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2022 Florida Statutes (including 2022C, 2022D, 2022A, and 2023B)

Title XXXVII INSURANCE
Chapter 641 HEALTH CARE SERVICE PROGRAMS Entire Chapter
SECTION 234
Administrative, provider, and management contracts.
F.S. 641.234
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.