a) With respect to the issuance of or the underwriting of a health maintenance organization contract regarding exposure to the HIV infection and sickness or medical conditions derived from such infection, a health maintenance organization shall only utilize medical tests which are reliable predictors of risk. A test which is recommended by the Centers for Disease Control and Prevention or by the federal Food and Drug Administration is deemed to be reliable for the purposes of this section. A test which is rejected or not recommended by the Centers for Disease Control and Prevention or the federal Food and Drug Administration is a test which is deemed to be not reliable for the purposes of this section. If a specific Centers for Disease Control and Prevention or federal Food and Drug Administration recommended test indicates the existence or potential existence of exposure by the HIV infection or a sickness or medical condition related to the HIV infection, before relying on a single test result to deny or limit coverage or to rate the coverage, the health maintenance organization shall follow the applicable Centers for Disease Control and Prevention or federal Food and Drug Administration recommended test protocol and shall utilize any applicable Centers for Disease Control and Prevention or federal Food and Drug Administration recommended followup tests or series of tests to confirm the indication.
(b) Prior to testing, the health maintenance organization must disclose its intent to test the person for the HIV infection or for a specific sickness or medical condition derived therefrom and must obtain the person’s written informed consent to administer the test. Written informed consent shall include a fair explanation of the test, including its purpose, potential uses, and limitations, and the meaning of its results and the right to confidential treatment of information. Use of a form approved by the office shall raise a conclusive presumption of informed consent.
(c) An applicant shall be notified of a positive test result by a physician designated by the applicant or, in the absence of such designation, by the Department of Health. Such notification must include:
1. Face-to-face posttest counseling on the meaning of the test results; the possible need for additional testing; and the need to eliminate behavior which might spread the disease to others;
2. The availability in the geographic area of any appropriate health care services, including mental health care, and appropriate social and support services;
3. The benefits of locating and counseling any individual by whom the infected individual may have been exposed to human immunodeficiency virus and any individual whom the infected individual may have exposed to the virus; and
4. The availability, if any, of the services of public health authorities with respect to locating and counseling any individual described in subparagraph 3.
(d) A medical test for exposure to the HIV infection or for a sickness or medical condition derived from such infection shall only be required of or given to a person if the test is required or given to all subscribers or applicants or if the decision to require the test is based on the person’s medical history. Sexual orientation shall not be used in the underwriting process or in the determination of which subscribers or applicants for enrollment shall be tested for exposure to the HIV infection. Neither the marital status, the living arrangements, the occupation, the gender, the beneficiary designation, nor the zip code or other territorial classification of an applicant shall be used to establish the applicant’s sexual orientation.
(e) A health maintenance organization may inquire whether a person has been tested positive for exposure to the HIV infection or been diagnosed as having AIDS or ARC caused by the HIV infection or other sickness or medical condition derived from such infection. A health maintenance organization shall not inquire whether a person has been tested for or has received a negative result from a specific test for exposure to the HIV infection or for a sickness or medical condition derived from such infection.
(f) A health maintenance organization shall maintain strict confidentiality regarding medical test results with respect to the HIV infection or a specific sickness or medical condition derived from such infection. Information regarding specific test results shall not be disclosed outside the health maintenance organization, its employees, its marketing representatives, or its insurance affiliates, except to the person tested and to persons designated in writing by the person tested. Specific test results shall not be furnished to an insurance industry or health maintenance organization data bank if a review of the information would identify the individual and the specific test results.
(g) No laboratory may be used by an insurer or insurance support organization for the processing of HIV-related tests unless it is certified by the United States Department of Health and Human Services under the Clinical Laboratories Improvement Act of 1967, permitting testing of specimens obtained in interstate commerce, and subjects itself to ongoing proficiency testing by the College of American Pathologists, the American Association of Bio Analysts, or an equivalent program approved by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.
(5) RESTRICTIONS ON CONTRACT EXCLUSIONS AND LIMITATIONS.—
(a) A health maintenance organization contract shall not exclude coverage of a member of a subscriber group because of a positive test result for exposure to the HIV infection or a specific sickness or medical condition derived from such infection, either as a condition for or subsequent to the issuance of the contract, provided that this prohibition shall not apply to persons applying for enrollment where individual underwriting is otherwise allowed by law.
(b) No health maintenance organization contract shall exclude or limit coverage for exposure to the HIV infection or a specific sickness or medical condition derived from such infection, except as provided in a preexisting condition clause.
History.—ss. 51, 54, ch. 88-380; s. 188, ch. 91-108; s. 4, ch. 91-429; s. 45, ch. 95-211; s. 54, ch. 99-3; s. 267, ch. 99-8; s. 1576, ch. 2003-261.
641.305 Language used in contracts and advertisements; translations.—
(1)(a) All health maintenance contracts or forms shall be printed in English.
(b) If the negotiations by a health maintenance organization with a member leading up to the effectuation of a health maintenance contract are conducted in a language other than English, the health maintenance organization shall supply to the member a written translation of the contract, which translation accurately reflects the substance of the contract and is in the language used to negotiate the contract. The written translation shall be affixed to and shall become a part of the contract or form. Any such translation shall be furnished to the office as part of the filing of the health maintenance contract form. No translation of a health maintenance contract form shall be approved by the department unless the translation accurately reflects the substance of the health maintenance contract form in translation.
(2) 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.
History.—ss. 22, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1577, ch. 2003-261.
641.309 Standards for marketing to persons eligible for Medicare.—
(1) Every health maintenance organization marketing coverage to Medicare participants or persons eligible for Medicare in this state, directly or through its agents, shall:
(a) Establish marketing procedures to assure that any comparison of benefits between Medicare or any other health maintenance organization offering such coverage by its agents will be fair and accurate.
(b) Establish marketing procedures to assure proper notification to the Medicare participant of enrollment or disenrollment from the health maintenance organization. Such notification shall be made in a timely manner.
(c) Display prominently by type, stamp, or other appropriate means, on the first page of the application and contract, the following:
“Notice to buyer: When you enroll in this health maintenance organization, you will be disenrolled from Medicare. The buyer should be aware that in order to receive payment or coverage for services such services must be rendered by physicians, hospitals, and other health care providers designated by the health maintenance organization. If the services are rendered by a nonparticipating physician, hospital, or other health care provider, the purchaser may be liable for payment for such services except in very limited circumstances.”
(d) Inquire and otherwise make every reasonable effort to identify whether a prospective Medicare participant has previously been enrolled in either the same health maintenance organization as a Medicare participant or in another health maintenance organization as a Medicare participant.
(2) In addition to the practices prohibited in s. 641.3903:
(a) No health maintenance organization or person representing such health maintenance organization shall employ any method of marketing having the effect of or tending to induce the purchase of health care plans through fraud, deceit, force, fright, threat whether explicit or implied, intimidation, harassment, or undue pressure to purchase or recommend the purchase of a health maintenance organization contract.
(b) No participating provider, employee, or agent of such participating provider shall be an agent for or conduct any sales activities for a health maintenance organization with whom they have a provider contract.
History.—ss. 120, 188, ch. 91-108; s. 4, ch. 91-429.
641.31 Health maintenance contracts.—
(1) 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.
(2) 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. 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.
(3)(a) If a health maintenance organization desires to amend any contract with its subscribers or any certificate or member handbook, or desires to change any basic health maintenance contract, certificate, grievance procedure, or member handbook form, or application form where written application is required and is to be made a part of the contract, or printed amendment, addendum, rider, or endorsement form or form of renewal certificate, it may do so, upon filing with the office the proposed change or amendment. Any proposed change shall be effective immediately, subject to disapproval by the office. Following receipt of notice of such disapproval or withdrawal of approval, no health maintenance organization shall issue or use any form disapproved by the office or as to which the office has withdrawn approval.
(b) Any change in the rate is subject to paragraph (d) and requires at least 30 days’ advance written notice to the subscriber. In the case of a group member, there may be a contractual agreement with the health maintenance organization to have the employer provide the required notice to the individual members of the group.
(c) The office shall disapprove any form filed under this subsection, or withdraw any previous approval thereof, if the form:
1. Is in any respect in violation of, or does not comply with, any provision of this part or rule adopted thereunder.
2. Contains or incorporates by reference, where such incorporation is otherwise permissible, any inconsistent, ambiguous, or misleading clauses or exceptions and conditions which deceptively affect the risk purported to be assumed in the general coverage of the contract.
3. Has any title, heading, or other indication of its provisions which is misleading.
4. Is printed or otherwise reproduced in such a manner as to render any material provision of the form substantially illegible.
5. Contains provisions which are unfair, inequitable, or contrary to the public policy of this state or which encourage misrepresentation.
6. Excludes coverage for human immunodeficiency virus infection or acquired immune deficiency syndrome or contains limitations in the benefits payable, or in the terms or conditions of such contract, for human immunodeficiency virus infection or acquired immune deficiency syndrome which are different than those which apply to any other sickness or medical condition.
(d) Any change in rates charged for the contract must be filed with the office not less than 30 days in advance of the effective date. At the expiration of such 30 days, the rate filing shall be deemed approved unless prior to such time the filing has been affirmatively approved or disapproved by order of the office. The approval of the filing by the office constitutes a waiver of any unexpired portion of such waiting period. The office may extend by not more than an additional 15 days the period within which it may so affirmatively approve or disapprove any such filing, by giving notice of such extension before expiration of the initial 30-day period. At the expiration of any such period as so extended, and in the absence of such prior affirmative approval or disapproval, any such filing shall be deemed approved. This paragraph does not apply to group health contracts effectuated and delivered in this state, insuring groups of 51 or more persons, except for Medicare supplement insurance, long-term care insurance, and any coverage under which the increase in claims costs over the lifetime of the contract due to advancing age or duration is prefunded in the premium.
(e) It is not the intent of this subsection to restrict unduly the right to modify rates in the exercise of reasonable business judgment.
(4) 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.
(5) 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.
(6) 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.
(7) A health maintenance organization is entitled to coordinate benefits on the same basis as an insurer under s. 627.4235.
(8) 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).
(9) 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.
(a) A contract may require the subscriber to notify the plan of the birth of a child within a time period, as specified in the contract, of not less than 30 days after the birth, or a contract may require the preenrollment of a newborn prior to birth. However, if timely notice is given, a plan may not charge an additional premium for additional coverage of the newborn child for not less than 30 days after the birth of the child. If timely notice is not given, the plan may charge an additional premium from the date of birth. If notice is given within 60 days of the birth of the child, the contract may not deny coverage of the child due to failure of the subscriber to timely notify the plan of the birth of the child or to preenroll the child.
(b) If the contract does not require the subscriber to notify the plan of the birth of a child within a specified time period, the plan may not deny coverage of the child nor may it retroactively charge the subscriber an additional premium for the child; however, the contract may prospectively charge the member an additional premium for the child if the plan provides at least 45 days’ notice of the additional charge.
(10) 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.
(11) 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.
(12) 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.
(13) 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:
(a) The health maintenance organization shall mail or deliver notification to the Medicare beneficiary of the date of enrollment in the health maintenance organization within 10 days after receiving notification of enrollment approval from the United States Department of Health and Human Services, Health Care Financing Administration. When a Medicare beneficiary who is a subscriber of the health maintenance organization requests disenrollment from the organization, the organization shall mail or deliver to the beneficiary notice of the effective date of the disenrollment within 10 days after receipt of the written disenrollment request. The health maintenance organization shall forward the disenrollment request to the United States Department of Health and Human Services, Health Care Financing Administration, in a timely manner so as to effectuate the next available disenrollment date, as prescribed by such federal agency.
(b) The health maintenance contract, certificate, or member handbook shall be delivered to the subscriber no later than the earlier of 10 working days after the health maintenance organization and the Health Care Financing Administration of the United States Department of Health and Human Services approve the subscriber’s enrollment application or the effective date of coverage of the subscriber under the health maintenance contract. However, if notice from the Health Care Financing Administration of its approval of the subscriber’s enrollment application is received by the health maintenance organization after the effective coverage date prescribed by the Health Care Financing Administration, the health maintenance organization shall deliver the contract, certificate, or member handbook to the subscriber within 10 days after receiving such notice. When a Medicare recipient is enrolled in a health maintenance organization program, the contract, certificate, or member handbook shall be accompanied by a health maintenance organization identification sticker with instruction to the Medicare beneficiary to place the sticker on the Medicare identification card.
(14) 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).
(15)(a) All health maintenance contracts, certificates, and member handbooks shall contain the following provision:
“Grace Period: This contract has a (insert a number not less than 10) day grace period. This provision means that if any required premium is not paid on or before the date it is due, it may be paid during the following grace period. During the grace period, the contract will stay in force.”
(b) The required provision of paragraph (a) shall not apply to certificates or member handbooks delivered to individual subscribers under a group health maintenance contract when the employer or other person who will hold the contract on behalf of the subscriber group pays the entire premium for the individual subscribers. However, such required provision shall apply to the group health maintenance contract.
(16) 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.
(17) 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.
(18)(a) Health maintenance contracts that provide coverage, benefits, or services for maternity care must provide, as an option to the subscriber, the services of nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed pursuant to ss. 383.30-383.332, if such services are available within the service area.
(b) Any health maintenance contract that provides maternity or newborn coverage may not limit coverage for the length of a maternity or newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists, by the treating obstetrical care provider or the pediatric care provider.
(c) This section does not affect any agreement between a health maintenance organization and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and this section does not prohibit appropriate utilization review or case management by a health maintenance organization.
(d) Any health maintenance contract that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician’s office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards.
(e) A health maintenance organization subject to paragraph (b) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such organization shall also use a process that includes a written protocol for utilization review and quality assurance.
(f) Any health maintenance organization subject to paragraph (b) may not:
1. Deny to a mother or her newborn infant eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the contract for the purpose of avoiding the requirements of this section.
2. Provide monetary payments or rebates to a mother to encourage the mother to accept less than the minimum protections available under this section.
3. Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an individual participant or beneficiary in accordance with this section.
4. Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.
5. Subject to paragraph (i), restrict benefits for any portion of a period within a hospital length of stay required under paragraph (b) in a manner that is less favorable than the benefits provided for any preceding portion of such stay.
(g) This subsection does not require a mother who is a participant or beneficiary to:
1. Give birth in a hospital.
2. Stay in the hospital for a fixed period of time following the birth of her infant.
(h) This subsection does not apply with respect to any coverage offered by a health maintenance organization that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant.
(i) This subsection does not prevent a health maintenance organization from imposing deductibles, coinsurance, or other cost sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant under the contract or under health insurance coverage offered in connection with a group health plan, except that such coinsurance or other cost sharing for any portion of a period within a hospital length of stay required under paragraph (b) may not be greater than such coinsurance or cost sharing for any preceding portion of such stay.
(19) Notwithstanding any other provision of law, health maintenance policies or contracts which provide coverage, benefits, or services as described in s. 463.002(7), shall offer to the subscriber the services of an optometrist licensed pursuant to chapter 463.
(20) 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.
(21) 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.
(22) 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.
(23) 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.”
(24) 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.
(25) 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.
(26)(a) Each health maintenance organization and prepaid health plan shall provide coverage for all medically appropriate and necessary equipment, supplies, and services used to treat diabetes, including outpatient self-management training and educational services, if the patient’s primary care physician, or the physician to whom the patient has been referred who specializes in treating diabetes, certifies that the equipment, supplies, or services are necessary.
(b) The contract may require that diabetes outpatient self-management training and educational services be provided under the direct supervision of a certified diabetes educator or a board-certified endocrinologist under contract with or designated by the health maintenance organization or prepaid health plan.
(c) The Agency for Health Care Administration shall adopt standards for outpatient self-management training and educational services, taking into consideration standards approved by the American Diabetes Association.
(27) 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.
(28) 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.
(29) If a health maintenance contract provides that coverage of a dependent child of the subscriber terminates 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:
(a) Incapable of self-sustaining employment by reason of an intellectual or physical disability.
(b) Chiefly dependent upon the employee or member for support and maintenance.
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 this subsection.
(30)(a) All health maintenance contracts which 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, also provide that the benefits applicable for children include coverage for child health supervision services from the moment of birth to age 16 years.
(b) As used in this subsection, the term “child health supervision services” means physician-delivered or physician-supervised services that include, at a minimum, services delivered at the intervals and scope stated in this subsection.
1. Child health supervision services must include periodic visits which shall include a history, a physical examination, a developmental assessment and anticipatory guidance, and appropriate immunizations and laboratory tests. Such services and periodic visits shall be provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics.
2. Minimum benefits may be limited to one visit payable to one provider for all of the services provided at each visit cited in this subsection.
(31)(a) Health maintenance contracts that provide coverage, benefits, or services for breast cancer treatment may not limit inpatient hospital coverage for mastectomies to any period that is less than that determined by the treating physician under contract with the health maintenance organization to be medically necessary in accordance with prevailing medical standards and after consultation with the covered patient. Such contract must also provide coverage for outpatient postsurgical followup care in keeping with prevailing medical standards by a licensed health care professional under contract with the health maintenance organization qualified to provide postsurgical mastectomy care. The treating physician under contract with the health maintenance organization, after consultation with the covered patient, may choose that the outpatient care be provided at the most medically appropriate setting, which may include the hospital, treating physician’s office, outpatient center, or home of the covered patient.
(b) A health maintenance organization subject to this subsection may not:
1. Deny to a covered person eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the contract for the purpose of avoiding the requirements of this subsection;
2. Provide monetary payments or rebates to a covered patient to accept less than the minimum protections available under this subsection;
3. Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to a covered patient under this subsection;
4. Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to a covered patient in a manner inconsistent with this subsection; or
5. Subject to the other provisions of this subsection, restrict benefits for any portion of a period within a hospital length of stay or outpatient care as required by this subsection in a manner that is less than favorable than the benefits provided for any preceding portion of such stay.
(c)1. This subsection does not require a covered patient to have the mastectomy in the hospital or stay in the hospital for a fixed period of time following the mastectomy.
2. This subsection does not prevent a contract from imposing deductibles, coinsurance, or other cost sharing in relation to benefits pursuant to this subsection, except that such cost sharing shall not exceed cost sharing with other benefits.
(d) Except as provided in paragraph (b), this subsection does not affect any agreement between a health maintenance organization and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and does not prohibit appropriate utilization review or case management by the health maintenance organization.
(e) As used in this subsection, the term “mastectomy” means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician.
(32) 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.
(33) 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.
(34) 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:
(a) Is under 8 years of age and is determined by a licensed dentist, and the child’s physician licensed under chapter 458 or chapter 459, to require necessary dental treatment in a hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or
(b) Has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center.
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.
(35) 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.
(36) 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.
(37) 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.
(38)(a) Notwithstanding any other provision of this part, a health maintenance organization that meets the requirements of paragraph (b) may, through a point-of-service rider to its contract providing comprehensive health care services, include a point-of-service benefit. Under such a rider, a subscriber or other covered person of the health maintenance organization may choose, at the time of covered service, a provider with whom the health maintenance organization does not have a health maintenance organization provider contract. The rider may not require a referral from the health maintenance organization for the point-of-service benefits.
(b) A health maintenance organization offering a point-of-service rider under this subsection must have a valid certificate of authority issued under the provisions of the chapter, must have been licensed under this chapter for a minimum of 3 years, and must at all times that it has riders in effect maintain a minimum surplus of $5 million. A health maintenance organization offering a point-of-service rider to its contract providing comprehensive health care services may offer the rider to employers who have employees living and working outside the health maintenance organization’s approved geographic service area without having to obtain a health care provider certificate, as long as the master group contract is issued to an employer that maintains its primary place of business within the health maintenance organization’s approved service area. Any member or subscriber that lives and works outside the health maintenance organization’s service area and elects coverage under the health maintenance organization’s point-of-service rider must provide a statement to the health maintenance organization that indicates the member or subscriber understands the limitations of his or her policy and that only those benefits under the point-of-service rider will be covered when services are provided outside the service area.
(c) Premiums paid in for the point-of-service riders may not exceed 15 percent of total premiums for all health plan products sold by the health maintenance organization offering the rider. If the premiums paid for point-of-service riders exceed 15 percent, the health maintenance organization must notify the office and, once this fact is known, must immediately cease offering such a rider until it is in compliance with the rider premium cap.
(d) Notwithstanding the limitations of deductibles and copayment provisions in this part, a point-of-service rider may require the subscriber to pay a reasonable copayment for each visit for services provided by a noncontracted provider chosen at the time of the service. The copayment by the subscriber may either be a specific dollar amount or a percentage of the reimbursable provider charges covered by the contract and must be paid by the subscriber to the noncontracted provider upon receipt of covered services. The point-of-service rider may require that a reasonable annual deductible for the expenses associated with the point-of-service rider be met and may include a lifetime maximum benefit amount. The rider must include the language required by s. 627.6044 and must comply with copayment limits described in s. 627.6471. Section 641.3154 does not apply to a point-of-service rider authorized under this subsection.
(e) The point-of-service rider must contain provisions that comply with s. 627.6044.
(f) The term “point of service” may not be used by a health maintenance organization except with riders permitted under this section or with forms approved by the office in which a point-of-service product is offered with an indemnity carrier.
(g) A point-of-service rider must be filed and approved under ss. 627.410 and 627.411.
(39) 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.
(40)(a) Any group rate, rating schedule, or rating manual for a health maintenance organization policy, which provides creditable coverage as defined in s. 627.6562(3), filed with the office shall provide for an appropriate rebate of premiums paid in the last policy year, contract year, or calendar year when the majority of members of a health plan are enrolled in and have maintained participation in any health wellness, maintenance, or improvement program offered by the group contract holder. The group must provide evidence of demonstrative maintenance or improvement of his or her health status as determined by assessments of agreed-upon health status indicators between the group and the health insurer, including, but not limited to, reduction in weight, body mass index, and smoking cessation. Any rebate provided by the health maintenance organization is presumed to be appropriate unless credible data demonstrates otherwise, or unless the rebate program requires the insured to incur costs to qualify for the rebate which equals or exceeds the value of the rebate but the rebate may not exceed 10 percent of paid premiums.
(b) The premium rebate authorized by this section shall be effective for a subscriber on an annual basis, unless the number of participating members on the contract renewal anniversary becomes fewer than the majority of the members eligible for participation in the wellness program.
(c) A health maintenance organization that issues individual contracts may offer a premium rebate, as provided under this section, for a healthy lifestyle program.
(41) All health maintenance contracts providing coverage for a member of the subscriber’s family must comply with the provisions of s. 627.6562.
(42) The contract, certificate, or member handbook must be accompanied by an identification card that contains, at a minimum:
(a) The name of the organization offering the contract or name of the organization administering the contract, whichever applies.
(b) The name of the subscriber.
(c) A statement that the health plan is a health maintenance organization. Only a health plan with a certificate of authority issued under this chapter may be identified as a health maintenance organization.
(d) The member identification number, contract number, and group number, if applicable.
(e) A contact phone number or electronic address for authorizations and admission certifications.
(f) A phone number or electronic address whereby the covered person or hospital, physician, or other person rendering services covered by the contract may obtain benefits verification and information in order to estimate patient financial responsibility, in compliance with privacy rules under the Health Insurance Portability and Accountability Act.
(g) The national plan identifier, in accordance with the compliance date set forth by the federal Department of Health and Human Services.
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.
(43) 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.
(44)(a) A health maintenance organization issuing or delivering in this state a health maintenance contract that provides prescription drug coverage shall offer medication synchronization to allow a subscriber to align at least once in a plan year the refill dates for prescription drugs covered by the health maintenance contract. The health maintenance organization shall implement a process for dispensing prescription drugs to a subscriber for the purpose of aligning the refill dates of such drugs, and such medication synchronization may be available only through a network pharmacy. A controlled substance, a prescription drug dispensed in an unbreakable package, or a multidose unit of a prescription drug may not be partially filled for the purpose of aligning refill dates. The health maintenance organization shall pay a full dispensing fee to the network pharmacy for each partial refill of a covered prescription drug dispensed to align refill dates, unless otherwise agreed to by the plan and the network pharmacy at the time a subscriber requests medication synchronization. The health maintenance organization shall prorate the cost-sharing obligations of the subscriber for each partial refill of a covered prescription drug dispensed to align refill dates. This subsection applies to contracts renewed or entered into on or after January 1, 2018.
(b) Notwithstanding paragraph (a), an alternate process used by a health maintenance organization which includes early refill dates, refill overrides, and access on the health maintenance organization’s public website to the terms and conditions of such a process is deemed to comply with the requirements of this subsection.
History.—s. 15, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 794, 804, 809(1st), ch. 82-243; s. 11, ch. 83-198; s. 9, ch. 84-313; s. 21, ch. 85-177; ss. 2, 11, ch. 87-236; s. 2, ch. 87-273; s. 3, ch. 88-269; s. 52, ch. 88-380; s. 14, ch. 88-388; s. 4, ch. 89-190; s. 1, ch. 89-357; s. 9, ch. 90-232; s. 38, ch. 90-295; ss. 121, 187, 188, ch. 91-108; s. 61, ch. 91-110; s. 3, ch. 91-185; s. 69, ch. 91-282; s. 4, ch. 91-429; s. 2, ch. 93-245; s. 27, ch. 95-418; s. 3, ch. 96-195; s. 25, ch. 96-199; ss. 3, 5, ch. 96-279; s. 4, ch. 96-282; s. 12, ch. 97-48; s. 1752, ch. 97-102; s. 4, ch. 97-166; s. 2, ch. 97-171; s. 23, ch. 97-179; s. 5, ch. 98-66; s. 23, ch. 98-159; s. 4, ch. 98-312; s. 5, ch. 99-264; s. 3, ch. 99-275; s. 4, ch. 99-393; s. 13, ch. 2000-252; s. 23, ch. 2000-256; s. 142, ch. 2000-318; s. 4, ch. 2003-139; s. 1578, ch. 2003-261; s. 135, ch. 2004-5; s. 34, ch. 2004-297; s. 10, ch. 2005-231; s. 98, ch. 2006-1; s. 1, ch. 2007-215; s. 10, ch. 2008-32; s. 4, ch. 2008-119; s. 7, ch. 2008-212; s. 16, ch. 2013-26; s. 24, ch. 2013-101; s. 21, ch. 2013-162; s. 14, ch. 2016-11; s. 21, ch. 2016-194; s. 2, ch. 2017-94; s. 111, ch. 2018-24.
641.3101 Additional contract contents.—A health maintenance contract may contain additional provisions not inconsistent with this part which are:
(1) 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
(2) Desired by the organization and neither prohibited by law nor in conflict with any provisions required to be included therein.
History.—ss. 23, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
1641.31015 Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.—Each health maintenance organization or exclusive provider organization shall provide prospective enrollees with written information about the terms and conditions of the plan in accordance with s. 641.31(4) so that the prospective enrollees can make informed decisions about accepting a managed-care system of health care delivery; however, information about where, in what manner, and from whom the comprehensive health care services or specific health care services can be obtained need be disclosed only upon request by the prospective enrollee. All marketing materials distributed by the health maintenance organization or exclusive provider organization must contain a notice in boldfaced type which states that the information required under this section is available to the prospective enrollee upon request.
History.—s. 8, ch. 96-223.
641.3102 Restrictions upon expulsion or refusal to issue or renew contract.—
(1) 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.
(2) 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.
History.—ss. 24, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 24, ch. 97-179.
641.3103 Charter, bylaw provisions.—No health maintenance contract shall contain any provision purporting to make any portion of the articles of incorporation, charter, bylaws, or other organizational document of the health maintenance organization a part of the contract unless the provision is set forth in full in the contract. Any contract provision in violation of this section is invalid, unless the provision operates to the benefit of the subscriber.
History.—ss. 25, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.3104 Execution of contracts.—
(1) 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.
(2) A facsimile signature of any executing individual may be used in lieu of an original signature.
(3) 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.
History.—ss. 26, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.3105 Validity of noncomplying contracts.—
(1) 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.
(2) 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.
History.—ss. 27, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 489, ch. 97-102; s. 1579, ch. 2003-261.
641.3106 Construction of contracts.—Every health maintenance 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 thereto.
History.—ss. 28, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.3107 Delivery of contract; definitions.—
(1) A health maintenance contract, certificate of coverage, endorsements and riders, or member handbook shall be mailed, delivered, or otherwise provided to the subscriber or, in the case of a group health maintenance contract, to the employer or other person who will hold the contract on behalf of the subscriber group, as provided in s. 627.421.
(2) As used in s. 627.421, the term:
(a) “Insurance policies and endorsements,” “policy and endorsements,” “policy,” and “policy form and endorsement form” includes the health maintenance contract, endorsement and riders, certificate of coverage, or member handbook.
(b) “Insured” includes a subscriber or, in the case of a group health maintenance contract, 1the employer or other person who will hold the contract on behalf of the subscriber group.
(c) “Insurer” includes a health maintenance organization.
(3) If the health maintenance organization elects to post health maintenance contracts on its Internet website in lieu of mailing or delivery to subscribers or the person who will hold the contract on behalf of a subscriber group, the health maintenance organization must comply with the requirements of s. 627.421(4). This section does not apply to the delivery of those contracts specified in s. 641.31(13).
History.—ss. 29, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 10, ch. 91-110; s. 4, ch. 91-429; s. 14, ch. 2018-131.
641.31071 Preexisting conditions.—
(1) As used in this section, the term:
(a) “Enrollment date” means, with respect to an individual covered under a group health maintenance organization contract, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period of such enrollment.
(b) “Late enrollee” means, with respect to coverage under a group health maintenance organization contract, a participant or beneficiary who enrolls under the contract other than during:
1. The first period in which the individual is eligible to enroll under the plan.
2. A special enrollment period, as provided under s. 641.31072.
(c) “Waiting period” means, with respect to a group health maintenance organization contract and an individual who is a potential participant or beneficiary under the contract, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the contract.
(2) 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:
(a) Such exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;
(b) Such exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date; and
(c) The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, as defined in s. 627.6562(3), applicable to the participant or beneficiary as of the enrollment date.
(3) 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.
(4)(a) Subject to paragraph (b), a health maintenance organization that offers group coverage may not impose any preexisting condition exclusion in the case of:
1. An individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage.
2. A child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This provision shall not apply to coverage before the date of such adoption or placement for adoption.
3. Pregnancy.
(b) Subparagraphs (a)1. and 2. do not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.
History.—s. 25, ch. 97-179; s. 55, ch. 99-3; s. 1580, ch. 2003-261; s. 22, ch. 2016-194.
641.31072 Special enrollment periods.—
(1) 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:
(a) The employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent. For the purpose of this section, the terms “group health plan” and “health insurance coverage” have the same meaning ascribed in s. 2791 of the Public Health Service Act.
(b) The employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or health maintenance organization, if applicable, required such a statement at such time and provided the employee with notice of such requirement and the consequences of such requirement at such time.
(c) The employee’s or dependent’s coverage described in paragraph (a):
1. Was under a COBRA continuation provision or continuation pursuant to s. 627.6692, and the coverage under such provision was exhausted; or
2. Was not under such a provision and the coverage was terminated as a result of loss of eligibility for the coverage, including legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, or the coverage was terminated as a result of the termination of employer contributions toward such coverage.
(d) Under the terms of the contract, the employee requests such enrollment not later than 30 days after the date of exhaustion of coverage described in subparagraph (c)1., or termination or employer contribution described in subparagraph (c)2.
(2) For dependent beneficiaries, if:
(a) A group health maintenance organization contract makes coverage available with respect to a dependent of an individual;
(b) The individual is a participant under the contract, or has met any waiting period applicable to becoming a participant under the contract, and is eligible to be enrolled under the contract but for a failure to enroll during a previous enrollment period; and
(c) A person becomes such a dependent of the individual through marriage, birth, or adoption or placement for adoption,
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.
(3) 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:
(a) The date dependent coverage is made available; or
(b) The date of the marriage, birth, or adoption or placement for adoption described in paragraph (2)(c).
(4) 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:
(a) In the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received.
(b) In the case of a dependent’s birth, as of the date of such birth.
(c) In the case of a dependent’s adoption or placement for adoption, the date of such adoption or placement for adoption.
History.—s. 26, ch. 97-179.
641.31073 Prohibiting discrimination against individual participants and beneficiaries based on health status.—
(1) 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:
(a) Health status.
(b) Medical condition, including physical and mental illnesses.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions arising out of acts of domestic violence.
(h) Disability.
(2) Subsection (1) does not:
(a) Require a health maintenance organization to provide particular benefits other than those provided under the terms of such plan or coverage.
(b) Prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the plan or coverage.
(3) 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.
(4)(a) A health maintenance organization that offers health insurance coverage may not require any individual, as a condition of enrollment or continued enrollment under the contract, to pay a premium or contribution that is greater than such premium or contribution for a similarly situated individual enrolled under the contract on the basis of any health-status-related factor in relation to the individual or to an individual enrolled under the contract as a dependent of the individual.
(b) This subsection does not:
1. Restrict the amount that an employer may be charged for coverage under a group health insurance contract.
2. Prevent a health maintenance organization offering group health insurance coverage from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.
History.—s. 27, ch. 97-179.
641.31074 Guaranteed renewability of coverage.—
(1) Except as otherwise provided in this section, a health maintenance organization that issues a health insurance contract must renew or continue in force such coverage at the option of the contract holder.
(2) A health maintenance organization may nonrenew or discontinue a contract based only on one or more of the following conditions:
(a) The contract holder has failed to pay premiums or contributions in accordance with the terms of the contract or the health maintenance organization has not received timely premium payments.
(b) The contract holder has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the contract.
(c) The contract holder has failed to comply with a material provision of the plan which relates to rules for employer contributions or group participation.
(d) The health maintenance organization is ceasing to offer coverage in such a market in accordance with subsection (3).
(e) There is no longer any enrollee in connection with such plan who lives, resides, or works in the service area of the health maintenance organization or in the area in which the health maintenance organization is authorized to do business.
(f) In the case of coverage that is made available only through one or more bona fide associations as defined in s. 627.6571(5), the membership of an employer in the association, on the basis of which the coverage is provided, ceases, but only if such coverage is terminated under this paragraph uniformly without regard to any health-status-related factor that relates to any covered individuals.
(3)(a) A health maintenance organization may discontinue offering a particular contract form only if:
1. The health maintenance organization provides notice to each contract holder provided coverage of this form in such market, and participants and beneficiaries covered under such coverage, of such discontinuation at least 90 days prior to the date of the nonrenewal of such coverage;
2. The health maintenance organization offers to each contract holder provided coverage of this form in such market the option to purchase all, or in the case of the large group market, any other health insurance coverage currently being offered by the health maintenance organization in such market; and
3. In exercising the option to discontinue coverage of this form and in offering the option of coverage under subparagraph 2., the health maintenance organization acts uniformly without regard to the claims experience of those contract holders or any health-status-related factor that relates to any participants or beneficiaries covered or new participants or beneficiaries who may become eligible for such coverage.
(b)1. In any case in which a health maintenance organization elects to discontinue offering all coverage in the individual market, the small group market, the large group market, or any combination thereof in this state, coverage may be discontinued by the insurer only if:
a. The health maintenance organization provides notice to the office and to each contract holder, and participants and beneficiaries covered under such coverage, of such discontinuation at least 180 days prior to the date of the nonrenewal of such coverage; and
b. All health insurance issued or delivered for issuance in this state in such market is discontinued and coverage under such health insurance coverage in such market is not renewed.
2. In the case of a discontinuation under subparagraph 1. in a market, the health maintenance organization may not provide for the issuance of any health maintenance organization contract coverage in the market in this state during the 5-year period beginning on the date of the discontinuation of the last insurance contract not renewed.
(4) At the time of coverage renewal, a health maintenance organization may modify the coverage for a product offered:
(a) In the large group market;
(b) In the small group market if, for coverage that is available in such market other than only through one or more bona fide associations, as defined in s. 627.6571(5), such modification is consistent with s. 627.6699 and effective on a uniform basis among group health plans with that product; or
(c) In the individual market if the modification is consistent with the laws of this state and effective on a uniform basis among all individuals with that policy form.
(5) 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.
History.—s. 28, ch. 97-179; s. 24, ch. 98-159; s. 1581, ch. 2003-261; s. 8, ch. 2015-121; s. 23, ch. 2016-194.
641.3108 Notice of cancellation of contract.—
(1) 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.
(2) 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.
(3) 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.
History.—ss. 30, 47, ch. 85-177; ss. 122, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 14, ch. 99-204; s. 8, ch. 99-275; s. 13, ch. 99-393.
641.31094 Nondiscrimination of coverage for certain surgical procedures involving bones or joints.—No health maintenance contract or policy which provides coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton shall discriminate against coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if, under accepted medical standards, such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. This section shall not be construed to affect any other coverage under this part or to restrict the scope of coverage under any policy, plan, or contract. Nothing in this section shall be construed to discourage appropriate nonsurgical procedures or to prohibit the continued coverage of nonsurgical procedures in the treatment of a bone or joint of the jaw and facial region. Furthermore, nothing in this subsection requires coverage for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes.
History.—s. 5, ch. 96-361.
641.31095 Coverage for mammograms.—
(1) Every health maintenance contract issued or renewed on or after January 1, 1996, shall provide coverage for at least the following:
(a) A baseline mammogram for any woman who is 35 years of age or older, but younger than 40 years of age.
(b) A mammogram every 2 years for any woman who is 40 years of age or older, but younger than 50 years of age, or more frequently based on the patient’s physician’s recommendations.
(c) A mammogram every year for any woman who is 50 years of age or older.
(d) One or more mammograms a year, based upon a physician’s recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30.
(2) 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.
History.—s. 9, ch. 95-188.
641.31096 Requirements with respect to breast cancer and routine followup care.—Routine followup care to determine whether a breast cancer has recurred in a person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment for purposes of determining preexisting conditions unless evidence of breast cancer is found during or as a result of the followup care.
History.—s. 11, ch. 97-48.
641.31097 Decreasing inappropriate utilization of emergency care.—
(1) 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.
(2) 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.
(3) 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.
(4) 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.
History.—s. 26, ch. 2004-297.
641.31098 Coverage for individuals with developmental disabilities.—
(1) This section and s. 627.6686 may be cited as the “Steven A. Geller Autism Coverage Act.”
(2) As used in this section, the term:
(a) “Applied behavior analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including, but not limited to, the use of direct observation, measurement, and functional analysis of the relations between environment and behavior.
(b) “Autism spectrum disorder” means any of the following disorders as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association:
1. Autistic disorder.
2. Asperger’s syndrome.
3. Pervasive developmental disorder not otherwise specified.
(c) “Eligible individual” means an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developmental disability at 8 years of age or younger.
(d) “Health maintenance contract” means a group health maintenance contract offered by a health maintenance organization. This term does not include a health maintenance contract offered in the individual market, a health maintenance contract that is individually underwritten, or a health maintenance contract provided to a small employer.
(3) A health maintenance contract issued or renewed on or after April 1, 2009, shall provide coverage to an eligible individual for:
(a) Well-baby and well-child screening for diagnosing the presence of autism spectrum disorder.
(b) Treatment of autism spectrum disorder and Down syndrome, through speech therapy, occupational therapy, physical therapy, and applied behavior analysis services. Applied behavior analysis services shall be provided by an individual certified pursuant to s. 393.17 or an individual licensed under chapter 490 or chapter 491.
(4) The coverage required pursuant to subsection (3) is subject to the following requirements:
(a) Coverage shall be limited to treatment that is prescribed by the subscriber’s treating physician in accordance with a treatment plan.
(b) Coverage for the services described in subsection (3) shall be limited to $36,000 annually and may not exceed $200,000 in total benefits.
(c) Coverage may not be denied on the basis that provided services are habilitative in nature.
(d) Coverage may be subject to general exclusions and limitations of the subscriber’s contract, including, but not limited to, coordination of benefits, participating provider requirements, and utilization review of health care services, including the review of medical necessity, case management, and other managed care provisions.
(5) 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).
(6) 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.
(7) 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.
(8) 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.
History.—s. 4, ch. 2008-30; s. 14, ch. 2012-27; s. 161, ch. 2014-17; s. 2, ch. 2016-222.
641.31099 Restrictions on use of state and federal funds for state exchanges.—
(1) A health maintenance contract under which coverage is purchased in whole or in part with any state or federal funds through an exchange created pursuant to the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, may not provide coverage for an abortion as defined in s. 390.011(1), except if the pregnancy is the result of an act of rape or incest, or in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, which would, as certified by a physician, place the woman in danger of death unless an abortion is performed. Coverage is deemed to be purchased with state or federal funds if any tax credit or cost-sharing credit is applied toward the health maintenance contract.
(2) This section does not prohibit a health maintenance contract from offering separate coverage for an abortion if such coverage is not purchased in whole or in part with state or federal funds.
(3) As used in this section, the term “state” means this state or any political subdivision of the state.
History.—s. 3, ch. 2011-111.
641.3111 Extension of benefits.—
(1) 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:
(a) The expiration of 12 months.
(b) Such time as the member is no longer totally disabled.
(c) A succeeding carrier elects to provide replacement coverage without limitation as to the disability condition.
(d) The maximum benefits payable under the contract have been paid.
(2) 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.
(3) 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.
(4) 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).
History.—ss. 16, 24, ch. 88-388; ss. 124, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 25, ch. 98-159.
641.312 Scope.—The Office of Insurance Regulation may adopt rules to administer the National Association of Insurance Commissioners’ Uniform Health Carrier External Review Model Act, issued by the National Association of Insurance Commissioners and dated April 2010. This section does not apply to the types of benefits or coverages provided under s. 627.6513(1)-(14) issued in any market.
History.—s. 13, ch. 2012-44; s. 108, ch. 2013-15; s. 24, ch. 2016-194; s. 112, ch. 2018-24.
641.313 Health maintenance contracts; cancer treatment parity; orally administered cancer treatment medications.—
(1) As used in this section, the term:
(a) “Cancer treatment medication” means medication prescribed by a treating physician who determines that the medication is medically necessary to kill or slow the growth of cancerous cells in a manner consistent with nationally accepted standards of practice.
(b) “Cost sharing” includes copayments, coinsurance, dollar limits, and deductibles imposed on the covered person.
(c) “Grandfathered health plan” has the same meaning as provided in 42 U.S.C. s. 18011 and is subject to the conditions for maintaining status as a grandfathered health plan as specified in 45 C.F.R. s. 147.140.
(2) A health maintenance contract delivered, issued for delivery, renewed, amended, or continued in this state that provides medical, major medical, or similar comprehensive coverage and includes coverage for cancer treatment medications must also cover prescribed, orally administered cancer treatment medications and may not apply cost-sharing requirements for orally administered cancer treatment medications that are less favorable to the covered person than cost-sharing requirements for intravenous or injected cancer treatment medications covered under the contract.
(3) A health maintenance organization providing a contract described in subsection (2) and any participating entity through which the health maintenance organization offers health services may not:
(a) Vary the terms of the policy in effect on July 1, 2014, to avoid compliance with this section.
(b) Provide any incentive, including, but not limited to, a monetary incentive, or impose treatment limitations to encourage a covered person to accept less than the minimum protections available under this section.
(c) Penalize a health care practitioner or reduce or limit the compensation of a health care practitioner for recommending or providing services or care to a covered person as required under this section.
(d) Provide any incentive, including, but not limited to, a monetary incentive, to induce a health care practitioner to provide care or services that do not comply with this section.
(e) Change the classification of any intravenous or injected cancer treatment medication or increase the amount of cost sharing applicable to any intravenous or injected cancer treatment medication in effect on the effective date of this section in order to achieve compliance with this section.
(4) This section does not apply to grandfathered health plans or to Medicare supplement, dental, vision, long-term care, disability, accident only, specified disease policies, or other supplemental limited-benefit plans.
Notwithstanding this section, if the cost-sharing requirements for intravenous or injected cancer treatment medications under the contract are less than $50 per month, then the cost-sharing requirements for orally administered cancer treatment medications may be up to $50 per month.
History.—s. 9, ch. 2013-153.
641.314 Pharmacy benefit manager contracts.—
(1) As used in this section, the term:
(a) “Maximum allowable cost” means the per-unit amount that a pharmacy benefit manager reimburses a pharmacist for a prescription drug, excluding dispensing fees, prior to the application of copayments, coinsurance, and other cost-sharing charges, if any.
(b) “Pharmacy benefit manager” means a person or entity doing business in this state which contracts to administer or manage prescription drug benefits on behalf of a health maintenance organization to residents of this state.
(2) A contract between a health maintenance organization and a pharmacy benefit manager must require that the pharmacy benefit manager:
(a) Update maximum allowable cost pricing information at least every 7 calendar days.
(b) Maintain a process that will, in a timely manner, eliminate drugs from maximum allowable cost lists or modify drug prices to remain consistent with changes in pricing data used in formulating maximum allowable cost prices and product availability.
(3) A contract between a health maintenance organization and a pharmacy benefit manager must prohibit the pharmacy benefit manager from limiting a pharmacist’s ability to disclose whether the cost-sharing obligation exceeds the retail price for a covered prescription drug, and the availability of a more affordable alternative drug, pursuant to s. 465.0244.
(4) A contract between a health maintenance organization and a pharmacy benefit manager must prohibit the pharmacy benefit manager from requiring a subscriber to make a payment for a prescription drug at the point of sale in an amount that exceeds the lesser of:
(a) The applicable cost-sharing amount; or
(b) The retail price of the drug in the absence of prescription drug coverage.
(5) This section applies to contracts entered into or renewed on or after July 1, 2018.
History.—s. 6, ch. 2018-91.
641.315 Provider contracts.—
(1) 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.
(2)(a) For all provider contracts executed after October 1, 1991, and within 180 days after October 1, 1991, for contracts in existence as of October 1, 1991:
1. The contracts must require the provider to give 60 days’ advance written notice to the health maintenance organization and the office before canceling the contract with the health maintenance organization for any reason; and
2. The contract must also provide that nonpayment for goods or services rendered by the provider to the health maintenance organization is not a valid reason for avoiding the 60-day advance notice of cancellation.
(b) All provider contracts must provide that the health maintenance organization will provide 60 days’ advance written notice to the provider and the office before canceling, without cause, the contract with the provider, except in a case in which a patient’s health is subject to imminent danger or a physician’s ability to practice medicine is effectively impaired by an action by the Board of Medicine or other governmental agency.
(3) 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.
(4) Whenever a contract exists between a health maintenance organization and a provider, the health maintenance organization shall disclose to the provider:
(a) The mailing address or electronic address where claims should be sent for processing.
(b) The telephone number that a provider may call to have questions and concerns regarding claims addressed.
(c) The address of any separate claims-processing centers for specific types of services.
(d)1. The complete schedule of reimbursements for all the services for which a health maintenance organization and a provider have contracted and any changes in or deviations from the contracted schedule of reimbursements. The health maintenance organization may satisfy this requirement by:
a. Providing the schedule of reimbursements or changes in or deviations from the schedule by electronic means to the provider; or
b. Providing a written copy of the schedule of reimbursements or changes or deviations from the schedule if requested by the provider.
2. The schedule of reimbursements is subject to the nondisclosure provisions of the contract, and the provider shall maintain the confidentiality of the schedule. For purposes of this paragraph, the term “provider” means a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 466.
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.
(5) 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.
(6) 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) The health care provider from entering into a commercial contract with any other health maintenance organization; or
(b) The health maintenance organization from entering into a commercial contract with any other health care provider.
(7) 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.
(8) 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.
(9) 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.
(10) 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.
(11) A contract between a health maintenance organization and a dentist licensed under chapter 466 for the provision of services to a subscriber of the health maintenance organization may not contain a provision that requires the dentist to provide services to the subscriber of the health maintenance organization at a fee set by the health maintenance organization unless such services are covered services under the applicable contract. As used in this subsection, the term “covered services” means dental care services for which a reimbursement is available under the subscriber’s contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
(12)(a) A health maintenance organization may not require an ophthalmologist licensed pursuant to chapter 458 or chapter 459 or an optometrist licensed pursuant to chapter 463 to join a network solely for the purpose of credentialing the licensee for another organization’s vision network. This paragraph does not prevent such organization from entering into a contract with another organization’s vision care plan to use the vision network.
(b) A health maintenance organization may not restrict an ophthalmologist licensed pursuant to chapter 458 or chapter 459, an optometrist licensed pursuant to chapter 463, or an optician licensed pursuant to part I of chapter 484 to specific suppliers of materials or optical laboratories. This paragraph does not restrict such organization in determining specific amounts of coverage or reimbursement for the use of network or out-of-network suppliers or laboratories.
(c) A health maintenance organization’s online vision care network provider directory must be updated monthly to reflect the vision care providers currently participating in the organization’s network.
(d) A knowing violation of paragraph (a) or paragraph (b) constitutes an unfair insurance trade practice under s. 626.9541(1)(d).
History.—ss. 795, 809(1st), ch. 82-243; s. 12, ch. 83-198; s. 17, ch. 88-388; ss. 125, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 5, ch. 96-223; s. 2, ch. 97-159; s. 2, ch. 99-264; s. 4, ch. 99-275; s. 1, ch. 2000-252; s. 24, ch. 2000-256; s. 3, ch. 2001-107; s. 1582, ch. 2003-261; s. 2, ch. 2004-321; s. 3, ch. 2009-41; s. 3, ch. 2014-64; s. 3, ch. 2016-69.
641.3154 Organization liability; provider billing prohibited.—
(1) 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.
(2) 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.
(3) 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.
(4) 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:
(a) The provider is informed by the organization that it accepts liability;
(b) A court of competent jurisdiction determines that the organization is liable; or
(c) The agency issues a final order that the organization is required to pay for such services subsequent to a recommendation made by a resolution organization pursuant to s. 408.7057.
(5) 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.
History.—s. 2, ch. 2000-252; s. 11, ch. 2002-389; s. 1583, ch. 2003-261; s. 14, ch. 2004-297; s. 113, ch. 2018-24.
641.3155 Prompt payment of claims.—
(1) 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.
(2) All claims for payment or overpayment, whether electronic or nonelectronic:
(a) Are considered received on the date the claim is received by the organization at its designated claims-receipt location or the date a claim for overpayment is received by the provider at its designated location.
(b) Must be mailed or electronically transferred to the primary organization within 6 months after the following have occurred:
1. Discharge for inpatient services or the date of service for outpatient services; and
2. The provider has been furnished with the correct name and address of the patient’s health maintenance organization.
All claims for payment, whether electronic or nonelectronic, must be mailed or electronically transferred to the secondary organization within 90 days after final determination by the primary organization. A provider’s claim is considered submitted on the date it is electronically transferred or mailed.
(c) Must not duplicate a claim previously submitted unless it is determined that the original claim was not received or is otherwise lost.
(3) For all electronically submitted claims, a health maintenance organization shall:
(a) Within 24 hours after the beginning of the next business day after receipt of the claim, provide electronic acknowledgment of the receipt of the claim to the electronic source submitting the claim.
(b) Within 20 days after 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.
(c)1. Notification of the health maintenance organization’s determination of a contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim.
2. A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Additional information is considered submitted on the date it is electronically transferred or mailed. The health maintenance organization may not request duplicate documents.
(d) For purposes of this subsection, electronic means of transmission of claims, notices, documents, forms, and payment shall be used to the greatest extent possible by the health maintenance organization and the provider.
(e) A claim must be paid or denied within 90 days after receipt of the claim. Failure to pay or deny a claim within 120 days after receipt of the claim creates an uncontestable obligation to pay the claim.
(4) For all nonelectronically submitted claims, a health maintenance organization shall:
(a) Effective November 1, 2003, provide acknowledgment of receipt of the claim within 15 days after receipt of the claim to the provider or designee or provide a provider or designee within 15 days after receipt with electronic access to the status of a submitted claim.
(b) Within 40 days after receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the health maintenance 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.
(c)1. Notification of the health maintenance organization’s determination of a contested claim must be accompanied by an itemized list of additional information or documents the organization can reasonably determine are necessary to process the claim.
2. A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Additional information is considered submitted on the date it is electronically transferred or mailed. The health maintenance organization may not request duplicate documents.
(d) For purposes of this subsection, electronic means of transmission of claims, notices, documents, forms, and payments shall be used to the greatest extent possible by the health maintenance organization and the provider.
(e) A claim must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny a claim within 140 days after receipt of the claim creates an uncontestable obligation to pay the claim.
(5) 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.
(a) If an overpayment determination is the result of retroactive review or audit of coverage decisions or payment levels not related to fraud, a health maintenance organization shall adhere to the following procedures:
1. All claims for overpayment must be submitted to a provider within 30 months after the health maintenance organization’s payment of the claim. A provider must pay, deny, or contest the health maintenance organization’s claim for overpayment within 40 days after the receipt of the claim. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.
2. A provider that denies or contests a health maintenance organization’s claim for overpayment or any portion of a claim shall notify the organization, in writing, within 35 days after the provider receives the claim that the claim for overpayment is contested or denied. The notice that the claim for overpayment is denied or contested must identify the contested portion of the claim and the specific reason for contesting or denying the claim and, if contested, must include a request for additional information. If the organization submits additional information, the organization must, within 35 days after receipt of the request, mail or electronically transfer the information to the provider. The provider shall pay or deny the claim for overpayment within 45 days after receipt of the information. The notice is considered made on the date the notice is mailed or electronically transferred by the provider.
3. The health maintenance organization may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization’s overpayment claim as required by this paragraph.
4. Payment of an overpayment claim is considered made on the date the payment was mailed or electronically transferred. An overdue payment of a claim bears simple interest at the rate of 12 percent per year. Interest on an overdue payment for a claim for an overpayment payment begins to accrue when the claim should have been paid, denied, or contested.
(b) A claim for overpayment shall not be permitted beyond 30 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.
(6) 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.
(7)(a) For all contracts entered into or renewed on or after October 1, 2002, a health maintenance organization’s internal dispute resolution process related to a denied claim not under active review by a mediator, arbitrator, or third-party dispute entity must be finalized within 60 days after the receipt of the provider’s request for review or appeal.
(b) All claims to a health maintenance organization begun after October 1, 2000, not under active review by a mediator, arbitrator, or third-party dispute entity, shall result in a final decision on the claim by the health maintenance organization by January 2, 2003, for the purpose of the statewide provider and health plan claim dispute resolution program pursuant to s. 408.7057.
(8) 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.
(9) The provisions of this section may not be waived, voided, or nullified by contract.
(10) 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.
(11) 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.
(12) 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.
(13) 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.
(14) 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.
(15) 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.
(16) 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.
(17) 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.
History.—s. 1, ch. 98-79; s. 5, ch. 99-393; s. 3, ch. 2000-252; s. 25, ch. 2000-256; s. 12, ch. 2002-389; s. 1584, ch. 2003-261; s. 8, ch. 2008-212.
641.3156 Treatment authorization; payment of claims.—
(1) 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.
(2) 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.
(3) Emergency services are subject to the provisions of s. 641.513 and are not subject to the provisions of this section.
History.—s. 4, ch. 2000-252.
641.316 Fiscal intermediary services.—
(1) 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.
(2)(a) The term “fiduciary” or “fiscal intermediary services” means reimbursements received or collected on behalf of health care professionals for services rendered, patient and provider accounting, financial reporting and auditing, receipts and collections management, compensation and reimbursement disbursement services, or other related fiduciary services pursuant to health care professional contracts with health maintenance organizations. All payments to a health care provider by a fiscal intermediary for noncapitated providers must include an explanation of services being reimbursed which includes, at a minimum, the patient’s name, the date of service, the procedure code, the amount of reimbursement, and the identification of the plan on whose behalf the payment is being made. For capitated providers, the statement of services must include the number of patients covered by the contract, the rate per patient, the total amount of the payment, and the identification of the plan on whose behalf the payment is being made.
(b) The term “fiscal intermediary services organization” means a person or entity that performs fiduciary or fiscal intermediary services to health care professionals who contract with health maintenance organizations 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, 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.
(3) 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.
(4) 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.
(5) A fiscal intermediary services organization may not collect from the subscriber any payment other than the copayment or deductible specified in the subscriber agreement.
(6) 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.
History.—s. 3, ch. 97-159; s. 26, ch. 98-159; ss. 162, 293, ch. 98-166; s. 5, ch. 99-275; s. 174, ch. 99-397; s. 3, ch. 2000-155; s. 223, ch. 2000-160; s. 1585, ch. 2003-261; s. 1, ch. 2007-140; s. 100, ch. 2013-18.
641.32 Acceptable payments.—Each health maintenance organization may accept from governmental agencies, corporations, associations, groups, or individuals payments covering all or part of the cost of contracts entered into between the health maintenance organization and its subscribers.
History.—s. 16, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 796, 804, 809(1st), ch. 82-243; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.33 Certain words prohibited in name of organization.—
(1) 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.
(2) 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.
History.—s. 17, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 797, 804, 809(1st), ch. 82-243; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.35 Assets, liabilities, and investments.—
(1) 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:
(a) Cash or cash equivalents in the possession of the health maintenance organization, or in transit under its control, including the true balance of any deposit in a solvent bank, savings and loan association, or trust company which is domiciled in the United States. Cash equivalents are short-term, highly liquid investments, with original maturities of 3 months or less, which are both readily convertible to known amounts of cash and so near their maturity that they present insignificant risk of changes in value because of changes in interest rates.
(b) Investments, securities, properties, and loans acquired or held in accordance with this part, and in connection therewith the following items:
1. Interest due or accrued on any bond or evidence of indebtedness which is not in default and which is not valued on a basis including accrued interest.
2. Declared and unpaid dividends on stock and shares, unless the amount of the dividends has otherwise been allowed as an asset.
3. Interest due or accrued upon a collateral loan which is not in default in an amount not to exceed 1 year’s interest thereon.
4. Interest due or accrued on deposits or certificates of deposit in solvent banks, savings and loan associations, and trust companies domiciled in the United States, and interest due or accrued on other assets, if such interest is in the judgment of the office a collectible asset.
5. Interest due or accrued on current mortgage loans, in an amount not exceeding in any event the amount, if any, of the excess of the value of the property less delinquent taxes thereon over the unpaid principal; but in no event shall interest accrued for a period in excess of 90 days be allowed as an asset.
(c) Premiums in the course of collection, not more than 3 months past due, less commissions payable thereon. The foregoing limitation shall not apply to premiums payable directly or indirectly by any governmental body in the United States or by any of their instrumentalities.
(d) The full amount of reinsurance recoverable from a solvent reinsurer, which reinsurance is authorized under s. 624.610.
(e) Pharmaceutical and medical supply inventories.
(f) Goodwill created by acquisitions and mergers occurring on or after January 1, 2001.
(g) Loans or advances by a health maintenance organization to its parent or principal owner if approved by the office.
(h) Other assets, not inconsistent with the provisions of this section, deemed by the office to be available for the payment of losses and claims, at values to be determined by it.
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.
(2) 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:
(a) Subscriber lists, patents, trade names, agreements not to compete, and other like intangible assets.
(b) Any note or account receivable from or advances to officers, directors, or controlling stockholders, whether secured or not, and advances to employees, agents, or other persons on personal security only, other than those transactions authorized under paragraph (1)(g).
(c) Stock of the health maintenance organization owned by it directly or owned by it through any entity in which the organization owns or controls, directly or indirectly, more than 25 percent of the ownership interest.
(d) Leasehold improvements, nonmedical libraries, stationery, literature, and nonmedical supply inventories, except that leasehold improvements made prior to October 1, 1985, shall be allowed as an asset and shall be amortized over the shortest of the following periods:
1. The life of the lease.
2. The useful life of the improvements.
3. The 3-year period following October 1, 1985.
(e) Furniture, fixtures, furnishings, vehicles, medical libraries, and equipment.
(f) Notes or other evidences of indebtedness which are secured by mortgages or deeds of trust which are in default and beyond the express period specified in the instrument for curing the default.
(g) Bonds in default for more than 60 days.
(h) Prepaid and deferred expenses.
(i) Any note, account receivable, advance, or other evidence of indebtedness, or investment in:
1. The parent of the health maintenance organization;
2. Any entity directly or indirectly controlled by the health maintenance organization parent; or
3. An affiliate of the parent or the health maintenance organization,
except as allowed in subsections (1), (11), and (12). The office may, however, allow all or a portion of such asset, at values to be determined by the office, if deemed by the office to be available for the payment of losses and claims.
(3) LIABILITIES.—In any determination of the financial condition of a health maintenance organization, liabilities to be charged against its assets shall include:
(a) The amount, estimated consistently with the provisions of this part, necessary to pay all of its unpaid losses and claims incurred for or on behalf of a subscriber, on or prior to the end of the reporting period, whether reported or unreported, including contract and premium deficiency reserves. If a health maintenance organization, through a health care risk contract, transfers to any entity the obligation to pay any provider for any claim arising from services provided to or for the benefit of any subscriber, the liabilities of the health maintenance organization under this section shall include the amount of those losses and claims to the extent that the provider has not received payment. No liability need be established if the entity has provided to the health maintenance organization a financial instrument acceptable to the office securing the obligations under the contract or if the health maintenance organization has in place an escrow or withhold agreement approved by the office which assures full payment of those claims. Financial instruments may include irrevocable, clean, and evergreen letters of credit. As used in this paragraph, the term “entity” does not include this state, the United States, or an agency thereof or an insurer or health maintenance organization authorized in this state.
(b) The amount equal to the unearned portions of the gross premiums charged on health maintenance contracts in force.
(c) Taxes, expenses, and other obligations due or accrued at the date of the statement.
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.
(4) 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.
(5) ELIGIBLE INVESTMENTS.—
(a) Health maintenance organizations shall invest in or lend their funds on the security of, and shall hold as invested assets, only eligible investments as prescribed in this part.
(b) Any particular investment held by a health maintenance organization on October 1, 1985, which was a legal investment at the time it was made and which the organization was legally entitled to possess immediately prior to October 1, 1985, shall be deemed to be an eligible investment.
(c) The eligibility of an investment shall be determined as of the date of its making or acquisition, except as stated in paragraph (b).
(d) Any investment limitation based upon the amount of the organization’s assets or particular funds shall relate to such assets or funds as shown by the organization’s annual or quarterly report as of the end of the reporting period immediately preceding the date of acquisition of the investment by the organization or as shown by a current financial statement of the organization.
(6) GENERAL QUALIFICATIONS.—
(a) No security or investment other than real property and personal property acquired under subsection (10) or investments in other health care providers acquired under subsection (11) shall be eligible for acquisition unless it is interest-bearing or interest-accruing, is entitled to receive dividends if and when declared and paid or is otherwise income-producing, and is not then in default in any respect and unless the health maintenance organization is entitled to receive for its exclusive account and benefit the interest or income accruing thereon.
(b) No security or investment shall be eligible for purchase at a price above its market value unless it is approved by the office.
(c) No provision of this part shall prohibit the acquisition by a health maintenance organization of other or additional securities or property if received as a dividend, as a lawful distribution of assets, or under a lawful and bona fide agreement of merger or consolidation. Any investment so acquired which is not otherwise eligible under this part shall be disposed of pursuant to subsection (17) if property or securities.
(7) 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.
(8) EXCESSIVE COMMISSIONS AND CERTAIN INTERESTS PROHIBITED.—
(a) No health maintenance organization shall pay any commission or brokerage for the purchase or sale of property, whether real or personal, in excess of that usual and customary at the time and in the locality where the purchases or sales are made. Information regarding payments of commissions and brokerage shall be maintained from the date of the most recent examination by the office pursuant to s. 641.27 until the date of completion of the following examination.
(b) No health maintenance organization shall knowingly invest in or loan upon any property, directly or indirectly, whether real or personal, in which any officer or director of the organization has a financial interest, nor shall any organization make a loan of any kind to any officer or director of the organization, except that:
1. This paragraph shall not apply to loans in circumstances in which the financial interest of the officer or director is only nominal, trifling, or so remote as not to give rise to a conflict of interest; and
2. In any case, the office may approve a transaction between an organization and its officers or directors under this paragraph if it is satisfied that:
a. The transaction is entered into in good faith for the advantage and benefit of the organization,
b. The amount of the proposed investment or loan does not violate any other provision of this part or exceed the reasonable, normal value of the property or the interest which the company proposed to acquire,
c. The transaction is otherwise fair and reasonable, and
d. The transaction will not adversely affect, to any substantial degree, the liquidity of the organization’s investments or its ability thereafter to comply with requirements of this part or the payment of its claims and obligations.
(9) 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:
(a) Nondemand obligations of certain financial institutions.—Direct, unconditional nondemand obligations for the payment of money issued by a solvent bank or by a mutual savings bank or trust company, savings and loan, building and loan, or credit union, subject to the following:
1. The financial institution is solvent.
2. The financial institution is incorporated under the laws of the United States or of any state thereof.
3. The obligations are of the type which are insured by an agency of the United States.
4. The investment is in the name of and owned by the health maintenance organization, unless the account is under a trusteeship with the organization named as the beneficiary.
(b) Obligations of the United States.—Direct obligations of the United States for the payment of money or obligations for the payment of money to the extent guaranteed or insured as to the payment of principal and interest by the United States.
(c) Obligations of agencies and instrumentalities of the United States.—Direct obligations for the payment of money issued by an agency or instrumentality of the United States or obligations for the payment of money to the extent guaranteed or insured as to the payment of principal and interest by an agency or instrumentality of the United States.
(d) Obligations of a state.—Direct, general obligations of any state of the United States for the payment of money, or obligations for the payment of money to the extent guaranteed or insured as to the payment of principal and interest by full faith and credit of any state of the United States, on the following conditions:
1. The state has the power to levy taxes for the prompt payment of the principal and interest of such obligations.
2. The state is not in default in the payment of principal or interest on any of its direct, guaranteed, or insured general obligations at the date of such investment.
(e) Obligations of political subdivisions of a state.—Direct, general obligations of any political subdivision of any state of the United States for the payment of money, or obligations for the payment of money to the extent guaranteed as to the payment of principal and interest by any political subdivision of any state of the United States, on the following conditions:
1. The obligations are payable or guaranteed from ad valorem taxes.
2. The political subdivision is not in default in the payment of principal or interest on any of its direct or guaranteed obligations.
3. No investment shall be made under this paragraph in obligations which are secured only by special assessments for local improvements.
(10) 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:
(a) Any parcel of real estate acquired under this subsection may include excess space for rent to others if it is reasonably anticipated that the excess will be required by the health maintenance organization for expansion or if the excess is reasonably required in order to have one or more buildings that will function as an economic unit.
(b) The real estate may be subject to a mortgage.
(c) The greater of the admitted value of the asset, as determined by statutory accounting principles, or, if approved by the office, the health maintenance organization’s equity in the real estate plus all encumbrances on the real estate owned by the organization under this subsection, when added to the value of all personal and mixed property used in the organization’s business, shall not exceed 75 percent of its admitted assets unless, with the permission of the office, it finds that the percentage of its admitted assets is insufficient to provide convenient accommodation for the organization’s business and the operations of the organization would not otherwise be impaired.
(11) 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:
(a) Investments authorized under this subsection shall not exceed 50 percent of admitted assets, and these investments shall be included in the calculation of the overall limitation in paragraph (10)(c) relating to all real and personal property.
(b) Investments may qualify under this section only insofar as a provider of management, administrative, or health care service relationship as defined herein exists. Upon cessation of such relationship, each investment shall be subject to the rules applicable to an investment of that type and must qualify under the appropriate limitation or, failing that, become ineligible and subject to disposal under subsection (17).
(12) 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.
(13) 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).
(a) United States Government obligations.—A health maintenance organization may invest in bonds, notes, warrants, and other evidences of indebtedness which are direct obligations of the Government of the United States or for which the full faith and credit of the Government of the United States is pledged for the payment of principal and interest.
(b) Loans guaranteed by the United States.—
1. A health maintenance organization may invest in loans insured or guaranteed as to principal and interest by the Government of the United States, or by any agency or instrumentality of the Government of the United States, to the extent of such insurance or guaranty.
2. A health maintenance organization may invest in student loans insured or guaranteed as to principal by the Government of the United States, or by any agency or instrumentality of the Government of the United States, to the extent of such insurance or guaranty.
(c) State public obligations.—A health maintenance organization may invest in bonds, notes, warrants, and other securities not in default which are the direct obligations of any state of the United States or the District of Columbia, or for which the full faith and credit of such state or district has been pledged for the payment of principal and interest.
(d) County, municipal, and district obligations.—A health maintenance organization may invest in bonds, notes, warrants, and other securities not in default of any county, district, incorporated city, or school district in any state of the United States or the District of Columbia, which are the direct obligations of such county, district, city, or school district and for payment of the principal and interest of which the county, district, city, or school district has lawful authority to levy taxes or make assessments.
(e) Public improvement bonds.—A health maintenance organization may invest in bonds, notes, certificates of indebtedness, warrants, or other evidences of indebtedness which are payable from revenues or earnings specifically pledged therefor of any public toll bridge, structure, or improvement owned by any state, incorporated city, or legally constituted public corporation or commission, all within the United States, for the payment of the principal and interest of which a lawful sinking fund has been established and is being maintained if no default on the part of the issuer in payment of principal or interest has occurred on any of its bonds, notes, warrants, or other securities within 5 years prior to the date of investment therein.
(f) Public utility obligations.—The health maintenance organization may invest in the bonds, notes, certificates of indebtedness, warrants, or other evidences of indebtedness which are valid obligations issued, assumed, or guaranteed by the United States or any state thereof or by any county, municipal corporation, district, political subdivision, civil division, or public instrumentality of any such government or unit thereof, if by statute or other legal requirements such obligations are payable as to both principal and interest from revenues or earnings from the whole or any part of any utility supplying water, gas, sewage disposal, electricity, or any other public service, including, but not limited to, a toll road or toll bridge.
(g) Securities of certain agencies.—The health maintenance organization may invest in bonds, debentures, or other securities of the following agencies, whether or not such obligations are guaranteed by the Government of the United States:
1. The Federal National Mortgage Association, and stock thereof, when acquired in connection with the sale of mortgage loans to such association.
2. Any federal land bank, when such securities are issued under provisions of the Act of Congress entitled the “Federal Farm Loan Act” and approved July 17, 1916, and any acts amendatory or supplementary to that act.
3. Any federal home loan bank, when such securities are issued under provisions of the Act of Congress entitled the “Federal Home Loan Bank Act” and approved July 22, 1932.
4. The Home Owners’ Loan Corporation, created by the Act of Congress entitled “Home Owners’ Loan Act of 1933” and approved June 13, 1933.
5. Any federal intermediate credit bank, created by the Act of Congress entitled “Agricultural Credits Act of March 4, 1923.”
6. The Central Bank for Cooperatives and regional banks for cooperatives organized under the Farm Credit Act of 1933, or by any of such banks; and any notes, bonds, debentures, or other similar obligations, consolidated or otherwise, issued by farm credit institutions pursuant to the Farm Credit Act of 1971, Pub. L. No. 92-181.
7. Any other similar agency of the Government of the United States which is of similar financial quality.
(h) Public housing obligations.—The health maintenance organization may invest in the bonds, debentures, or other securities of public housing authorities, issued under the provisions of the Act of Congress entitled the “Housing Act of 1949” and approved July 1949, the “Municipal Housing Commission Act,” or the “Rural Housing Commission Act,” and any additional amendments, or issued by any public housing authority or agency in the United States, if such bonds, debentures, or other securities are secured by a pledge of annual contributions to be paid by the United States or any agency thereof.
(i) Obligations of State Board of Education.—The health maintenance organization may invest in bonds or motor vehicle anticipation certificates issued by the State Board of Education under authority of s. 18, Art. XII of the State Constitution of 1885 as adopted by s. 9(d), Art. XII of the State Constitution, 1968 Revision, and the additional provisions of s. 9(d) thereof.
(j) Corporate bonds and debentures.—A health maintenance organization may invest in bonds, notes, or other interest-bearing or interest-accruing obligations of any solvent corporation organized under the laws of the United States or any state, territory, or possession of the United States, including the District of Columbia, but such investment must be in securities of investment grade and may not exceed 10 percent of admitted assets for any one corporate entity. As used in this paragraph, “investment grade” means that the obligation has been determined to be in one of the top two rating classifications used by the Securities Valuation Office of the National Association of Insurance Commissioners.
(14) SPECIAL LIMITATION INVESTMENTS.—
(a) After satisfying the requirements of this part, any funds of the health maintenance organization may be invested in the following investments, subject to a cost limitation of 10 percent of its admitted assets in each category of investment:
1. Anticipation obligations of political subdivisions of a state.—Anticipation obligations of any political subdivision of any state of the United States, including, but not limited to, bond anticipation notes, tax anticipation notes, preliminary loan anticipation notes, revenue anticipation notes, and construction anticipation notes, for the payment of money within 12 months from the issuance of the obligation, on the following conditions:
a. The anticipation notes are a direct obligation of the issuer under conditions set forth in subsection (9).
b. The political subdivision is not in default in the payment of the principal or interest on any of its direct general obligations or any obligation guaranteed by such political subdivision.
c. The anticipated funds are specifically pledged to secure the obligations.
2. Revenue obligations of state or municipal public utilities.—Obligations of any state of the United States, a political subdivision thereof, or a public instrumentality of any one or more of the foregoing for the payment of money, on the following conditions:
a. The obligations are payable from revenues or earnings of a public utility of such state, political subdivision, or public instrumentality which are specifically pledged therefor.
b. The law under which the obligations are issued requires that such rates for service shall be charged and collected at all times so as to produce sufficient revenue or earning, together with any other revenues or moneys pledged, to pay all operating and maintenance charges of the public utility and all principal and interest on such charges.
c. No prior or parity obligations payable from the revenues or earnings of that public utility are in default at the date of such investment.
3. Other revenue obligations.—Obligations of any state of the United States, a political subdivision thereof, or a public instrumentality of any of the foregoing for the payment of money, on the following conditions:
a. The obligations are payable from revenues or earnings, excluding revenues or earnings from public utilities, specifically pledged therefor by such state, political subdivision, or public instrumentality.
b. No prior or parity obligation of the same issuer payable from revenues or earnings from the same source has been in default as to principal or interest during the 5 years next preceding the date of the investment, but the issuer need not have been in existence for that period, and obligations acquired under this paragraph may be newly issued.
4. Corporate stocks.—Stocks, common or preferred, of any corporation created or existing under the laws of the United States or any state thereof. The organization may invest in stocks, common or preferred, of any corporation created or existing under the laws of any foreign country if such stocks are listed and traded on a national securities exchange in the United States or, in the alternative, if such investment in stocks of any corporation created or existing under the laws of any foreign country are first approved by the office. Investment in common stock of any one corporation shall not exceed 3 percent of the health maintenance organization’s admitted assets.
(b) After satisfying the requirements of this part, the health maintenance organization may invest its funds and accumulations in the following investments, subject to a cost limitation of 5 percent of admitted assets in each category of investment:
1. Obligations of the International Bank for Reconstruction and Development.—Obligations issued or guaranteed by the International Bank for Reconstruction and Development.
2. Obligations of the Inter-American Development Bank.—Obligations issued or guaranteed by the Inter-American Development Bank.
3. Obligations of the Asian Development Bank.—Obligations issued or guaranteed by the Asian Development Bank.
4. Obligations of the State of Israel.—Direct obligations of the State of Israel for the payment of money, or obligations for the payment of money which are guaranteed as to the payment of principal and interest by the State of Israel, on the condition that the State of Israel shall not be in default in the payment of principal or interest on any of its direct, general obligations on the date of such investment.
5. Obligations of the African Development Bank.—Obligations issued or guaranteed by the African Development Bank.
6. Obligations of the Government of Canada or any province thereof.—Obligations issued or guaranteed by the Government of Canada or any province thereof.
7. Obligations of the International Finance Corporation.—Obligations issued or guaranteed by the International Finance Corporation.
(15) INVESTMENT OF EXCESS FUNDS.—
(a) After satisfying the requirements of this part, any funds of a health maintenance organization in excess of its statutorily required reserves and surplus may be invested:
1. Without limitation in any investments otherwise authorized by this part; or
2. In such other investments not specifically authorized by this part, provided such investments do not exceed the lesser of 5 percent of the health maintenance organization’s admitted assets or 25 percent of the amount by which a health maintenance organization’s surplus exceeds its statutorily required minimum surplus. A health maintenance organization may exceed the limitations of this subparagraph only with the prior written approval of the office.
(b) Nothing in this section authorizes a health maintenance organization to:
1. Invest any funds in excess of the amount by which its actual surplus exceeds its statutorily required minimum surplus; or
2. Make any investment prohibited by this code.
(16) PROHIBITED INVESTMENTS AND INVESTMENT UNDERWRITING.—
(a) In addition to investments excluded pursuant to other provisions of this act, a health maintenance organization shall not directly or indirectly invest in or lend its funds upon the security of:
1. Issued shares of its own capital stock, except in connection with a plan approved by the office for purchase of the shares by the organization’s officers, employees, or agents. However, no such stock shall constitute an asset of the organization in any determination of its financial condition.
2. Except with the consent of the office, securities issued by any corporation or enterprise the controlling interest of which is, or will after such acquisition by the organization be, held directly or indirectly by the organization or any combination of the organization and its directors, officers, parent corporation, subsidiaries, or controlling stockholders. Investments in health care providers under subsections (11) and (12) shall not be subject to this provision.
3. Any note or other evidence of indebtedness of any director, officer, or controlling stockholder of the health maintenance organization.
(b) No health maintenance organization shall underwrite or participate in the underwriting of an offering of securities or property by any other person.
(17) TIME LIMIT FOR DISPOSAL OF INELIGIBLE PROPERTY AND SECURITIES; EFFECT OF FAILURE TO DISPOSE.—
(a) Any property or securities lawfully acquired by a health maintenance organization which it could not otherwise have invested in or loaned its funds upon at the time of such acquisition shall be disposed of within 6 months from the date of acquisition, unless within such period the security has attained to the standard of eligibility; except that any security or property acquired under any agreement of merger or consolidation may be retained for a longer period if so provided in the plan for such merger or consolidation, as approved by the office. Upon application by the organization and proof to the office that forced sale of any such property or security would materially injure the interests of the health maintenance organization, the office shall extend the disposal period for an additional reasonable time.
(b) Notwithstanding the provisions of paragraph (a), any ineligible property or securities shall not be allowed as an asset of the organization.
(18) 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).
History.—s. 19, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 799, 804, 809(1st), ch. 82-243; s. 33, ch. 85-177; s. 18, ch. 88-388; s. 76, ch. 89-360; ss. 126, 184, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 23, ch. 2001-213; s. 8, ch. 2002-247; s. 9, ch. 2002-282; s. 96, ch. 2003-1; s. 1586, ch. 2003-261.
641.36 Adoption of rules; penalty for violation.—The commission shall adopt rules necessary to carry out the provisions of this part. The office shall collect and make available all health maintenance organization rules adopted by the commission. Any violation of a rule adopted under this section shall subject the violating entity to the provisions of s. 641.23.
History.—s. 20, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 800, 804, 809(1st), ch. 82-243; s. 12, ch. 87-236; ss. 127, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1587, ch. 2003-261.
641.365 Dividends.—
(1)(a) A health maintenance organization shall not pay any dividend or distribute cash or other property to stockholders except out of that part of its available and accumulated surplus funds which is derived from realized net operating profits on its business and net realized capital gains.
(b) Unless prior written approval is obtained from the office, a health maintenance organization may not pay or declare any dividend or distribute cash or other property to or on behalf of any stockholder if, immediately before or after such distribution, the health maintenance organization’s available and accumulated surplus funds, which are derived from realized net operating profits on its business and net realized gains, are or would be less than zero.
(c) A health maintenance organization may make dividend payments or distributions to stockholders without the prior written approval of the office when:
1. The dividend is equal to or less than the greater of:
a. Ten percent of the health maintenance organization’s accumulated surplus funds which are derived from realized net operating profits on its business and net realized capital gains as of the immediate preceding calendar year; or
b. The health maintenance organization’s entire net operating profit and realized net capital gains derived during the immediately preceding calendar year.
2. The health maintenance organization will have surplus equal to or exceeding 115 percent of the minimum required statutory surplus after the dividend or distribution is made.
3. The health maintenance organization has filed a notice with the office at least 30 days prior to the dividend payment or distribution, or such shorter period of time as approved by the office on a case-by-case basis.
4. The notice includes a certification by an officer of the health maintenance organization attesting that after payment of the dividend or distribution the health maintenance organization will have at least 115 percent of required statutory surplus.
5. The health maintenance organization has negative retained earnings, statutory surplus in excess of $50 million, and statutory surplus greater than or equal to 150 percent of its required statutory surplus before and after the dividend distribution is made based upon the health maintenance organization’s most recently filed annual financial statement.
(2) 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:
(a) The liquidity, quality, and diversification of the health maintenance organization’s assets and the effect on its ability to meet its obligations.
(b) Any reduction of investment portfolio and investment income.
(c) History of capital contributions.
(d) Prior dividend distributions of the health maintenance organization.
(e) Whether the dividend is only a pass-through dividend from a subsidiary of the health maintenance organization.
(3) 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.
(4) Any stockholder receiving such an illegal dividend shall be liable in the amount thereof to the health maintenance organization.
(5) The office may revoke or suspend the certificate of authority of a health maintenance organization which has declared or paid such an illegal dividend.
History.—ss. 19, 24, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 9, ch. 2002-247; s. 1588, ch. 2003-261.
641.37 Prohibited activities; penalties.—
(1) 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.
(2) 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.
(3) 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.
(4) 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.
(5) 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.
History.—s. 21, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 801, 804, 809(1st), ch. 82-243; s. 34, ch. 85-177; s. 52, ch. 87-226; ss. 187, 188, ch. 91-108; s. 164, ch. 91-224; s. 4, ch. 91-429; s. 26, ch. 96-199; s. 70, ch. 2002-206.
641.38 Operational health maintenance organizations; issuance of certificate.—The provisions of this part do not apply to those organizations providing the services defined in ss. 641.17-641.38 which have been continuously engaged in providing such services since January 1, 1947. This exemption shall terminate upon a change in controlling ownership of the organization.
History.—s. 23, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 802, 804, 809(1st), ch. 82-243; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.385 Order to discontinue certain advertising.—If in the opinion of the office any advertisement by a health maintenance organization violates any of the provisions of this part, the department may enter an immediate order requiring that the use of the advertisement be discontinued. If requested by the health maintenance organization, the office shall conduct a hearing within 10 days of the entry of such order. If, after the hearing or by agreement with the health maintenance organization, a final determination is made that the advertising was in fact violative of any provision of this part, the office may, in lieu of revocation of the certificate of authority, require the publication of a corrective advertisement; impose an administrative penalty of up to $10,000; and, in the case of an initial solicitation, require that the health maintenance organization, prior to accepting any application received in response to the advertisement, provide an acceptable clarification of the advertisement to each individual applicant.
History.—s. 8, ch. 84-313; s. 188, ch. 91-108; s. 4, ch. 91-429; s. 1589, ch. 2003-261.
641.386 Agent licensing and appointment required; exceptions.—
(1) 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:
(a) Solicit contracts or procure applications; or
(b) Engage or hold himself or herself out as engaging in the business of analyzing or abstracting health maintenance contracts or of counseling or advising or giving opinions to persons relative to such contracts other than as a consulting actuary advising a health maintenance organization or as a salaried bona fide full-time employee so counseling and advising his or her employer relative to coverage for the employer and his or her employees.
(2) 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.
(3) 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.
(4) All agents and health maintenance organizations shall comply with and be subject to the applicable provisions of ss. 641.309 and 409.912(3), 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.
History.—ss. 77, 80, ch. 89-360; ss. 176, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 27, ch. 96-199; s. 1753, ch. 97-102; s. 18, ch. 2002-223; s. 136, ch. 2004-5; s. 28, ch. 2004-344; s. 27, ch. 2011-135; s. 32, ch. 2015-3; s. 19, ch. 2017-4.
641.39001 Soliciting or accepting new or renewal health maintenance contracts by insolvent or impaired health maintenance organization prohibited; penalty.—
(1) 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.
(2) 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.
History.—s. 75, ch. 2000-318; s. 1590, ch. 2003-261.
641.3901 Unfair methods of competition and unfair or deceptive acts or practices prohibited.—No person, entity, or health maintenance organization shall engage in this state in any trade practice which is defined in this part as, or determined pursuant to s. 641.3905 to be, an unfair method of competition or an unfair or deceptive act or practice involving the business of health maintenance organizations.
History.—ss. 35, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.3903 Unfair methods of competition and unfair or deceptive acts or practices defined.—The following are defined as unfair methods of competition and unfair or deceptive acts or practices:
(1) 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:
(a) Misrepresents the benefits, advantages, conditions, or terms of any health maintenance contract.
(b) Is misleading, or is a misrepresentation as to the financial condition of any person.
(c) Uses any name or title of any contract misrepresenting the true nature thereof.
(d) Is a misrepresentation for the purpose of inducing, or tending to induce, the lapse, forfeiture, exchange, conversion, or surrender of any health maintenance contract or health insurance policy, or contract providing health insurance as defined in s. 624.603.
(e) Misrepresents the benefits, nature, characteristics, uses, standard, quantity, quality, cost, rate, scope, source, or geographic origin or location of any goods or services available from or provided by, directly or indirectly, any health maintenance organization.
(f) Misrepresents the affiliation, connection, or association of any goods, services, or business establishment.
(g) Advertises goods or services with intent not to sell them as advertised.
(h) Disparages the goods, services, or business of another person by any false or misleading representation.
(i) Misrepresents the sponsorship, endorsement, approval, or certification of goods or services.
(j) Uses an advertising format which, by virtue of the design, location, or size of printed matter, is deceptive or misleading or which would be deceptive or misleading to any reasonable person.
(k) Offers to provide a service which the health maintenance organization is unable to provide.
(l) Misrepresents the availability of a service provided by the health maintenance organization, either directly or indirectly, including the availability of the service as to location.
(2) 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:
(a) In a newspaper, magazine, or other publication;
(b) In the form of a notice, circular, pamphlet, letter, or poster;
(c) Over any radio or television station; or
(d) In any other way,
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.
(3) 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.
(4) FALSE STATEMENTS AND ENTRIES.—
(a) Knowingly:
1. Filing with any supervisory or other public official,
2. Making, publishing, disseminating, or circulating,
3. Delivering to any person,
4. Placing before the public, or
5. Causing, directly or indirectly, to be made, published, disseminated, circulated, or delivered to any person, or place before the public,
any material false statement.
(b) Knowingly making any false entry of a material fact in any book, report, or statement of any person.
(5) UNFAIR CLAIM SETTLEMENT PRACTICES.—
(a) Attempting to settle claims on the basis of an application or any other material document which was altered without notice to, or knowledge or consent of, the subscriber or group of subscribers to a health maintenance organization;
(b) Making a material misrepresentation to the subscriber for the purpose and with the intent of effecting settlement of claims, loss, or damage under a health maintenance contract on less favorable terms than those provided in, and contemplated by, the contract; or
(c) Committing or performing with such frequency as to indicate a general business practice any of the following:
1. Failing to adopt and implement standards for the proper investigation of claims;
2. Misrepresenting pertinent facts or contract provisions relating to coverage at issue;
3. Failing to acknowledge and act promptly upon communications with respect to claims;
4. Denying of claims without conducting reasonable investigations based upon available information;
5. Failing to affirm or deny coverage of claims upon written request of the subscriber within a reasonable time not to exceed 30 days after a claim or proof-of-loss statements have been completed and documents pertinent to the claim have been requested in a timely manner and received by the health maintenance organization;
6. Failing to promptly provide a reasonable explanation in writing to the subscriber of the basis in the health maintenance contract in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement;
7. Failing to provide, upon written request of a subscriber, itemized statements verifying that services and supplies were furnished, where such statement is necessary for the submission of other insurance claims covered by individual specified disease or limited benefit policies, provided that the organization may receive from the subscriber a reasonable administrative charge for the cost of preparing such statement;
8. Failing to provide any subscriber with services, care, or treatment contracted for pursuant to any health maintenance contract without a reasonable basis to believe that a legitimate defense exists for not providing such services, care, or treatment. To the extent that a national disaster, war, riot, civil insurrection, epidemic, or any other emergency or similar event not within the control of the health maintenance organization results in the inability of the facilities, personnel, or financial resources of the health maintenance organization to provide or arrange for provision of a health service in accordance with requirements of this part, the health maintenance organization is required only to make a good faith effort to provide or arrange for provision of the service, taking into account the impact of the event. For the purposes of this paragraph, an event is not within the control of the health maintenance organization if the health maintenance organization cannot exercise influence or dominion over its occurrence; or
9. Systematic downcoding with the intent to deny reimbursement otherwise due.
(6) 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.
(7) 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.
(8) 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.
(9) 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.
(10) ILLEGAL DEALINGS IN PREMIUMS; EXCESS OR REDUCED CHARGES FOR HEALTH MAINTENANCE COVERAGE.—
(a) Knowingly collecting any sum as a premium or charge for health maintenance coverage which is not then provided or is not in due course to be provided, subject to acceptance of the risk by the health maintenance organization, by a health maintenance contract issued by a health maintenance organization as permitted by this part.
(b) Knowingly collecting as a premium or charge for health maintenance coverage any sum in excess of or less than the premium or charge applicable to health maintenance coverage, in accordance with the applicable classifications and rates as filed with the office, and as specified in the health maintenance contract.
(11) 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.
(12) PROHIBITED DISCRIMINATORY PRACTICES.—A health maintenance organization may not:
(a) Engage or attempt to engage in discriminatory practices that discourage participation on the basis of actual or perceived health status of Medicaid recipients.
(b) Refuse to provide services or care to a subscriber solely because medical services may be or have been sought for injuries resulting from an assault, battery, sexual assault, sexual battery, or any other offense by a family or household member, as defined in s. 741.28, or by another who is or was residing in the same dwelling unit.
(13) MISREPRESENTATION IN HEALTH MAINTENANCE ORGANIZATION; AVAILABILITY OF PROVIDERS.—Knowingly misleading potential enrollees as to the availability of providers.
(14) 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.
(15) PARTICIPATION IN A WELLNESS OR HEALTH IMPROVEMENT PROGRAM.—
(a) Authorization to offer rewards or incentives for participation.—A health maintenance organization issuing a group or individual health benefit plan may offer a voluntary wellness or health improvement program and may encourage or reward participation in the program by authorizing rewards or incentives, including, but not limited to, merchandise, gift cards, debit cards, premium discounts, contributions to a member’s health savings account, or modifications to copayment, deductible, or coinsurance amounts.
(b) Verification of medical condition by nonparticipants due to medical condition.—A health maintenance organization may require a member of a health benefit plan to provide verification, such as an affirming statement from the member’s physician, that the member’s medical condition makes it unreasonably difficult or inadvisable to participate in the wellness or health improvement program in order for that nonparticipant to receive the reward or incentive.
(c) Disclosure requirement.—A reward or incentive offered under this subsection shall be disclosed in the policy or certificate.
(d) Other incentives.—This subsection does not prohibit health maintenance organizations from offering other incentives or rewards for adherence to a wellness or health improvement program if otherwise authorized by state or federal law.
History.—ss. 36, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 28, ch. 96-199; s. 6, ch. 96-223; s. 1, ch. 99-264; s. 5, ch. 2000-252; s. 8, ch. 2002-55; s. 1591, ch. 2003-261; s. 2, ch. 2011-167.
641.3905 General powers and duties of the department and office.—In addition to the powers and duties set forth in s. 624.307, the department and office shall each have the power within its respective regulatory jurisdiction to examine and investigate the affairs of every person, entity, or health maintenance organization in order to determine whether the person, entity, or health maintenance organization is operating in accordance with the provisions of this part or has been or is engaged in any unfair method of competition or in any unfair or deceptive act or practice prohibited by s. 641.3901, and each shall have the powers and duties specified in ss. 641.3907-641.3913 in connection therewith.
History.—ss. 37, 47, ch. 85-177; ss. 128, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1592, ch. 2003-261.
641.3907 Defined unfair practices; hearings, witnesses, appearances, production of books, and service of process.—
(1) 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.
(2) 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.
(3) 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.
History.—ss. 38, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 285, ch. 96-410; s. 1754, ch. 97-102; s. 1593, ch. 2003-261.
641.3909 Cease and desist and penalty orders.—After the hearing provided in s. 641.3907, the department or office shall enter a final order in accordance with s. 120.569. If it is determined that the person, entity, or health maintenance organization charged has engaged in an unfair or deceptive act or practice or the unlawful operation of a health maintenance organization without a subsisting certificate of authority, the department or office shall also issue an order requiring the violator to cease and desist from engaging in such method of competition, act, or practice or unlawful operation of a health maintenance organization. Further, if the act or practice constitutes a violation of s. 641.3155, s. 641.3901, or s. 641.3903, the department or office may, at its discretion, order any one or more of the following:
(1) 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.
(2) 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.
History.—ss. 39, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 286, ch. 96-410; s. 6, ch. 2000-252; s. 1594, ch. 2003-261.
641.3911 Appeals from the department or office.—Any person, entity, or health maintenance organization subject to an order of the department or office under s. 641.3909 or s. 641.3913 may obtain a review of the order by filing an appeal therefrom in accordance with the provisions and procedures for appeal under s. 120.68.
History.—ss. 40, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1595, ch. 2003-261.
641.3913 Penalty for violation of cease and desist orders.—Any person, entity, or health maintenance organization which violates a cease and desist order of the department or office under s. 641.3909 while such order is in effect, after notice and hearing as provided in s. 641.3907, shall be subject, at the discretion of the department or office, to any one or more of the following:
(1) A monetary penalty of not more than $200,000 as to all matters determined in such hearing.
(2) Suspension or revocation of the health maintenance organization’s certificate of authority.
History.—ss. 41, 47, ch. 85-177; s. 20, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1596, ch. 2003-261.
641.3915 Health maintenance organization anti-fraud plans and investigative units.—Each authorized health maintenance organization and applicant for a certificate of authority shall comply with the provisions of ss. 626.989 and 626.9891 as though such organization or applicant were an authorized insurer.
History.—s. 4, ch. 99-204; ss. 4, 14, ch. 2017-178.
641.3917 Civil liability.—The provisions of this part are cumulative to rights under the general civil and common law, and no action of the department or office shall abrogate such rights to damage or other relief in any court.
History.—ss. 42, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1597, ch. 2003-261.
641.3921 Conversion on termination of eligibility.—A group health maintenance contract delivered or issued for delivery in this state by a health maintenance organization shall provide that a subscriber or covered dependent whose coverage under the group health maintenance contract has been terminated for any reason, including discontinuance of the group health maintenance contract in its entirety or with respect to a covered class, and who has been continuously covered under the group health maintenance contract, and under any group health maintenance contract providing similar benefits which it replaces, for at least 3 months immediately prior to termination, shall be entitled to have issued to him or her by the health maintenance organization a health maintenance contract, hereafter referred to as a “converted contract.” A subscriber or covered dependent shall not be entitled to have a converted contract issued to him or her if termination of his or her coverage under the group health maintenance contract occurred for any of the following reasons:
(1) 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;
(2) Replacement of any discontinued group coverage by similar group coverage within 31 days;
(3) Fraud or material misrepresentation in applying for any benefits under the health maintenance contract;
(4) 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.
(a) Effort to resolve the problem. The organization must make a serious effort to resolve the problem presented by the subscriber, including the use or attempted use of subscriber grievance procedures.
(b) Consideration of extenuating circumstances. The organization must ascertain that the subscriber’s behavior does not directly result from an existing medical condition.
(c) Documentation. The organization must document the problems, efforts, and medical conditions as described in this subsection;
(5) Willful and knowing misuse of the health maintenance organization identification membership card by the subscriber;
(6) 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
(7) 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.
History.—ss. 43, 47, ch. 85-177; s. 21, ch. 88-388; ss. 129, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 490, ch. 97-102; s. 29, ch. 97-179.
641.3922 Conversion contracts; conditions.—Issuance of a converted contract shall be subject to the following conditions:
(1) 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).
(2) EVIDENCE OF INSURABILITY.—The converted contract shall be issued without evidence of insurability.
(3) 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.
(4) 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.
(5) 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.
(6) OPTIONAL COVERAGE.—The health maintenance organization may 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 is not required to issue or renew a converted health maintenance contract covering any person if:
(a)1. The person is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by any other plan or program;
2. The person is eligible for similar benefits, whether actually covered, under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or
3. Similar benefits are provided for or are available to the person pursuant to or in accordance with the requirements of state or federal law; and
(b) A converted health maintenance contract may include a provision whereby the health maintenance organization may request information, in advance of any premium due date of a health maintenance contract, of any person covered thereunder as to whether:
1. She or he is covered for similar benefits by another hospital, surgical, medical, or major medical expense insurance policy or hospital or medical service subscriber contract or medical practice or other prepayment plan or by another plan or program;
2. She or he is covered for similar benefits under an arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or
3. Similar benefits are provided for or are available to the person pursuant to or in accordance with the requirements of state or federal law.
(7) 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:
(a) Fraud or intentional misrepresentation, subject to the limitations of s. 641.31(23), in applying for any benefits under the converted health maintenance contract;
(b) Disenrollment for cause, after following the procedures outlined in s. 641.3921(4).
(c) Willful and knowing misuse of the health maintenance organization identification membership card by the subscriber or the 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.
(d) Failure, after notice, to pay required premiums.
(e) 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.
(f) A dependent of the subscriber has reached the limiting age under the converted contract, subject to subsection (12); but the refusal to renew coverage shall apply only to coverage of the dependent, except in the case of handicapped children.
(g) A change in marital status that makes a person ineligible under the original terms of the converted contract, subject to subsection (12).
(h) The subscriber is covered for similar benefits or eligible for similar benefits, or similar benefits are provided for or are available to the subscriber as described in paragraph (6)(a). The reason for nonrenewal authorized by this paragraph is not required to be contained in the converted health maintenance contract but must be provided in writing to the subscriber at least 90 days before the contract renewal date.
(8) 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.
(9) 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.
(10) ALTERNATE PLANS.—The health maintenance organization may, at its option, 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.
(11) 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.
(12) CONVERSION PRIVILEGE ALLOWED.—Subject to the conditions set forth above, the conversion privilege shall also be available:
(a) To the surviving spouse, if any, at the death of the subscriber, with respect to the spouse and such children whose coverages under the group health maintenance contract terminate by reason of such death, otherwise to each surviving child whose coverage under the group health maintenance contract terminates by reason of such death or, if the group contract provides for continuation of dependents’ coverages following the subscriber’s death, at the end of such continuation;
(b) To the former spouse whose coverage would otherwise terminate because of annulment or dissolution of marriage, if the former spouse is dependent for financial support;
(c) To the spouse of the subscriber upon termination of coverage of the spouse, while the subscriber remains covered under the group health maintenance contract, by reason of ceasing to be a qualified family member under the group health maintenance contract, with respect to the spouse and such children whose coverages under the group health maintenance contract terminate at the same time; or
(d) To a child solely with respect to herself or himself upon termination of the child’s coverage by reason of ceasing to be a qualified family member under the group health maintenance contract or under any converted contract, if a conversion privilege is not otherwise provided above with respect to such termination.
(13) 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.
(14) 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.
History.—ss. 44, 47, ch. 85-177; ss. 130, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 491, ch. 97-102; s. 30, ch. 97-179; s. 27, ch. 98-159; s. 15, ch. 99-204; s. 9, ch. 99-275; s. 14, ch. 99-393; s. 1598, ch. 2003-261; s. 25, ch. 2013-101; s. 9, ch. 2015-121.
641.3923 Discrimination against providers prohibited.—A health maintenance organization may not discriminate with respect to participation as to any advanced practice registered nurse licensed pursuant to s. 464.012, who is acting within the scope of such license, solely on the basis of such license. This section may not be construed to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan’s enrollees or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan.
History.—s. 2, ch. 98-285; s. 77, ch. 2018-106.
PART II
PREPAID HEALTH CLINICS641.40 Short title.
641.401 Declaration of legislative intent, findings, and purposes.
641.4015 Part exclusive; applicability of other laws.
641.402 Definitions.
641.403 Rulemaking authority.
641.405 Application for certificate of authority to operate prepaid health clinic.
641.406 Issuance of certificate of authority.
641.4065 Insurance business not authorized.
641.407 Minimum surplus.
641.408 Use of certain words prohibited in the name of a prepaid health clinic.
641.409 Insolvency protection.
641.4091 Levy upon deposit; limitation.
641.41 Annual report of prepaid health clinic; administrative penalty.
641.411 Other reporting requirements.
641.412 Fees.
641.414 Investment of funds of prepaid health clinic.
641.416 Acquisition.
641.418 Examination of prepaid health clinic by the office.
641.419 Rehabilitation, liquidation, conservation, or dissolution of prepaid health clinic.
641.42 Prepaid health clinic contracts.
641.421 Language used in contracts and advertisements; translations.
641.422 Contract provisions incorporating charter or bylaw provisions.
641.423 Execution of contracts.
641.424 Validity of noncomplying contracts.
641.425 Construction of contracts.
641.426 Delivery of contract to subscriber.
641.427 Notice of cancellation, termination, or nonrenewal of contract.
641.428 Nondiscrimination of coverage for certain surgical procedures involving bones or joints.
641.429 Acceptable payments to prepaid health clinic.
641.43 Provider contracts.
641.432 Providers of service; penalty for unauthorized use of providers; interference with judgment prohibited.
641.437 Investigatory power of office.
641.438 Genetic information restrictions.
641.44 Unfair methods of competition and unfair or deceptive acts or practices prohibited.
641.441 Unfair methods of competition and unfair or deceptive acts or practices defined.
641.442 Penalty for operation of prepaid health clinic, or issuance, delivery, or renewal of prepaid health clinic contract, without certificate of authority.
641.443 Temporary restraining orders.
641.444 Injunction.
641.445 Defined practices; hearings, witnesses, appearances, production of books, and service of process.
641.446 Cease and desist and penalty orders.
641.447 Appeal from order.
641.448 Penalty for violation of cease and desist order.
641.45 Revocation or cancellation of certificate of authority; suspension of authority to enroll new subscribers; terms of suspension.
641.452 Administrative penalty in lieu of suspension or revocation of certificate of authority.
641.453 Civil liability.
641.454 Civil action to enforce prepaid health clinic contract; attorney’s fees; court costs.
641.455 Disposition of moneys collected under this part.
641.457 Exemption for certain operational prepaid health clinics.
641.459 Construction and relationship to other laws.
641.40 Short title.—This part shall be known and may be cited as the “Prepaid Health Clinic Act.”
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.401 Declaration of legislative intent, findings, and purposes.—
(1) 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.
(2) 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.
(3) It is the purpose of this part to:
(a) Minimize legal barriers to the organization, promotion, and expansion of prepaid health clinics.
(b) Recognize an exemption for prepaid health clinics, when operating under a subsisting certificate of authority issued pursuant to this part, from the operation of the Florida Insurance Code, as defined in s. 624.01, except in the manner and to the extent set forth in this part.
(4) 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.
(5) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.4015 Part exclusive; applicability of other laws.—Except as provided in this part, prepaid health clinics shall be covered by the provisions of this part and shall be exempt from all other provisions of the Florida Insurance Code.
History.—ss. 27, 50, ch. 85-321; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.402 Definitions.—As used in this part, the term:
(1) “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.
(2) “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.
(3) “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.
(4) “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.
(5) “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.
(6) “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.
(7) “Reporting period” means the particular span of time by or for which accounts are redeemed on an annualized basis.
(8) “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.
(9) “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.
(10) “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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1599, ch. 2003-261.
641.403 Rulemaking authority.—The commission may adopt rules pursuant to ss. 120.536(1) and 120.54 to implement the provisions of this part.
History.—ss. 10, 11, ch. 84-313; s. 13, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 214, ch. 98-200; s. 1600, ch. 2003-261.
641.405 Application for certificate of authority to operate prepaid health clinic.—
(1) 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.
(2) Each application for a certificate of authority shall be on such form as the commission prescribes, and such application shall be accompanied by:
(a) A copy of the basic organizational document of the applicant, if any, such as the articles of incorporation, articles of association, partnership agreement, trust agreement, or other applicable document, and all amendments to such document.
(b) A copy of the constitution, bylaws, rules and regulations, or similar form of document, if any, regulating the conduct of the affairs of the applicant.
(c) A list of the names, addresses, and official capacities with the applicant of the persons who are to be responsible for the conduct of the affairs of the clinic, including all members of the governing body, the officers and directors in the case of a corporation, and the partners or associates in the case of a partnership or association. Such persons shall fully disclose to the office and the governing body of the clinic the extent and nature of any contracts or arrangements between them and the clinic, including any possible conflicts of interest.
(d) A statement generally describing the clinic and its operations.
(e) Each form of prepaid health clinic contract that the applicant proposes to offer the subscribers, showing for each form of contract the benefits to which the subscribers are entitled, together with a table of the rates charged, or proposed to be charged.
(f) A copy of the applicant’s Health Care Provider Certificate from the Agency for Health Care Administration, issued pursuant to part III of this chapter.
(g) A financial statement prepared on the basis of generally accepted accounting principles, except that surplus notes acceptable to the office may be included in the calculation of surplus.
History.—ss. 10, 11, ch. 84-313; s. 29, ch. 85-62; s. 14, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 46, ch. 95-211; s. 268, ch. 99-8; s. 1601, ch. 2003-261.
641.406 Issuance of certificate of authority.—The office shall issue a certificate of authority for a prepaid health clinic to any applicant filing a properly completed application in conformity with s. 641.405, upon payment of the prescribed fees and upon the office’s being satisfied that:
(1) 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.
(2) The proposed rates are actuarially sound for the benefits provided, including administrative costs.
(3) The applicant has met the minimum surplus requirements of s. 641.407.
(4) 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.
(5) 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.
(6) 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.
(7) 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.
(8) The application and the applicant are in conformity with all requirements of this part.
History.—ss. 10, 11, ch. 84-313; s. 15, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 47, ch. 95-211; s. 269, ch. 99-8; s. 1602, ch. 2003-261.
641.4065 Insurance business not authorized.—Nothing in the Florida Insurance Code or this part shall be deemed to authorize any prepaid health clinic to transact any insurance business other than that issuing prepaid health clinic contracts or otherwise to engage in any other type of insurance unless it is authorized under a certificate of authority issued by the office under the provisions of the Florida Insurance Code.
History.—ss. 28, 50, ch. 85-321; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1603, ch. 2003-261.
641.407 Minimum surplus.—
(1) 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.
(2) 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.
History.—ss. 10, 11, ch. 84-313; s. 30, ch. 85-62; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 56, ch. 93-148; s. 82, ch. 2000-158; s. 1604, ch. 2003-261.
641.408 Use of certain words prohibited in the name of a prepaid health clinic.—
(1) 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.
(2) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.409 Insolvency protection.—
(1) Every prepaid health clinic shall comply with one of the following paragraphs:
(a) The prepaid health clinic shall secure insurance to the satisfaction of the office to protect subscribers in the event the prepaid health clinic is unable to meet its obligations to subscribers under the terms of any prepaid health clinic contract issued to a subscriber.
(b) The prepaid health clinic shall file with the office a surety bond issued by an authorized surety insurer. The bond shall be for the same purpose as the insurance in lieu of which the bond is filed. The office shall not approve any bond under the terms of which the protection afforded against insolvency is not equivalent to the protection afforded by such insurance. The bond shall guarantee that the prepaid health clinic will faithfully and truly perform all the conditions of any prepaid health clinic contract. No such bond shall be canceled or subject to cancellation unless at least 60 days’ notice of the cancellation, in writing, is filed with the office. In the event that the notice of termination of the bond is filed with the office, the prepaid health clinic insured under the bond shall, within 30 days of the filing of the notice of termination, provide the office with a replacement bond meeting the requirements of this part or secure insurance as required by paragraph (a). The cancellation of a bond does not relieve the obligation of the issuer of the bond for claims arising out of contracts issued prior to the cancellation of the bond unless a replacement bond or insurance is secured. In no event shall the issuer’s aggregate liability under the bond exceed the face amount of the bond. If, within 30 days of filing the notice of termination, a replacement bond or insurance has not been secured and filed with the office, the office shall suspend the certificate of the prepaid health clinic until the deposit requirements are satisfied. Whenever the prepaid health clinic ceases to do business in this state and furnishes to the office satisfactory proof that it has discharged or otherwise adequately provided for all of its obligations to its subscribers, the office shall release any bond filed by the prepaid health clinic.
(2) 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.
(3) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1605, ch. 2003-261.
641.4091 Levy upon deposit; limitation.—No judgment creditor or other claimant of a prepaid health clinic shall have the right to levy upon any of the assets or securities held in this state as a deposit under s. 641.409.
History.—ss. 40, 50, ch. 85-321; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.41 Annual report of prepaid health clinic; administrative penalty.—
(1) 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:
(a) A financial statement of the clinic, including its balance sheet and a statement of operations for the preceding year;
(b) A list of the name and residence address of every person responsible for the conduct of the affairs of the clinic, together with a disclosure of the extent and nature of any contract or arrangement between such person and the clinic, including any possible conflicts of interest;
(c) The number of prepaid health clinic contracts issued and outstanding, and the number of prepaid health clinic contracts terminated and a compilation of the reasons for such terminations;
(d) Such statistical information as is requested by the commission or office, which information shows the rates of the clinic for all basic services provided under prepaid health clinic contracts;
(e) The number and amount of damage claims for medical injury initiated against the clinic and any of the providers engaged by it during the reporting year, broken down into claims with and without formal legal process, and the disposition, if any, of each such claim; and
(f) Such other information relating to the performance of the clinic as is required by the commission or office.
(2) 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.
History.—ss. 10, 11, ch. 84-313; s. 31, ch. 85-62; s. 16, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1606, ch. 2003-261.
641.411 Other reporting requirements.—
(1) 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.
(2) 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.
History.—s. 7, ch. 87-377; s. 1, ch. 88-303; s. 10, ch. 90-232; s. 39, ch. 90-295; ss. 187, 188, ch. 91-108; s. 70, ch. 91-282; s. 4, ch. 91-429; s. 48, ch. 95-211; s. 270, ch. 99-8; s. 190, ch. 99-397.
641.412 Fees.—
(1) Every prepaid health clinic shall pay to the office the following fees:
(a) For filing a copy of its application for a certificate of authority or an amendment to such certificate, a nonrefundable fee in the amount of $150.
(b) For filing each annual report, a fee in the amount of $150.
(2) The fees charged under this section shall be distributed as follows:
(a) One-third of the total amount of fees shall be distributed to the Agency for Health Care Administration; and
(b) Two-thirds of the total amount of fees shall be distributed to the office.
History.—ss. 10, 11, ch. 84-313; s. 53, ch. 87-226; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 271, ch. 99-8; s. 1607, ch. 2003-261.
641.414 Investment of funds of prepaid health clinic.—The funds of any prepaid health clinic shall be invested only in securities permitted by the laws of this state for the investment of assets of life insurance companies.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.416 Acquisition.—Every prepaid health clinic shall be subject to the provisions of s. 628.4615.
History.—ss. 10, 11, ch. 84-313; ss. 14, 17, ch. 86-250; s. 4, ch. 87-50; s. 10, ch. 90-248; ss. 184, 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.418 Examination of prepaid health clinic by the office.—The office shall examine the affairs, transactions, accounts, business records, and assets of any prepaid health clinic as often as the office deems it expedient for the protection of the people of this state. Every clinic shall submit its books and records and take other appropriate action as may be necessary to facilitate an examination. However, medical records of individuals and records of physicians providing services under contracts to the clinic are not subject to audit, although such records 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 clinic concerning its business and affairs. The expenses for the examination of each clinic by the office are subject to the same terms and conditions that apply to insurers under part II of chapter 624. In no event shall the expenses of all examinations exceed the maximum amount of $15,000 per year.
History.—ss. 10, 11, ch. 84-313; s. 17, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1608, ch. 2003-261.
641.419 Rehabilitation, liquidation, conservation, or dissolution of prepaid health clinic.—Any rehabilitation, liquidation, conservation, or dissolution of a prepaid health clinic shall be conducted under the supervision of the department. The department shall have all the powers with respect to such rehabilitation, liquidation, conservation, or dissolution that are granted to the department under the laws governing the rehabilitation, liquidation, conservation, or dissolution of life insurance companies.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.42 Prepaid health clinic contracts.—
(1) 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.
(2) 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.
(3) 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.
(4) 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.
(5) 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.
(6) 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.
(7)(a) If a clinic desires to amend any contract with any of its subscribers or desires to change any rate charged for the contract, the clinic may do so, upon filing with the office the proposed amendment or change in rates.
(b) No prepaid health clinic contract form or application form when written application is required and is to be made a part of the policy or contract, or no printed amendment, addendum, rider, or endorsement form or form of renewal certificate, shall be delivered or issued for delivery in this state, unless the form has been filed with the office by or in behalf of the clinic which proposes to use such form and has been approved by the office. Every such filing shall be made not less than 30 days in advance of any such use or delivery. At the expiration of such 30 days, the form so filed shall be deemed approved unless prior to the end of the 30 days the form has been affirmatively approved or disapproved by the office. The approval of any such form by the office constitutes a waiver of any unexpired portion of such waiting period. The office may extend by not more than an additional 15 days the period within which the office may so affirmatively approve or disapprove any such form, by giving notice of such extension before the expiration of the initial 30-day period. At the expiration of any such period as so extended, and in the absence of such prior affirmative approval or disapproval, such form shall be deemed approved. The office may, for cause, withdraw a previous approval. No clinic shall issue or use any form which has been disapproved by the office or any form for which the office has withdrawn approval.
(c) The office shall disapprove any form filed under this subsection, or withdraw any previous approval of the form, only if the form:
1. Is in any respect in violation of, or does not comply with, any provision of this part or rule adopted under this part.
2. Contains or incorporates by reference, where such incorporation is otherwise permissible, any inconsistent, ambiguous, or misleading clauses, or exceptions and conditions which deceptively affect the risk purported to be assumed in the general coverage of the contract.
3. Has a misleading title, misleading heading, or other indication of the provisions of the form which is misleading.
4. Is printed or otherwise reproduced in such manner as to render any material provision of the form substantially illegible.
5. Provides benefits which are unreasonable in relation to the rate charged or contains provisions which are unfair, inequitable, or contrary to the public policy of this state or encourage misrepresentation.
(d) In determining whether the benefits are reasonable in relation to the rate charged, the office, in accordance with reasonable actuarial techniques, shall consider:
1. Past loss experience and prospective loss experience.
2. Allocation of expenses.
3. Risk and contingency margins, along with justification of such margins.
4. Acquisition costs.
5. Other factors deemed appropriate by the office, based on sound actuarial techniques.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1609, ch. 2003-261.
641.421 Language used in contracts and advertisements; translations.—
(1)(a) All prepaid health clinic contracts or forms shall be printed in English.
(b) If the negotiations by a prepaid health clinic with a subscriber leading up to the effectuation of a prepaid health clinic contract are conducted in a language other than English, the prepaid health clinic shall supply to the subscriber a written translation of the contract, which translation accurately reflects the substance of the contract and is in the language used to negotiate the contract. Any such translation shall be furnished to the office as part of the filing of the prepaid health clinic contract form and shall be approved by the office prior to use. No translation of a prepaid health clinic contract form shall be approved by the office unless the translation accurately reflects the substance of the prepaid health clinic contract form in translation. When a translation of a prepaid health clinic contract is used, the translation shall clearly and conspicuously state on its face and in the language of the translation:
READ THIS FIRST
This is a translation of the document that you are about to sign.
(2) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1610, ch. 2003-261.
641.422 Contract provisions incorporating charter or bylaw provisions.—No prepaid health clinic contract shall contain any provision purporting to make a portion of the charter, bylaws, or other constituent document of the clinic a part of the contract unless the provision is set forth in full in the contract. Any contract provision in violation of this section is invalid, unless the provision operates to the benefit of the subscriber.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.423 Execution of contracts.—
(1) 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.
(2) 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.
(3) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 492, ch. 97-102.
641.424 Validity of noncomplying contracts.—
(1) 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.
(2) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 493, ch. 97-102; s. 1611, ch. 2003-261.
641.425 Construction of contracts.—
(1) 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.
(2) 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.
(3) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 226, ch. 98-166.
641.426 Delivery of contract to subscriber.—Unless delivered upon execution or issuance, every prepaid health clinic contract shall be mailed or delivered to the subscriber within 10 days of its execution or issuance, except when a condition required by the clinic has not been met by the applicant or subscriber.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.427 Notice of cancellation, termination, or nonrenewal of contract.—A prepaid health clinic may not cancel or otherwise terminate or fail to renew a prepaid health clinic contract without giving the subscriber at least 30 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. Every prepaid health clinic contract shall contain a clause which requires that this notice be given.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.428 Nondiscrimination of coverage for certain surgical procedures involving bones or joints.—No prepaid health clinic contract or policy which provides coverage on a group or individual basis for any diagnostic or surgical procedure involving bones or joints of the skeleton shall discriminate against coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if, under accepted medical standards, such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. This section shall not be construed to affect any other coverage under this part or to restrict the scope of coverage under any policy, plan, or contract. Nothing in this section shall be construed to discourage appropriate nonsurgical procedures or to prohibit the continued coverage of nonsurgical procedures in the treatment of a bone or joint of the jaw and facial region. Furthermore, nothing in this subsection requires coverage for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes.
History.—s. 6, ch. 96-361.
641.429 Acceptable payments to prepaid health clinic.—Each prepaid health clinic may accept payments from governmental agencies, corporations, associations, groups, or individuals, which payments cover all or part of the cost of contracts entered into between the prepaid health clinic and its subscribers.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.43 Provider contracts.—Whenever a prepaid health clinic provides services to subscribers through an arrangement with a provider, there shall be a written contract with the provider. The contract shall include a provision that, if the prepaid health clinic fails to meet its obligation to pay fees for services already rendered by the provider to a subscriber, the prepaid health clinic and not the subscriber is liable for the payment of such fees.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.432 Providers of service; penalty for unauthorized use of providers; interference with judgment prohibited.—
(1) 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.
(2) 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.
(3) 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.
History.—ss. 10, 11, ch. 84-313; s. 32, ch. 85-62; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.437 Investigatory power of office.—The office has the power to examine and investigate the affairs of every person, entity, or prepaid health clinic in order to determine whether the person, entity, or prepaid health clinic is operating in accordance with the provisions of this part or has been or is engaged in any unfair method of competition or any unfair or deceptive act or practice prohibited by s. 641.44.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1612, ch. 2003-261.
641.438 Genetic information restrictions.—A prepaid health clinic must comply with the provisions of s. 627.4301.
History.—s. 6, ch. 97-182.
641.44 Unfair methods of competition and unfair or deceptive acts or practices prohibited.—No person, entity, or prepaid health clinic shall engage in this state in any trade practice which is defined in this part as, or determined pursuant to s. 641.437 to be, an unfair method of competition or an unfair or deceptive act or practice involving the business of prepaid health clinics.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.441 Unfair methods of competition and unfair or deceptive acts or practices defined.—The following are defined as unfair methods of competition and unfair or deceptive acts or practices:
(1) 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:
(a) Misrepresents the benefits, advantages, conditions, or terms of any prepaid health clinic contract.
(b) Is misleading, or is a misrepresentation as to the financial condition of any person.
(c) Uses any name or title of a contract, which name or title misrepresents the true nature of the contract.
(d) Is a misrepresentation for the purpose of inducing, or tending to induce, the lapse, forfeiture, exchange, conversion, or surrender of any prepaid health clinic contract, health maintenance contract as defined in s. 641.19, or health insurance policy or contract providing health insurance as defined in s. 624.603.
(e) Misrepresents the benefits, nature, characteristics, uses, standard, quantity, quality, cost, rate, scope, source, or geographic origin or location of any goods or services available from or provided by, directly or indirectly, a prepaid health clinic.
(f) Misrepresents the affiliation, connection, or association of any goods, services, or business establishment.
(g) Advertises goods or services with intent not to sell them as advertised.
(h) Disparages the goods, services, or business of another person by any false or misleading representation.
(i) Misrepresents the sponsorship, endorsement, approval, or certification of goods or services.
(j) Uses an advertising format which, by virtue of the design, location, or size of printed matter, is deceptive or misleading, or which may tend to be deceptive or misleading, or which would be deceptive or misleading to any reasonable person.
(k) Offers to provide a service which the prepaid health clinic is unable to provide.
(l) Misrepresents the availability of a service provided by the prepaid health clinic, either directly or indirectly, including the availability of the service as to location.
(m) Disseminates any advertisement, information, or other material pertaining to the prepaid health clinic, including any radio or television transmittal of an advertisement or of information, without disclosing as a part of such dissemination adequate reference to the existence of any limitations or exclusions contained in the contract.
(n) Disseminates any advertisement, information, or other material, including any radio or television transmittal of an advertisement or of information, which contains any limitation or exclusion in a language that is not the language principally used in such dissemination or in such advertisement.
(o) Makes an offer in which there is a material contingency, condition, exclusion, or limitation without conspicuously stating the contingency, condition, exclusion, or limitation in the offer and in the language in which the offer was made.
(2) 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:
(a) In a newspaper, magazine, or other publication;
(b) In the form of a notice, circular, pamphlet, letter, or poster;
(c) Over any radio or television station; or
(d) In any other way
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.
(3) 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.
(4) FALSE STATEMENTS AND ENTRIES.—
(a) Knowingly:
1. Filing a false statement with any supervisory or other public official;
2. Making, publishing, disseminating, or circulating a false statement;
3. Delivering a false statement to any person;
4. Placing a false statement before the public; or
5. Causing, directly or indirectly, a false statement to be made, published, disseminated, circulated, or delivered to a person or placed before the public; or
(b) Knowingly making a false entry of a material fact in any book, report, or statement of a person.
(5) UNFAIR CLAIM SETTLEMENT PRACTICES.—
(a) Attempting to settle claims on the basis of an application or any other material document which was altered without notice to, or the knowledge or consent of, the subscriber or group of subscribers to a prepaid health clinic;
(b) A material misrepresentation made to the subscriber for the purpose and with the intent of effecting settlement of claims, loss, or damage under a prepaid health clinic contract on less favorable terms than those terms provided in, and contemplated by, the contract; or
(c) Committing or performing any of the following:
1. Failure to properly investigate claims;
2. Misrepresentation of pertinent facts or contract provisions relating to the coverage at issue;
3. Failure to acknowledge and act promptly upon communications with respect to claims;
4. Denial of claims without conducting reasonable investigations based upon available information;
5. Failure to affirm or deny coverage of claims upon the written request of the subscriber within a reasonable time, not to exceed 30 days, after a claim or proof-of-loss statement has been completed;
6. Failure to provide promptly a reasonable explanation to the subscriber of the basis in the contract, in relation to the facts or applicable law, for a denial of a claim or for the offer of a compromise settlement; or
7. Unless a legitimate coverage defense exists, failure to provide any subscriber with services, care, or treatment contracted for pursuant to any prepaid health clinic contract.
(6) 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.
(7) 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.
(8) 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.
History.—ss. 10, 11, ch. 84-313; s. 33, ch. 85-62; s. 78, ch. 89-360; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.442 Penalty for operation of prepaid health clinic, or issuance, delivery, or renewal of prepaid health clinic contract, without certificate of authority.—Any person or entity that operates a prepaid health clinic, or issues, delivers, or renews any prepaid health clinic contract, without first obtaining and then maintaining thereafter a certificate of authority is guilty of a felony of the third degree and is, in addition to any prescribed applicable denial, suspension, or revocation of a certificate of authority, punishable as provided in s. 775.082 or s. 775.083. Each instance of such violation shall be considered a separate offense.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
641.443 Temporary restraining orders.—
(1) The office is vested with the power to seek a temporary restraining order:
(a) On behalf of the office or on behalf of a subscriber or subscribers of a prepaid health clinic that is being operated by a person or entity without a subsisting certificate of authority; or
(b) On behalf of the office or on behalf of a subscriber or subscribers to whom a prepaid health clinic, person, or entity is issuing, delivering, or renewing prepaid health clinic contracts without an existing certificate of authority.
(2) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 272, ch. 99-8; s. 1613, ch. 2003-261.
641.444 Injunction.—In addition to the penalties and other enforcement provisions of this part, if a person, entity, or prepaid health clinic has engaged in any activity prohibited by this part or any rule adopted pursuant to this part, the office may resort to a proceeding for injunction in the circuit court of the county where such person, entity, or prepaid health clinic is located or has her or his or its principal place of business; and the office may apply in such court for such temporary and permanent orders as the office may deem necessary to restrain the person, entity, or prepaid health clinic from engaging in any such activity, until the person, entity, or prepaid health clinic complies with the provisions and rules.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 494, ch. 97-102; s. 1614, ch. 2003-261.
641.445 Defined practices; hearings, witnesses, appearances, production of books, and service of process.—
(1) 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.
(2) 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.
(3) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 287, ch. 96-410; s. 1755, ch. 97-102; s. 1615, ch. 2003-261.
641.446 Cease and desist and penalty orders.—After the hearing provided in s. 641.445, the office shall enter a final order in accordance with s. 120.569. If it is determined that the person, entity, or prepaid health clinic charged has engaged in an unfair or deceptive act or practice or the unlawful operation of a prepaid health clinic, the office also shall issue an order requiring the violator to cease and desist from engaging in such method of competition, act, or practice or unlawful operation of a prepaid health clinic. Furthermore, the office may, at its discretion, order any one or more of the following:
(1) 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.
(2) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 288, ch. 96-410; s. 1616, ch. 2003-261.
641.447 Appeal from order.—Any person, entity, or prepaid health clinic that is subject to an order of the office under s. 641.446 may obtain a review of the order by filing an appeal from the order in accordance with the provisions and procedures for appeal under s. 120.68.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1617, ch. 2003-261.
641.448 Penalty for violation of cease and desist order.—Any person, entity, or prepaid health clinic that violates a cease and desist order of the office under s. 641.446 while such order is in effect, after notice and hearing as provided in s. 641.445, is subject, at the discretion of the office, to any one or more of the following:
(1) A monetary penalty of not more than $50,000 as to all matters determined in such hearing.
(2) The suspension or revocation of the certificate of authority of the prepaid health clinic.
History.—ss. 10, 11, ch. 84-313; s. 54, ch. 87-226; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1618, ch. 2003-261.
641.45 Revocation or cancellation of certificate of authority; suspension of authority to enroll new subscribers; terms of suspension.—
(1) 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.
(2) 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:
(a) The clinic is not operating in compliance with this part or any rule promulgated under this part.
(b) The plan is no longer actuarially sound or the clinic does not have the minimum surplus as required by this part.
(c) The existing contract rates are excessive, inadequate, or unfairly discriminatory.
(d) The clinic has advertised, merchandised, or attempted to merchandise its services in such a manner as to misrepresent its services or capacity for services or has engaged in deceptive, misleading, or unfair practices with respect to advertising or merchandising.
(e) The organization is insolvent.
(f) The clinic has not complied with the grievance procedures for subscribers that are set forth in any prepaid health clinic contract.
(g) The clinic has not fully satisfied a judgment against the clinic within 10 days of the entry of the judgment by any court in the state or, in the case of an appeal from such judgment, has not fully satisfied the judgment within 60 days after affirmance of the judgment by the appellate court.
(3) 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.
History.—ss. 10, 11, ch. 84-313; s. 18, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 49, ch. 95-211; s. 1619, ch. 2003-261.
641.452 Administrative penalty in lieu of suspension or revocation of certificate of authority.—The office may, in lieu of suspension or revocation of a certificate of authority, levy an administrative penalty in an amount not more than $10,000 for each violation by a prepaid health clinic. In levying such fine, the office shall consider the number of members and total revenues of the clinic and whether the violation was committed knowingly and willfully.
History.—ss. 10, 11, ch. 84-313; s. 20, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1620, ch. 2003-261.
641.453 Civil liability.—The provisions of this part are cumulative to the rights under the general civil law and common law, and no action of the office shall abrogate such rights to damages or other relief in any court.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1621, ch. 2003-261.
641.454 Civil action to enforce prepaid health clinic contract; attorney’s fees; court costs.—In any civil action brought to enforce the terms and conditions of a prepaid health clinic contract, the prevailing party is entitled to recover reasonable attorney’s fees and court costs. This section shall not be construed to authorize a civil action against the commission or office, or their employees, or against the Agency for Health Care Administration, the employees of the Agency for Health Care Administration, or the Secretary of Health Care Administration.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 273, ch. 99-8; s. 22, ch. 2000-305; s. 1622, ch. 2003-261.
641.455 Disposition of moneys collected under this part.—Fees, administrative penalties, examination expenses, and other sums collected by the office under this part shall be deposited to the credit of the Insurance Regulatory Trust Fund; however, fees, examination expenses, and other sums collected by, or allocated to, the Agency for Health Care Administration under this part shall be deposited to the credit of the General Revenue Fund.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 274, ch. 99-8; s. 1623, ch. 2003-261.
641.457 Exemption for certain operational prepaid health clinics.—The provisions of this part do not apply to those prepaid health clinics providing the services defined in ss. 641.40 through 641.459, which clinics have been continuously engaged in providing such services since January 1, 1947, provided that any prepaid health clinic claiming an exemption under this section notified the former Department of Insurance of its claim on or before January 1, 1985. This exemption will terminate upon a change in controlling ownership of the organization.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1624, ch. 2003-261.
641.459 Construction and relationship to other laws.—
(1) 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.
(2) 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.
History.—ss. 10, 11, ch. 84-313; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 56, ch. 99-3.
PART III
HEALTH CARE SERVICES641.47 Definitions.
641.48 Purpose and application of part.
641.49 Certification of health maintenance organization and prepaid health clinic as health care providers; application procedure.
641.495 Requirements for issuance and maintenance of certificate.
641.51 Quality assurance program; second medical opinion requirement.
641.511 Subscriber grievance reporting and resolution requirements.
641.512 Accreditation and external quality assurance assessment.
641.513 Requirements for providing emergency services and care.
641.515 Investigation by the agency.
641.52 Revocation of certificate; suspension of new enrollment; suspension of the health care provider certificate; administrative fine; notice of action to the office; penalty for use of unlicensed providers.
641.54 Information disclosure.
641.545 Subscriber risk assessments; requirements.
641.55 Internal risk management program.
641.56 Rulemaking authority.
641.57 Disposition of moneys collected under this part.
641.58 Regulatory assessment; levy and amount; use of funds; tax returns; penalty for failure to pay.
641.59 Psychotherapeutic services; records and reports.
641.61 Subscriber satisfaction assessment.
641.62 Chronic diseases among subscriber populations.
641.47 Definitions.—As used in this part, the term:
(1) “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.
(2) “Agency” means the Agency for Health Care Administration.
(3) “Clinical peer” means a health care professional in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review.
(4) “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.
(5) “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).
(6) “Concurrent review” means utilization review conducted during a patient’s hospital stay or course of treatment.
(7) “Emergency medical condition” means:
(a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
1. Serious jeopardy to the health of a patient, including a pregnant woman or a fetus.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
(b) With respect to a pregnant woman:
1. That there is inadequate time to effect safe transfer to another hospital prior to delivery;
2. That a transfer may pose a threat to the health and safety of the patient or fetus; or
3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.
(8) “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.
(9) “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.
(10) “Grievance” means a written complaint submitted by or on behalf of a subscriber to an organization or a state agency regarding the:
(a) Availability, coverage for the delivery, or quality of health care services, including a complaint regarding an adverse determination made pursuant to utilization review;
(b) Claims payment, handling, or reimbursement for health care services; or
(c) Matters pertaining to the contractual relationship between a subscriber and an organization.
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.
(11) “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.
(12) “Minimum services” includes any of the following: emergency care, inpatient hospital services, physician care, ambulatory diagnostic treatment, and preventive health care services.
(13) “Organization” means any health maintenance organization as defined in s. 641.19 and any prepaid health clinic as defined in s. 641.402.
(14) “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.
(15) “Retrospective review” means a review, for coverage purposes, of medical necessity conducted after services have been provided to a patient.
(16) “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.
(17) “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.
History.—ss. 21, 27, ch. 87-236; s. 79, ch. 89-360; ss. 184, 187, 188, ch. 91-108; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 29, ch. 96-199; s. 4, ch. 96-223; s. 5, ch. 97-159.
641.48 Purpose and application of part.—The purpose of this part is to ensure that health maintenance organizations and prepaid health clinics deliver high-quality health care to their subscribers. To achieve this purpose, this part requires all such organizations to obtain a health care provider certificate from the agency as a condition precedent to obtaining a certificate of authority to do business in Florida from the office, under part I or part II of this chapter.
History.—ss. 21, 27, ch. 87-236; ss. 187, 188, ch. 91-108; ss. 83, 91, ch. 91-282; s. 4, ch. 91-429; s. 12, ch. 93-260; s. 30, ch. 96-199; s. 1625, ch. 2003-261.
641.49 Certification of health maintenance organization and prepaid health clinic as health care providers; application procedure.—
(1) 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.
(2) 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.
(3) 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:
(a) A copy of the articles of incorporation and all amendments to the articles.
(b) A copy of the bylaws, rules and regulations, or similar form of document, if any, regulating the conduct of the affairs of the applicant or organization.
(c) A list of the names, addresses, and official capacities with the applicant or organization of the persons who are to be responsible for the conduct of the affairs of the applicant or organization, including all officers and directors of the corporation. Such persons shall fully disclose to the agency and the directors of the applicant or organization the extent and nature of any contracts or arrangements between them and the applicant or organization, including any possible conflicts of interest.
(d) The name and address of the applicant and the name by which the applicant or organization is to be known.
(e) A statement generally describing the applicant or organization and its operations.
(f) A copy of the form for each group and individual contract, certificate, subscriber handbook, and any other similar documents issued to subscribers.
(g) A statement describing the manner in which health care services shall be regularly available.
(h) A statement that the applicant has an established network of health care providers which is capable of providing the health care services that are to be offered by the organization.
(i) The locations at which health care services shall be regularly available to subscribers.
(j) The type of health care personnel engaged to provide the health care services and the quantity of the personnel of each type.
(k) A statement giving the present and projected number of subscribers to be enrolled yearly for the next 3 years.
(l) A statement indicating the source of emergency services and care on a 24-hour basis.
(m) A statement that the physicians employed by the applicant have been formally organized as a medical staff and that the applicant’s governing body has designated a chief of medical staff.
(n) A statement describing the manner in which the applicant or organization assures the maintenance of a medical records system in accordance with accepted medical records’ standards and practices.
(o) If general anesthesia is to be administered in a facility not licensed by the agency, a copy of architectural plans that meet the requirements for institutional occupancy (NFPA 101 Life Safety Code, current edition as adopted by the State Fire Marshal).
(p) A description of the applicant’s or organization’s internal quality assurance program, including committee structure, as required under s. 641.51.
(q) A description and supporting documentation concerning how the applicant or health maintenance organization will comply with internal risk management program requirements under s. 641.55.
(r) An explanation of how coverage for emergency services and care is to be effected outside the applicant’s or health maintenance organization’s stated geographic area.
(s) A statement and map describing with reasonable accuracy the specific geographic area to be served.
(t) A nonrefundable application fee of $1,000.
(u) Such additional information as the agency may reasonably require.
History.—ss. 21, 27, ch. 87-236; ss. 187, 188, ch. 91-108; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 50, ch. 95-211; s. 31, ch. 96-199; s. 1626, ch. 2003-261.
641.495 Requirements for issuance and maintenance of certificate.—
(1) 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.
(2) 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.
(3) 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.
(4) 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.
(5) The organization shall exercise reasonable care in assuring that delivered health care services are performed by appropriately licensed providers.
(6) 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.
(7) 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.
(8) 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.
(9) 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.
(10) The organization shall provide, through contract or otherwise, for periodic review of its medical facilities and services, as required under s. 641.512.
(11) The organization shall designate a medical director who is a physician licensed under chapter 458 or chapter 459.
(12) 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 an accrediting organization whose standards incorporate comparable regulations required by this state.
History.—ss. 21, 27, ch. 87-236; s. 1, ch. 90-213; ss. 187, 188, ch. 91-108; ss. 84, 91, ch. 91-282; s. 4, ch. 91-429; s. 3, ch. 95-281; s. 32, ch. 96-199; s. 6, ch. 97-159; s. 186, ch. 97-264; s. 28, ch. 98-159; s. 57, ch. 99-3; s. 7, ch. 2000-252; s. 1627, ch. 2003-261; s. 15, ch. 2013-93.
641.51 Quality assurance program; second medical opinion requirement.—
(1) 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.
(2) 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:
(a) A written statement of goals and objectives which stress health outcomes as the principal criteria for the evaluation of the quality of care rendered to subscribers;
(b) A written statement describing how state-of-the-art methodology has been incorporated into an ongoing system for monitoring of care which is individual case oriented and, when implemented, can provide interpretation and analysis of patterns of care rendered to individual patients by individual providers;
(c) Written procedures for taking appropriate remedial action whenever, as determined under the quality assurance program, inappropriate or substandard services have been provided or services which should have been furnished have not been provided;
(d) A written plan for providing review of physicians and other licensed medical providers which includes ongoing review within the organization.
(3) 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.
(4) 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.
(5)(a) Each organization shall give the subscriber the right to a second medical opinion in any instance in which the subscriber disputes the organization’s or the physician’s opinion of the reasonableness or necessity of surgical procedures or is subject to a serious injury or illness.
(b) The second opinion, if requested, is to be provided by a physician chosen by the subscriber who may select:
1. A contract or employed physician listed in a directory that shall be provided by the organization; or
2. A noncontract physician located in the same geographical service area of the organization.
(c) For second opinions provided by contract physicians, the organization is prohibited from charging a fee to the subscriber in an amount in excess of the subscriber fees established by contract for referral contract physicians. The organization shall pay the amount of all charges, which are usual, reasonable, and customary in the community, for second opinion services performed by a physician not under contract with the organization, but may require the subscriber to be responsible for up to 40 percent of such amount. The organization may require that any tests deemed necessary by a noncontract physician shall be conducted by the organization. The organization may deny reimbursement rights granted under this section in the event the subscriber seeks in excess of three such referrals per year if such subsequent referral costs are deemed by the organization to be evidence that the subscriber has unreasonably overutilized the second opinion privilege. A subscriber denied reimbursement under this section has recourse to grievance procedures as specified in ss. 641.495 and 641.511. The organization’s physician’s professional judgment concerning the treatment of a subscriber derived after review of a second opinion is controlling as to the treatment obligations of the health maintenance organization. Treatment not authorized by the health maintenance organization is at the subscriber’s expense.
(6) 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.
(7) 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.
(8) 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.
(9) 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:
(a) They must relate to access and quality of care measures.
(b) They must be consistent with data collected pursuant to accreditation activities and standards.
(c) They must be consistent with frequency requirements under the accreditation process.
(d) They must include measures of the management of chronic diseases.
(e) They must include preventive health care for adults and children.
(f) They must include measures of prenatal care.
(g) They must include measures of health checkups for children.
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.
(10) 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.
(11) 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.
(12) 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.
History.—ss. 21, 27, ch. 87-236; ss. 187, 188, ch. 91-108; ss. 85, 91, ch. 91-282; s. 4, ch. 91-429; s. 7, ch. 97-159; s. 58, ch. 99-3; s. 3, ch. 99-264; s. 14, ch. 99-356; s. 7, ch. 99-393; s. 26, ch. 2000-256; s. 67, ch. 2000-318; s. 1, ch. 2001-173; s. 78, ch. 2001-277; s. 13, ch. 2002-389; s. 47, ch. 2003-416; s. 125, ch. 2005-2; s. 114, ch. 2018-24.
1Note.—As amended by s. 78, ch. 2001-277. The amendment by s. 1, ch. 2001-173, uses the word “subsection” instead of the word “provision.”
641.511 Subscriber grievance reporting and resolution requirements.—
(1) 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. 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.
(2) 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.
(3) Each organization’s grievance procedure, as required under subsection (1), must include, at a minimum:
(a) An explanation of how to pursue redress of a grievance.
(b) The names of the appropriate employees or a list of grievance departments that are responsible for implementing the organization’s grievance procedure. The list must include the address and the toll-free telephone number of each grievance department, the address of the agency and its toll-free telephone hotline number, and the address of the 1Subscriber Assistance Program and its toll-free telephone number.
(c) The description of the process through which a subscriber may, at any time, contact the toll-free telephone hotline of the agency to inform it of the unresolved grievance.
(d) A procedure for establishing methods for classifying grievances as urgent and for establishing time limits for an expedited review within which such grievances must be resolved.
(e) A notice that a subscriber may voluntarily pursue binding arbitration in accordance with the terms of the contract if offered by the organization, after completing the organization’s grievance procedure. Such notice shall include an explanation that the subscriber may incur some costs if the subscriber pursues binding arbitration, depending upon the terms of the subscriber’s contract.
(f) A process whereby the grievance manager acknowledges the grievance and investigates the grievance in order to notify the subscriber of a final decision in writing.
(g) A procedure for providing individuals who are unable to submit a written grievance with access to the grievance process, which shall include assistance by the organization in preparing the grievance and communicating back to the subscriber.
(4)(a) With respect to a grievance concerning an adverse determination, an organization shall make available to the subscriber a review of the grievance by an internal review panel; such review must be requested within 30 days after the organization’s transmittal of the final determination notice of an adverse determination. A majority of the panel shall be persons who previously were not involved in the initial adverse determination. A person who previously was involved in the adverse determination may appear before the panel to present information or answer questions. The panel shall have the authority to bind the organization to the panel’s decision.
(b) An organization shall ensure that a majority of the persons reviewing a grievance involving an adverse determination are providers who have appropriate expertise. An organization shall issue a copy of the written decision of the review panel to the subscriber and to the provider, if any, who submits a grievance on behalf of a subscriber. In cases where there has been a denial of coverage of service, the reviewing provider shall not be a provider previously involved with the adverse determination.
(c) An organization shall establish written procedures for a review of an adverse determination. Review procedures shall be available to the subscriber and to a provider acting on behalf of a subscriber.
(5) 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.
(6)(a) An organization shall establish written procedures for the expedited review of an urgent grievance. A request for an expedited review may be submitted orally or in writing and shall be subject to the review procedures of this section, if it meets the criteria of this section. Unless it is submitted in writing, for purposes of the grievance reporting requirements in subsection (1), the request shall be considered an appeal of a utilization review decision and not a grievance. Expedited review procedures shall be available to a subscriber and to the provider acting on behalf of a subscriber. For purposes of this subsection, “subscriber” includes the legal representative of a subscriber.
(b) Expedited reviews shall be evaluated by an appropriate clinical peer or peers. The clinical peer or peers shall not have been involved in the initial adverse determination.
(c) In an expedited review, all necessary information, including the organization’s decision, shall be transmitted between the organization and the subscriber, or the provider acting on behalf of the subscriber, by telephone, facsimile, or the most expeditious method available.
(d) In an expedited review, an organization shall make a decision and notify the subscriber, or the provider acting on behalf of the subscriber, as expeditiously as the subscriber’s medical condition requires, but in no event more than 72 hours after receipt of the request for review. If the expedited review is a concurrent review determination, the service shall be continued without liability to the subscriber until the subscriber has been notified of the determination.
(e) An organization shall provide written confirmation of its decision concerning an expedited review within 2 working days after providing notification of that decision, if the initial notification was not in writing.
(f) An organization shall provide reasonable access, not to exceed 24 hours after receiving a request for an expedited review, to a clinical peer who can perform the expedited review.
(g) An organization shall not provide an expedited retrospective review of an adverse determination.
(7) The agency shall investigate all reports of unresolved quality of care grievances received from annual and quarterly grievance reports submitted by the organization to the office.
(8) 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 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.
(9) The agency may impose administrative sanction, in accordance with s. 641.52, against an organization for noncompliance with this section.
History.—ss. 86, 91, ch. 91-282; s. 4, ch. 91-429; s. 8, ch. 97-159; s. 2, ch. 98-10; s. 45, ch. 2000-256; s. 1628, ch. 2003-261; s. 15, ch. 2004-297; s. 115, ch. 2018-24.
1Note.—Section 67, ch. 2018-24, repealed s. 408.7056, which established the Subscriber Assistance Program.
641.512 Accreditation and external quality assurance assessment.—
(1)(a) To promote the quality of health care services provided by health maintenance organizations and prepaid health clinics in this state, the office shall require each health maintenance organization and prepaid health clinic to be accredited within 1 year of the organization’s receipt of its certificate of authority and to maintain accreditation by an accreditation organization approved by the office, as a condition of doing business in the state.
(b) In the event that no accreditation organization can be approved by the office, the office shall require each health maintenance organization and prepaid health clinic to have an external quality assurance assessment performed by a review organization approved by the office, as a condition of doing business in the state. The assessment shall be conducted within 1 year of the organization’s receipt of its certificate of authority and every 2 years thereafter, or when the office deems additional assessments necessary.
(2) 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.
(3) 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).
(4) The accreditation or assessment process shall include a review of:
(a) All documentation necessary to determine the current professional credentials of employed health care providers or physicians providing service under contract to the health maintenance organization or prepaid health clinic.
(b) At least a representative sample of not fewer than 50 medical records of individual subscribers. When selecting a sample, any and all medical records may be subject to review. The sample of medical records shall be representative of all subscribers’ records.
(5) 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.
(6) 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.
(7) 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.
History.—ss. 87, 91, ch. 91-282; s. 4, ch. 91-429; s. 59, ch. 99-3; s. 1629, ch. 2003-261.
641.513 Requirements for providing emergency services and care.—
(1) In providing for emergency services and care as a covered service, a health maintenance organization may not:
(a) Require prior authorization for the receipt of prehospital transport or treatment or for emergency services and care.
(b) Indicate that emergencies are covered only if care is secured within a certain period of time.
(c) Use terms such as “life threatening” or “bona fide” to qualify the kind of emergency that is covered.
(d) Deny payment based on the subscriber’s failure to notify the health maintenance organization in advance of seeking treatment or within a certain period of time after the care is given.
(2) 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.
(3)(a) When a subscriber is present at a hospital seeking emergency services and care, the determination as to whether an emergency medical condition, as defined in s. 641.47 exists shall be made, for the purposes of treatment, by a physician of the hospital or, to the extent permitted by applicable law, by other appropriate licensed professional hospital personnel under the supervision of the hospital physician. The physician or the appropriate personnel shall indicate in the patient’s chart the results of the screening, examination, and evaluation. The health maintenance organization shall compensate the provider for the screening, evaluation, and examination that is reasonably calculated to assist the health care provider in arriving at a determination as to whether the patient’s condition is an emergency medical condition. The health maintenance organization shall compensate the provider for emergency services and care. If a determination is made that an emergency medical condition does not exist, payment for services rendered subsequent to that determination is governed by the contract under which the subscriber is covered.
(b) If a determination has been made that an emergency medical condition exists and the subscriber has notified the hospital, or the hospital emergency personnel otherwise have knowledge that the patient is a subscriber of the health maintenance organization, the hospital must make a reasonable attempt to notify the subscriber’s primary care physician, if known, or the health maintenance organization, if the health maintenance organization had previously requested in writing that the notification be made directly to the health maintenance organization, of the existence of the emergency medical condition. If the primary care physician is not known, or has not been contacted, the hospital must:
1. Notify the health maintenance organization as soon as possible prior to discharge of the subscriber from the emergency care area; or
2. Notify the health maintenance organization within 24 hours or on the next business day after admission of the subscriber as an inpatient to the hospital.
If notification required by this paragraph is not accomplished, the hospital must document its attempts to notify the health maintenance organization of the circumstances that precluded attempts to notify the health maintenance organization. A health maintenance organization may not deny payment for emergency services and care based on a hospital’s failure to comply with the notification requirements of this paragraph. Nothing in this paragraph shall alter any contractual responsibility of a subscriber to make contact with the health maintenance organization, subsequent to receiving treatment for the emergency medical condition.
(c) If the subscriber’s primary care physician responds to the notification, the hospital physician and the primary care physician may discuss the appropriate care and treatment of the subscriber. The health maintenance organization may have a member of the hospital staff with whom it has a contract participate in the treatment of the subscriber within the scope of the physician’s hospital staff privileges. The subscriber may be transferred, in accordance with state and federal law, to a hospital that has a contract with the health maintenance organization and has the service capability to treat the subscriber’s emergency medical condition. Notwithstanding any other state law, a hospital may request and collect insurance or financial information from a patient in accordance with federal law, which is necessary to determine if the patient is a subscriber of a health maintenance organization, if emergency services and care are not delayed.
1(4) A subscriber may be charged a reasonable copayment, as provided in s. 641.31(12), for the use of an emergency room.
1(5) 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:
(a) The provider’s charges;
(b) The usual and customary provider charges for similar services in the community where the services were provided; or
(c) The charge mutually agreed to by the health maintenance organization and the provider within 60 days of the submittal of the claim.
Such reimbursement shall be net of any applicable copayment authorized pursuant to subsection (4).
(6) 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 determined under chapter 409.
(7) Reimbursement for services under this section provided to subscribers who are enrolled in a health maintenance organization pursuant to s. 624.91 by a provider for whom no contract exists between the provider and the health maintenance organization shall be the lesser of:
(a) The provider’s charges;
(b) The usual and customary provider charges for similar services in the community where the services were provided;
(c) The charge mutually agreed to by the entity and the provider within 60 days after submittal of the claim; or
(d) The Medicaid rate.
History.—s. 33, ch. 96-199; s. 9, ch. 96-223; s. 25, ch. 2016-65.
1Note.—As created by s. 33, ch. 96-199. As created by s. 9, ch. 96-223, s. 641.513(4) and (5) read:
(4) A subscriber may be charged a reasonable copayment, as provided in s. 641.31(12), for the use of an emergency room, except for Medicaid recipients. Nothing in this section is intended to prohibit or limit application of a nominal copayment as provided in s. 409.9081 for the use of an emergency room for services other than emergency services and care.
(5) Reimbursement for services under this section provided to subscribers who are not Medicaid recipients by a provider for whom no contract exists between the provider and the health maintenance organization shall be the lesser of:
(a) The provider’s charges;
(b) The usual and customary provider charges for similar services in the community where the services were provided; or
(c) The charge mutually agreed to by the health maintenance organization and the provider within 60 days after the submittal of the claim.
Such reimbursement shall be net of any applicable copayment authorized pursuant to subsection (4).
641.515 Investigation by the agency.—
(1) The agency shall investigate further any quality of care issue contained in recommendations and reports submitted pursuant to s. 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 administer this part.
(2) 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).
(3) 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.
(4) 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.
History.—ss. 21, 27, ch. 87-236; ss. 187, 188, ch. 91-108; ss. 88, 91, ch. 91-282; s. 4, ch. 91-429; s. 1, ch. 93-85; s. 34, ch. 96-199; s. 399, ch. 96-406; s. 60, ch. 99-3; s. 116, ch. 2018-24.
641.52 Revocation of certificate; suspension of new enrollment; suspension of the health care provider certificate; administrative fine; notice of action to the office; penalty for use of unlicensed providers.—
(1) 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:
(a) The organization is in substantial violation of its contracts.
(b) The organization is unable to fulfill its obligations under outstanding contracts entered into with its subscribers.
(c) The organization knowingly utilizes a provider who is furnishing or has furnished health care services and who does not have a subsisting license or other authority to practice or furnish health care services in this state.
(d) The organization no longer meets the requirements for the certificate as originally issued.
(e) The organization has violated any lawful rule or order of the agency or any provision of this part.
(f) The organization has refused to be examined or to produce its accounts, records, and files for examination or to perform any other legal obligation as to such examination, when required by the agency.
(g) The organization has not, after given reasonable notice, maintained accreditation or received favorable external quality assurance reviews under s. 641.512 or, following an investigation under s. 641.515, has been determined to not materially meet requirements under this part.
(2) 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.
(3) 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.
(4) 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.
(5) 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.
(6) 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.
(7) 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.
History.—ss. 21, 27, ch. 87-236; ss. 187, 188, ch. 91-108; ss. 89, 91, ch. 91-282; s. 4, ch. 91-429; s. 35, ch. 96-199; s. 1630, ch. 2003-261.
641.54 Information disclosure.—
(1) 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:
(a) Name.
(b) Office location.
(c) Medical area or areas of specialty.
(d) Board certification or eligibility in any area.
(e) License number.
(2) The list shall be made available, upon request, to the office. The list shall also be made available, upon request:
(a) With respect to negotiation, application, or effectuation of a group health maintenance contract, to the employer or other person who will hold the contract on behalf of the subscriber group. The list may be restricted to include only physicians and hospitals in the group’s geographic area.
(b) With respect to an individual health maintenance contract or any contract offered to a person who is entitled to have payments for health care costs made under Medicare, to the person considering or making application to, or under contract with, the health maintenance organization. The list may be restricted to include only physicians and hospitals in the person’s geographic area.
(3) 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.
(4) 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.
(5) Each organization shall provide to subscribers, upon request, the following:
(a) A description of the organization’s quality assurance program.
(b) Policies and procedures relating to the organization’s prescription drug benefits, including the disclosure, upon request of a subscriber or potential subscriber, of whether the organization uses a formulary. A subscriber or potential subscriber may also request information as to whether a specific drug is covered by the organization.
(c) Policies and procedures relating to the confidentiality and disclosure of the subscriber’s medical records.
(d) The decisionmaking process used for approving or denying experimental or investigational medical treatments.
(e) Policies and procedures for addressing the needs of non-English-speaking subscribers.
(f) A detailed description of the process used to examine qualifications of and the credentialing of all providers under contract with or employed by the organization.
(6) Each health maintenance organization shall make available to its subscribers on its website or by request the estimated copayment, coinsurance percentage, or deductible, whichever is applicable, for any covered services as described by the searchable bundles established on a consumer-friendly, Internet-based platform pursuant to s. 408.05(3)(c) or as described by a personalized estimate received from a facility pursuant to s. 395.301 or a practitioner pursuant to s. 456.0575, 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 does not preclude the actual copayment, coinsurance percentage, or deductible, whichever is applicable, from exceeding the estimate.
(7) Each health maintenance organization that participates in the state group health insurance plan created under s. 110.123 or Medicaid managed care pursuant to part IV of chapter 409 shall contribute all claims data from Florida subscribers held by the organization and its affiliates to the contracted vendor selected by the Agency for Health Care Administration under s. 408.05(3)(c). Health maintenance organizations shall submit Medicaid managed care claims data to the vendor beginning July 1, 2017, and may submit data before that date. However, each health maintenance organization and its affiliates may not contribute claims data to the contracted vendor which reflect the following types of coverage:
(a) Coverage only for accident, or disability income insurance, or any combination thereof.
(b) Coverage issued as a supplement to liability insurance.
(c) Liability insurance, including general liability insurance and automobile liability insurance.
(d) Workers’ compensation or similar insurance.
(e) Automobile medical payment insurance.
(f) Credit-only insurance.
(g) Coverage for onsite medical clinics, including prepaid health clinics under part II of chapter 641.
(h) Limited scope dental or vision benefits.
(i) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
(j) Coverage only for a specified disease or illness.
(k) Hospital indemnity or other fixed indemnity insurance.
(l) Medicare supplemental health insurance as defined under s. 1882(g)(1) of the Social Security Act, coverage supplemental to the coverage provided under chapter 55 of Title 10, U.S.C., and similar supplemental coverage provided to supplement coverage under a group health plan.
(8) Each health maintenance organization shall make available on its website a hyperlink to the health information that is disseminated by the Agency for Health Care Administration pursuant to s. 408.05(3) and shall include in every policy delivered or issued for delivery to any person in the state or in materials provided as required by s. 627.64725 notice that such information is available electronically and the address of its website.
History.—ss. 31, 47, ch. 85-177; s. 22, ch. 87-236; ss. 187, 188, ch. 91-108; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 9, ch. 97-159; s. 1631, ch. 2003-261; s. 41, ch. 2004-297; s. 16, ch. 2006-261; s. 7, ch. 2016-234.
Note.—Former s. 641.3109.
641.545 Subscriber risk assessments; requirements.—The agency shall require an organization, when providing services to Medicaid subscribers, to attempt, at least twice if necessary, to contact each new Medicaid subscriber within 3 months after the Medicaid subscriber enrolls, in order to perform a health risk assessment. The health risk assessment instrument must include questions regarding early and periodic screening, diagnosis, and treatment history of Medicaid subscribers who are under 21 years of age and questions regarding pregnancy history. The organization shall ask Medicaid subscribers to release to the plan or its providers medical records from providers who treated the Medicaid subscribers before their enrollment with the organization. The organization must use the health risk assessments and the released medical records to identify Medicaid subscribers who have not received screenings in the past according to the agency-approved periodic schedule. The organization must contact, up to twice if necessary, any Medicaid subscriber who is more than 2 months behind in the periodic screening schedule to urge that Medicaid subscriber or the Medicaid subscriber’s responsible party to make an appointment for a screening visit. The agency shall require each organization, for its Medicaid subscribers, to report its early and periodic screening, diagnosis, and treatment rate, the trimester of pregnancy when prenatal care began, and the rate of low birth weight babies born to the organization’s Medicaid subscribers. The agency shall monitor the organization’s compliance with this section.
History.—s. 36, ch. 96-199.
641.55 Internal risk management program.—
(1) 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:
(a) The investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents causing injury to patients;
(b) The development of appropriate measures to minimize the risk of injuries and adverse incidents to patients, including risk management and risk prevention education and training of all nonphysician personnel as follows:
1. Such education and training of all nonphysician personnel as part of their initial orientation; and
2. At least 1 hour of such education and training annually for all nonphysician personnel of the organization who work in clinical areas and provide patient care;
(c) The analysis of patient grievances which relate to patient care and the quality of medical services; and
(d) The development and implementation of an incident reporting system based upon the affirmative duty of all providers and all agents and employees of the organization to report injuries and adverse incidents to the risk manager.
(2) 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 who is responsible for implementation of the organization’s risk management program required by this section. A part-time risk manager may not be responsible for risk management programs in more than four organizations or facilities. Every organization that 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.
(3) 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.
(4) 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.
(5)(a) Each organization subject to this section must submit an annual report to the agency summarizing the incident reports that were filed in the organization during the preceding calendar year pertaining to services rendered on the premises of the organization. The report must be on a form prescribed by rule of the agency and must include, with respect to medical services rendered on the premises of the organization:
1. The total number of adverse incidents causing injury to patients.
2. A listing, by category, of the types of operations, diagnostic or treatment procedures, or other actions causing the injuries and the number of incidents occurring within each category.
3. A listing, by category, of the types of injuries caused and the number of incidents occurring within each category.
4. The name of each provider or a code number using each health care professional’s license number and a separate code number identifying all other individuals directly involved in adverse incidents causing injury to a patient, the relationship of the individual or provider to the organization, and the number of incidents with the organization in which each individual or provider has been directly involved. Each organization must maintain names of the health care professionals and individuals identified by code numbers for purposes of this section.
5. A description of all medical malpractice claims filed against the organization or its providers, including the total number of pending and closed claims and the nature of the incident that led to, the persons involved in, and the status and disposition of each claim. Each report must update status and disposition for all prior reports.
6. A report of all disciplinary actions taken against any provider or any medical staff member of the organization, including the nature and cause of the action.
(b) The information reported to the agency under paragraph (a) which relates to providers licensed under chapter 458, chapter 459, chapter 461, or chapter 466 must also be reported to the agency quarterly. The agency shall review the information and determine whether any of the incidents potentially involved conduct by a licensee that is subject to disciplinary action, in which case s. 456.073 applies.
(c) Except as otherwise provided in this subsection, any identifying information contained in the annual report and the quarterly reports under paragraphs (a) and (b) is confidential and exempt from s. 119.07(1). This information must not be 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.
(d) The annual report shall also contain the name of the risk manager of the organization, a copy of its policy and procedures governing the measures taken by the organization and its risk manager to reduce the risk of injuries and adverse or untoward incidents, and the result of these measures.
(6) 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:
(a) The death of a patient;
(b) Severe brain or spinal damage to a patient;
(c) A surgical procedure being performed on the wrong patient; or
(d) A surgical procedure unrelated to the patient’s diagnosis or medical needs being performed on any patient,
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.
(7) 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).
(8) 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.
(9) 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).
(10) 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.
(11) 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.
(12) 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.
The gross data compiled under this section or s. 395.0197 shall be furnished by the agency upon request to organizations to be utilized for risk management purposes. The agency shall adopt rules necessary to administer this section.
History.—ss. 46, 54, ch. 85-175; s. 7, ch. 86-287; s. 23, ch. 87-236; s. 44, ch. 88-1; s. 23, ch. 88-277; ss. 187, 188, ch. 91-108; s. 11, ch. 91-110; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 91, ch. 92-289; s. 2, ch. 93-85; s. 228, ch. 94-218; s. 85, ch. 95-211; s. 37, ch. 96-199; s. 400, ch. 96-406; s. 40, ch. 98-89; s. 163, ch. 98-166; s. 224, ch. 2000-160; s. 1632, ch. 2003-261; s. 117, ch. 2018-24.
Note.—Former s. 641.395.
641.56 Rulemaking authority.—The Agency for Health Care Administration has authority to adopt rules pursuant to ss. 120.536(1) and 120.54 to implement the provisions of this part conferring duties upon it.
History.—ss. 24, 27, ch. 87-236; ss. 187, 188, ch. 91-108; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 38, ch. 96-199; s. 215, ch. 98-200.
641.57 Disposition of moneys collected under this part.—Fees, administrative penalties, examination expenses, and other sums collected by the Agency for Health Care Administration under this part shall be deposited to the credit of the Health Care Trust Fund to be administered by the agency and shall be used to defray the expenses of the agency in the discharge of its administrative and regulatory powers and duties as prescribed by this part, including the maintaining of offices and necessary supplies, essential equipment and other materials, salaries and expenses of required personnel, and all other legitimate expenses relating to the discharge of the administrative and regulatory powers and duties imposed under such laws.
History.—ss. 25, 27, ch. 87-236; ss. 187, 188, ch. 91-108; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 39, ch. 96-199; s. 26, ch. 96-418.
641.58 Regulatory assessment; levy and amount; use of funds; tax returns; penalty for failure to pay.—
(1) 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.
(2) 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).
(3) 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.
(4) 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.
(5) 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.
(6) 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.
(7) 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.
History.—ss. 26, 27, ch. 87-236; ss. 187, 188, ch. 91-108; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 51, ch. 95-211; s. 40, ch. 96-199; s. 27, ch. 96-418; s. 8, ch. 99-393; s. 1633, ch. 2003-261; s. 16, ch. 2004-297.
641.59 Psychotherapeutic services; records and reports.—A health maintenance organization or prepaid health clinic, as defined in this chapter, must maintain strict confidentiality against unauthorized or inadvertent disclosure of confidential information to persons inside or outside the health maintenance organization or prepaid health clinic regarding psychotherapeutic services provided to subscribers by psychotherapists licensed under chapter 490 or chapter 491 and psychotherapeutic records and reports related to the services. A report, in lieu of records, may be submitted by a psychotherapist in support of the services. Such report must include clear statements summarizing the subscriber’s presenting symptoms, what transpired in any provided therapy, what progress, if any, was made by the subscriber, and results obtained. However, the health maintenance organization or prepaid health clinic may require the records upon which the report is based, if the report does not contain sufficient information supporting the services. A psychotherapist submitting records in support of services may obscure portions to conceal the names, identities, or identifying information of people other than the subscriber if this information is unnecessary to utilization review, quality management, discharge planning, case management, or claims processing conducted by the health maintenance organization or prepaid health clinic. A health maintenance organization or prepaid health clinic may provide aggregate data which does not disclose subscriber identities or identities of other persons to entities such as payors, sponsors, researchers, and accreditation bodies.
History.—s. 1, ch. 96-180.
641.61 Subscriber satisfaction assessment.—Each organization must establish systems for:
(1) Assessing subscriber satisfaction with providers, particularly primary care physicians;
(2) Sharing subscriber-satisfaction indicators and scores with providers;
(3) Publicly acknowledging providers with high positive subscriber-satisfaction scores;
(4) Addressing behaviors of providers with low subscriber-satisfaction scores; and
(5) Assessing subscriber access and physician availability.
History.—s. 41, ch. 96-199.
641.62 Chronic diseases among subscriber populations.—Each organization must:
(1) 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;
(2) Request the input and assistance of its providers and share the information developed under subsection (1) with its providers; and
(3) Share the information developed under subsections (1) and (2) with subscribers identified as having these chronic diseases.
History.—s. 42, ch. 96-199.