House Bill 3895
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Florida House of Representatives - 1998 HB 3895
By Representative Saunders
1 A bill to be entitled
2 An act relating to provider sponsored
3 organizations; creating pt. IV of ch. 641,
4 F.S.; providing for establishment and licensure
5 of provider sponsored organizations; providing
6 a short title; providing legislative intent,
7 findings, and purposes; providing definitions;
8 providing applicability of other laws;
9 requiring incorporation; providing
10 construction; providing for application for
11 certificates of authority; providing conditions
12 precedent to issuance or maintenance of
13 certificates of authority; providing for effect
14 of bankruptcy proceedings; providing for
15 issuance of certificates of authority;
16 providing for continuing eligibility for
17 certificates of authority; providing surplus
18 requirements; specifying deposit into and
19 disposition of certain moneys in the
20 Rehabilitation Administrative Trust Fund;
21 providing for revocation or cancellation of
22 certificates of authority; providing for
23 suspending enrollment of subscribers; providing
24 for administrative, provider, and management
25 contracts; providing requirements for contract
26 providers; providing for administrative
27 penalties; providing for acquisition, merger,
28 or consolidation; requiring an annual report;
29 providing for examination by the Department of
30 Insurance; providing for civil remedies;
31 providing for injunctions; providing for
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1 payment of judgments; providing for
2 liquidation, rehabilitation, reorganization,
3 and conservation; providing for application
4 fees and filing fees; providing construction;
5 prohibiting unfair practices relating to human
6 immunodeficiency virus infections for contract
7 purposes; specifying language used in contracts
8 and advertisements; providing for standards for
9 marketing to certain persons; providing for
10 provider sponsored contracts; requiring
11 disclosure of certain plan terms and
12 conditions; requiring coverage for mammograms;
13 providing requirements relating to breast
14 cancer and followup care; providing for
15 provider contracts; prohibiting certain words
16 in organization names; providing requirements
17 relating to certain assets, liabilities, and
18 investments; requiring the Department of
19 Insurance to adopt rules; providing penalties;
20 providing for dividends; specifying prohibited
21 activities; providing penalties; providing for
22 orders to discontinue certain advertising;
23 requiring licensing and appointment of agents;
24 providing exceptions; specifying unfair methods
25 of competition; prohibiting unfair or deceptive
26 acts or practices; providing definitions;
27 providing general powers and duties of the
28 Department of Insurance; authorizing the
29 department to take certain actions against
30 unfair competition and unfair or deceptive acts
31 or practices; providing for cease and desist
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1 orders and penalty orders; providing for
2 appeals from the department; providing a
3 penalty for violating cease and desist orders;
4 providing for civil liability; exempting
5 provider service organizations from certain
6 joint venture financial arrangement
7 restrictions; amending ss. 641.316, 641.227,
8 641.47, 641.48, 641.49, 641.495, 641.51,
9 641.512, 641.513, 641.515, 641.54, 641.59, and
10 641.60, F.S., to conform; providing an
11 effective date.
12
13 Be It Enacted by the Legislature of the State of Florida:
14
15 Section 1. Legislative findings and declarations.--
16 (1) The Legislature finds that a major restructuring
17 of health care has taken place in the last several decades
18 changing how health care is paid for and delivered and that,
19 today, the emphasis is on providing cost-conscious health care
20 services through managed care. The Legislature recognizes that
21 alternative methods for the delivery of health care are needed
22 to promote competition and increase patients' choices.
23 (2) The Legislature finds that Congress has recently
24 enacted legislation that allows provider sponsored
25 organizations to provide coordinated care plans to Medicare
26 enrollees through the Medicare+Choice program. The federal
27 legislation requires each organization which offers
28 Medicare+Choice plans to be organized under state law as an
29 entity eligible to offer health benefit coverage in each state
30 in which such organization offers a Medicare+Choice plan.
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1 (3) The Legislature finds that such plans, when
2 properly operated, will enhance the quality of medical
3 decisionmaking while emphasizing effective cost and quality
4 controls.
5 (4) The Legislature declares that it shall be the
6 policy of this state to:
7 (a) Eliminate legal barriers to the organization,
8 promotion, and expansion of provider sponsored organizations
9 offering Medicare+Choice plans in order to encourage the
10 development of valuable options for the Medicare beneficiaries
11 of this state.
12 (b) Not extend insurance regulation or onerous
13 reporting requirements to hospitals, physicians, single or
14 multi-specialty groups, other licensed providers, or any
15 combination of such entities when contracting with entities
16 licensed pursuant to chapter 627, Florida Statutes, or part I
17 of chapter 641, Florida Statutes, or with plans qualified and
18 created under the Employee Retirement Income Security Act of
19 1974.
20 (c) Recognize that comprehensive provider sponsored
21 organizations shall be exempt from operation of the insurance
22 laws of this state except in the manner and to the extent set
23 forth in this act.
24 Section 2. Part IV of chapter 641, Florida Statutes,
25 consisting of sections 641.801, 641.803, 641.805, 641.807,
26 641.809, 641.811, 641.813, 641.815, 641.817, 641.819, 641.821,
27 641.823, 641.825, 641.827, 641.829, 641.831, 641.833, 641.835,
28 641.837, 641.839, 641.841, 641.843, 641.845, 641.847, 641.849,
29 641.851, 641.853, 641.855, 641.857, 641.859, 641.861, 641.863,
30 641.865, 641.867, 641.869, 641.871, 641.873, 641.875, 641.877,
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1 641.879, 641.881, 641.883, 641.885, 641.887, 641.889, 641.891,
2 641.893, and 641.895, Florida Statutes, is created to read:
3 641.801 Short title.--This part shall be known and may
4 be cited as the "Provider Sponsored Organization Act."
5 641.803 Declaration of legislative intent, findings,
6 and purposes.--
7 (1) Faced with the continuation of mounting costs of
8 health care, coupled with the state's interest in high-quality
9 care, the Legislature has determined that there is a need to
10 explore alternative methods for the delivery of health care
11 services, with a view toward achieving greater efficiency and
12 economy in providing these services and to promote competition
13 and increase patients' choices.
14 (2) Health maintenance organizations, consisting of
15 prepaid health care plans, hereinafter referred to as "plans,"
16 are developing rapidly in many communities. Through these
17 organizations, structured in various forms, health care
18 services are provided directly to a group of people who make
19 regular premium payments.
20 (3) These plans, when properly operated, emphasize
21 effective cost and quality controls and enhance the quality of
22 medical decisionmaking.
23 (4) It shall be the policy of this state to:
24 (a) Eliminate legal barriers to the organization,
25 promotion, and expansion of comprehensive prepaid health care
26 plans.
27 (b) Recognize that prepaid comprehensive health care
28 plans shall be exempt from operation of the insurance laws of
29 this state except in the manner and to the extent set forth in
30 this part.
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1 (c) Ensure that comprehensive prepaid health care
2 plans deliver high-quality health care.
3 (5) Although it is the intent of this act to provide
4 an opportunity for the development of health maintenance
5 organizations, there is no intent to impair the present system
6 for the delivery of health services.
7 (6) The Legislature has determined that the operation
8 of a health maintenance organization without a subsisting
9 certificate of authority or the renewal, issuance, or delivery
10 of a health maintenance contract without a subsisting
11 certificate of authority constitutes a danger to the citizens
12 of this state and exposes any subscriber to immediate and
13 irreparable injury, loss, or damage.
14 641.805 Definitions.--As used in this part, the term:
15 (1) "Affiliation" means a provider is affiliated with
16 another provider, if, through contract, ownership, or
17 otherwise:
18 (a) A single provider, directly or indirectly,
19 controls, is controlled by, or is under common control with
20 the other;
21 (b) Both providers are part of a controlled group of
22 corporations under s. 1563 of the Internal Revenue Code of
23 1986, as amended;
24 (c) Each provider is a participant in a lawful
25 combination under which each provider shares substantial
26 financial risk in connection with the organization's
27 operations or;
28 (d) Both providers are part of an affiliated service
29 group under s. 414 of the Internal Revenue Code of 1986, as
30 amended.
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1 (2) "Agency" means the Agency for Health Care
2 Administration.
3 (3) "Comprehensive health care services" means
4 services, medical equipment, and supplies required under the
5 Medicare+Choice program.
6 (4) "Copayment" means a specific dollar amount that
7 the subscriber must pay upon receipt of covered health care
8 services as required or authorized pursuant to the
9 Medicare+Choice program.
10 (5) "Department" means the Department of Insurance.
11 (6) "Emergency medical condition" means:
12 (a) A medical condition manifesting itself by acute
13 symptoms of sufficient severity, which may include severe pain
14 or other acute symptoms, such that the absence of immediate
15 medical attention could reasonably be expected to result in
16 any of the following:
17 1. Serious jeopardy to the health of a patient,
18 including a pregnant woman or a fetus.
19 2. Serious impairment to bodily functions.
20 3. Serious dysfunction of any bodily organ or part.
21 (b) With respect to a pregnant woman:
22 1. That there is inadequate time to effect safe
23 transfer to another hospital prior to delivery;
24 2. That a transfer may pose a threat to the health and
25 safety of the patient or fetus; or
26 3. That there is evidence of the onset and persistence
27 of uterine contractions or rupture of the membranes.
28 (7) "Emergency services and care" means medical
29 screening, examination, and evaluation by a physician, or, to
30 the extent permitted by applicable law, by other appropriate
31 personnel under the supervision of a physician, to determine
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1 if an emergency medical condition exists and, if it does, the
2 care, treatment, or surgery for a covered service by a
3 physician necessary to relieve or eliminate the emergency
4 medical condition, within the service capability of a
5 hospital.
6 (8) "Entity" means any legal entity with continuing
7 existence, including, but not limited to, a corporation,
8 association, trust, or partnership.
9 (9) "Geographic area" means the county or counties, or
10 any portion of a county or counties, within which the provider
11 sponsored organization provides or arranges for comprehensive
12 health care services to be available to its subscribers.
13 (10) "Insolvent" or "insolvency" means that all the
14 statutory assets of the provider sponsored organization, if
15 made immediately available, would not be sufficient to
16 discharge all of its liabilities or that the provider
17 sponsored organization is unable to pay its debts as they
18 become due in the usual course of business.
19 (11) "Provider" means any physician, hospital or other
20 institution, organization, or person that furnishes health
21 care services and is licensed or otherwise authorized to
22 practice in the state.
23 (12) "Provider sponsored contract" means any contract
24 entered into by a provider sponsored organization with
25 Medicare+Choice beneficiaries.
26 (13) "Provider sponsored organization" means any
27 organization authorized under this part which:
28 (a) Is established, organized, and operated by a
29 health care provider or a group of affiliated health care
30 providers.
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1 (b) Provides a substantial proportion of the health
2 care items and services as specified in the Medicare+Choice
3 contract, as defined by the Secretary, directly through the
4 provider or affiliated group of providers.
5 (c) With respect to which the affiliated providers
6 share, directly or indirectly, substantial financial risk with
7 respect to the provision of such items and services and have
8 at least a majority financial interest in the entity. The
9 term "substantial proportion" shall be as defined by the
10 Secretary after having taken into account the need for such an
11 organization to assume responsibility for providing
12 significantly more than the majority of the items and services
13 under the Medicare+Choice contract through its own affiliated
14 providers and for providing the remainder of the items and
15 services under such contract through providers with which the
16 organization has an agreement to provide such items and
17 services. Consideration shall also be given to the need for
18 the organization to provide a limited proportion of the items
19 and services under the contract through providers that are
20 neither affiliated with nor have an agreement with the
21 organization. Additionally, some variation in the definition
22 of substantial proportion may be allowed based upon relevant
23 differences among the organizations, such as their location in
24 an urban or rural area.
25 (14) "Reporting period" means the annual accounting
26 period or any part thereof or the fiscal year of the provider
27 sponsored organization.
28 (15) "Secretary" means the Secretary of the United
29 States Department of Health and Human Services.
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1 (16) "Statutory accounting principles" means generally
2 accepted accounting principles, except as modified by this
3 part.
4 (17) "Subscriber" means a Medicare+Choice enrollee who
5 is eligible for coverage as a Medicare beneficiary.
6 (18) "Surplus" means total assets in excess of total
7 liabilities, as determined by federal rules and regulations on
8 solvency standards established by the Secretary pursuant to s.
9 1856(a) of the Balanced Budget Act of 1997, for provider
10 sponsored organizations offering the Medicare+Choice plan.
11 641.807 Applicability of other laws.--Except as
12 provided in this part, provider sponsored organizations shall
13 be governed by the provisions of this part and part III of
14 this chapter and shall be exempt from all other provisions of
15 the Florida Insurance Code.
16 641.809 Incorporation required.--On or after October
17 1, 1998, any entity that has not yet obtained a certificate of
18 authority to operate a provider sponsored organization in this
19 state shall be incorporated or shall be a division of a
20 corporation formed under the provisions of either chapter 607
21 or chapter 617 or shall be a public entity that is organized
22 as a political subdivision. In the case of a division of a
23 corporation, the financial requirements of this part shall
24 apply to the entire corporation.
25 641.811 Insurance business not authorized.--Nothing in
26 the Florida Insurance Code or this part shall be deemed to
27 authorize any provider sponsored organization to transact any
28 insurance business other than to offer Medicare+Choice plans
29 pursuant to s. 1855 of the Balanced Budget Act of 1997. In
30 the determination of the type of activities by a provider
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1 sponsored organization that would require licensure by this
2 state, the following apply:
3 (1) A provider sponsored organization as defined in
4 this part, a hospital, a physician licensed pursuant to
5 chapter 458 or chapter 459, a single specialty group of
6 physicians, a multi-specialty group of physicians, other
7 licensed providers, or any combination of such physicians and
8 providers, when contracting with a self-insured employer to
9 provide health care benefits to its employees, when
10 contracting with an health maintenance organization licensed
11 pursuant to part I or a provider sponsored organization
12 licensed pursuant to this part, or when contracting with an
13 insurer, are exempt from the requirements of this chapter 641
14 and chapter 627.
15 (2) In any arrangement enumerated in subsection (1),
16 the provider group is not subject to regulation by the
17 department due to the absence of any contractual obligation to
18 the employees covered under the self-insured agreement, the
19 agreement with the health maintenance organization, the
20 provider sponsored organization, or the insurer. A
21 contractual relationship exists only between the provider
22 group and the self-insured employer, the licensed health
23 maintenance organization, provider sponsored organization, or
24 insurer, which entity shall bear the full and direct
25 responsibility to the individual with no transfer of risk. If
26 the provider group fails to perform, the employer, health
27 maintenance organization, provider sponsored organization, or
28 insurer retains the risk to either provide or pay for health
29 care services.
30 (3) The department has regulatory jurisdiction when
31 any health care provider group becomes the ultimate risk
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1 bearer and is directly obligated to individuals to provide,
2 arrange, or pay for health care services. In such situations,
3 the provider group must be appropriately licensed as a health
4 maintenance organization, provider sponsored organization, or
5 insurance company.
6 641.813 Application for certificate.--Before any
7 entity may operate a provider sponsored organization, it shall
8 obtain a certificate of authority from the department. The
9 department shall accept and shall begin its review of an
10 application for a certificate of authority anytime after an
11 organization has filed an application for a health care
12 provider certificate pursuant to part III of this chapter.
13 However, the department shall not issue a certificate of
14 authority to any applicant which does not possess a valid
15 health care provider certificate issued by the agency. Each
16 application for a certificate shall be on such form as the
17 department shall prescribe, shall be verified by the oath of
18 two officers of the corporation and properly notarized, and
19 shall be accompanied by the following:
20 (1) A copy of the articles of incorporation and all
21 amendments thereto;
22 (2) A copy of the bylaws, rules, and regulations, or
23 similar form of document, if any, regulating the conduct of
24 the affairs of the applicant;
25 (3) A list of the names, addresses, and official
26 capacities with the organization of the persons who are to be
27 responsible for the conduct of the affairs of the provider
28 sponsored organization, including all officers, directors, and
29 owners of in excess of 5 percent of the common stock of the
30 corporation. Such persons shall fully disclose to the
31 department and the directors of the provider sponsored
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1 organization the extent and nature of any contracts or
2 arrangements between them and the provider sponsored
3 organization, including any possible conflicts of interest;
4 (4) A complete biographical statement on forms
5 prescribed by the department, and an independent investigation
6 report and fingerprints obtained pursuant to chapter 624, of
7 all of the individuals referred to in subsection (3);
8 (5) A statement generally describing the provider
9 sponsored organization, its operations, and its grievance
10 procedures;
11 (6) A statement describing with reasonable certainty
12 the geographic area or areas to be served by the provider
13 sponsored organization;
14 (7) An audited financial statement prepared on the
15 basis of statutory accounting principles and certified by an
16 independent certified public accountant, except that surplus
17 notes acceptable to the department and meeting the
18 requirements of this act shall be included in the calculation
19 of surplus; and
20 (8) Such additional reasonable data, financial
21 statements, and other pertinent information as the department
22 may require with respect to the determination that the
23 applicant can provide the services to be offered, including a
24 comprehensive feasibility study, performed by a certified
25 actuary in conjunction with a certified public accountant.
26 The study shall be for the greater of 3 years or until the
27 provider sponsored organization has been projected to be
28 profitable for 12 consecutive months.
29 641.815 Conditions precedent to issuance or
30 maintenance of certificate of authority; effect of bankruptcy
31 proceedings.--
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1 (1) As a condition precedent to the issuance or
2 maintenance of a certificate of authority, a provider
3 sponsored organization insurer must file or have on file with
4 the department:
5 (a) An acknowledgment that a delinquency proceeding
6 pursuant to part I of chapter 631 or supervision by the
7 department pursuant to ss. 624.80-624.87 constitutes the sole
8 and exclusive method for the liquidation, rehabilitation,
9 reorganization, or conservation of a provider sponsored
10 organization.
11 (b) A waiver of any right to file or be subject to a
12 bankruptcy proceeding.
13 (2) The commencement of a bankruptcy proceeding either
14 by or against a provider sponsored organization shall, by
15 operation of law:
16 (a) Terminate the provider sponsored organization's
17 certificate of authority.
18 (b) Vest in the department for the use and benefit of
19 the subscribers of the provider sponsored organization the
20 title to any deposits of the insurer held by the department.
21
22 If the proceeding is initiated by a party other than the
23 provider sponsored organization, the operation of subsection
24 (2) shall be stayed for a period of 60 days following the date
25 of commencement of the proceeding.
26 641.817 Issuance of certificate of authority.--The
27 department shall issue a certificate of authority to any
28 entity filing a completed application in conformity with s.
29 641.21, within 90 days after receiving such application, upon
30 payment of the prescribed fees and upon the department's being
31 satisfied that:
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1 (1) As a condition precedent to the issuance of any
2 certificate, the entity has obtained a health care provider
3 certificate from the Department of Health pursuant to part III
4 of this chapter.
5 (2) The provider sponsored organization is actuarially
6 sound.
7 (3) The entity has met the applicable requirements
8 specified in s. 641.821.
9 (4) The procedures for offering comprehensive health
10 care services and offering and terminating contracts to
11 subscribers will not unfairly discriminate on the basis of
12 age, sex, race, health, or economic status. However, this
13 section does not prohibit reasonable underwriting
14 classifications for the purposes of establishing contract
15 rates, nor does it prohibit experience rating.
16 (5) The entity furnishes evidence of adequate
17 insurance coverage or an adequate plan for self-insurance to
18 respond to claims for injuries arising out of the furnishing
19 of comprehensive health care.
20 (6) The ownership, control, and management of the
21 entity is competent and trustworthy and possesses managerial
22 experience that would make the proposed provider sponsored
23 organization operation beneficial to the subscribers. The
24 department shall not grant nor continue authority to transact
25 the business of a provider sponsored organization in this
26 state at any time during which the department has good reason
27 to believe that:
28 (a) The ownership, control, or management of the
29 organization includes any person:
30 1. Who is incompetent or untrustworthy;
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1 2. Who is so lacking in provider sponsored
2 organization expertise as to make the operation of the
3 provider sponsored organization hazardous to potential and
4 existing subscribers;
5 3. Who is so lacking in provider sponsored
6 organization experience, ability, and standing as to
7 jeopardize the reasonable promise of successful operation;
8 4. Who is affiliated, directly or indirectly, through
9 ownership, control, reinsurance transactions, or other
10 business relations, with any person whose business operations
11 are or have been marked by business practices or conduct that
12 is to the detriment of the public, stockholders, investors, or
13 creditors; or
14 5. Whose business operations are or have been marked
15 by business practices or conduct that is to the detriment of
16 the public, stockholders, investors, or creditors;
17 (b) Any person, including any stock subscriber,
18 stockholder, or incorporator, who exercises or has the ability
19 to exercise effective control of the organization, or who
20 influences or has the ability to influence the transaction of
21 the business of the provider sponsored organization, does not
22 possess the financial standing and business experience for the
23 successful operation of the provider sponsored organization;
24 (c) Any person, including any stock subscriber,
25 stockholder, or incorporator, who exercises or has the ability
26 to exercise effective control of the organization, or who
27 influences or has the ability to influence the transaction of
28 the business of the provider sponsored organization, who has
29 been found guilty of, or has pled guilty or no contest to, any
30 felony or crime punishable by imprisonment of 1 year or more
31 under the laws of the United States or any state thereof, or
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1 under the laws of any other country, which involves moral
2 turpitude, without regard to whether a judgment or conviction
3 has been entered by the court having jurisdiction in such
4 case. However, in the case of a provider sponsored
5 organization operating under a subsisting certificate of
6 authority, the provider sponsored organization shall remove
7 any such person immediately upon discovery of the conditions
8 set forth in this paragraph when applicable to such person or
9 under the order of the department, and the failure to so act
10 by the organization is grounds for revocation or suspension of
11 the provider sponsored organization's certificate of
12 authority; or
13 (d) Any person, including any stock subscriber,
14 stockholder, or incorporator, who exercises or has the ability
15 to exercise effective control of the organization, or who
16 influences or has the ability to influence the transaction of
17 the business of the provider sponsored organization, who is
18 now or was in the past affiliated, directly or indirectly,
19 through ownership interest of 10 percent or more, control, or
20 reinsurance transactions, with any business, corporation, or
21 other entity that has been found guilty of or has pleaded
22 guilty or nolo contendere to any felony or crime punishable by
23 imprisonment for 1 year or more under the laws of the United
24 States, any state, or any other country, regardless of
25 adjudication. In the case of a provider sponsored organization
26 operating under a subsisting certificate of authority, the
27 provider sponsored organization shall immediately remove such
28 person or immediately notify the department of such person
29 upon discovery of the conditions set forth in this paragraph,
30 either when applicable to such person or upon order of the
31 department. The failure to remove such person, provide such
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1 notice, or comply with such order constitutes grounds for
2 suspension or revocation of the provider sponsored
3 organization's certificate of authority.
4 (7) The entity has a blanket fidelity bond in the
5 amount of $100,000, issued by a licensed insurance carrier in
6 this state, that will reimburse the entity in the event that
7 anyone handling the funds of the entity either misappropriates
8 or absconds with the funds. All employees handling the funds
9 shall be covered by the blanket fidelity bond. An agent
10 licensed under the provisions of the Florida Insurance Code
11 may either directly or indirectly represent the provider
12 sponsored organization in the solicitation, negotiation,
13 effectuation, procurement, receipt, delivery, or forwarding of
14 any provider sponsored organization subscriber's contract or
15 collect or forward any consideration paid by the subscriber to
16 the provider sponsored organization; and the licensed agent
17 shall not be required to post the bond required by this
18 subsection.
19 (8) The provider sponsored organization has a
20 grievance procedure that will facilitate the resolution of
21 subscriber grievances and that includes both formal and
22 informal steps available within the organization.
23 641.819 Continued eligibility for certificate of
24 authority.--In order to maintain its eligibility for a
25 certificate of authority, a provider sponsored organization
26 shall continue to meet all conditions required to be met under
27 this part and the rules promulgated thereunder for the initial
28 application for and issuance of its certificate of authority
29 under s. 641.817.
30 641.821 Surplus requirements.--Surplus requirements
31 for provider sponsored organizations offering the
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1 Medicare+Choice plan shall be consistent with federal rules
2 and regulations on solvency standards established by the
3 Secretary pursuant to s. 1856(a) of the Balanced Budget Act of
4 1997.
5 641.823 Revocation or cancellation of certificate of
6 authority; suspension of enrollment of new subscribers; terms
7 of suspension.--
8 (1) The maintenance of a valid and current health care
9 provider certificate issued pursuant to part III of this
10 chapter is a condition of the maintenance of a valid and
11 current certificate of authority issued by the department to
12 operate a provider sponsored organization. Denial or
13 revocation of a health care provider certificate shall be
14 deemed to be an automatic and immediate cancellation of a
15 provider sponsored organization's certificate of authority.
16 At the discretion of the Department of Insurance, nonrenewal
17 of a health care provider certificate may be deemed to be an
18 automatic and immediate cancellation of a provider sponsored
19 organization's certificate of authority if the Department of
20 Health notifies the Department of Insurance, in writing, that
21 the health care provider certificate will not be renewed.
22 (2) The department may suspend the authority of a
23 provider sponsored organization to enroll new subscribers or
24 revoke any certificate issued to a provider sponsored
25 organization, or order compliance within 30 days, if it finds
26 that any of the following conditions exists:
27 (a) The organization is not operating in compliance
28 with this part;
29 (b) The plan is no longer actuarially sound or the
30 organization does not have the minimum surplus as required by
31 rules and regulations governing provider sponsored
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1 organizations established by the Secretary pursuant to s.
2 1856(a) of the Balanced Budget Act of 1997;
3 (c) The organization has advertised, merchandised, or
4 attempted to merchandise its services in such a manner as to
5 misrepresent its services or capacity for service or has
6 engaged in deceptive, misleading, or unfair practices with
7 respect to advertising or merchandising; or
8 (d) The organization is insolvent.
9 (3) Whenever the financial condition of the provider
10 sponsored organization is such that, if not modified or
11 corrected, its continued operation would result in impairment
12 or insolvency, the department may order the provider sponsored
13 organization to file with the department and implement a
14 corrective action plan designed to do one or more of the
15 following:
16 (a) Reduce the total amount of present potential
17 liability for benefits by reinsurance or other means.
18 (b) Reduce the volume of new business being accepted.
19 (c) Reduce the expenses of the provider sponsored
20 organization by specified methods.
21 (d) Suspend or limit the writing of new business for a
22 period of time.
23 (e) Require an increase in the provider sponsored
24 organization's net worth which is not inconsistent with the
25 standards established by the Secretary pursuant to s. 1856(a)
26 of the Balanced Budget Act of 1997.
27
28 If the provider sponsored organization fails to submit a plan
29 within 30 days of the department's order or submits a plan
30 which is insufficient to correct the provider sponsored
31 organization's financial condition, the department may order
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1 the provider sponsored organization to implement one or more
2 of the corrective actions listed in this subsection.
3 (4) The department shall, in its order suspending the
4 authority of a provider sponsored organization to enroll new
5 subscribers, specify the period during which the suspension is
6 to be in effect and the conditions, if any, which must be met
7 by the provider sponsored organization prior to reinstatement
8 of its authority to enroll new subscribers. The order of
9 suspension is subject to rescission or modification by further
10 order of the department prior to the expiration of the
11 suspension period. Reinstatement shall not be made unless
12 requested by the provider sponsored organization; however, the
13 department shall not grant reinstatement if it finds that the
14 circumstances for which the suspension occurred still exist or
15 are likely to recur.
16 (5) The department shall calculate and publish at
17 least annually the medical loss ratios of all licensed
18 provider sponsored organizations. The publication shall
19 include an explanation of what the medical loss ratio means
20 and shall disclose that the medical loss ratio is not a direct
21 reflection of quality, but must be looked at along with
22 patient satisfaction and other standards that define quality.
23 641.825 Administrative, provider, and management
24 contracts.--
25 (1) The department may require a provider sponsored
26 organization to submit any contract for administrative
27 services, contract with a provider other than an individual
28 physician, contract for management services, and contract with
29 an affiliated entity to the department.
30 (2) After review of a contract, the department may
31 order the provider sponsored organization to cancel the
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1 contract in accordance with the terms of the contract and
2 applicable law if it determines that the fees to be paid by
3 the provider sponsored organization under the contract are so
4 unreasonably high as compared with similar contracts entered
5 into by the provider sponsored organization, or as compared
6 with similar contracts entered into by other provider
7 sponsored organizations in similar circumstances, that the
8 contract is detrimental to the subscribers, stockholders,
9 investors, or creditors of the provider sponsored
10 organization.
11 (3) All contracts for administrative services,
12 management services, provider services other than individual
13 physician contracts, and with affiliated entities entered into
14 or renewed by a provider sponsored organization on or after
15 October 1, 1998, shall contain a provision that the contract
16 shall be canceled upon issuance of an order by the department
17 pursuant to this section.
18 641.827 Contract providers.--Each provider sponsored
19 organization shall file, upon the request of the department,
20 financial statements for all contract providers of
21 comprehensive health care services who have assumed, through
22 capitation or other means, more than 10 percent of the health
23 care risks of the provider sponsored organization. However,
24 this provision shall not apply to any individual physician.
25 641.829 Administrative penalty in lieu of suspension
26 or revocation.--If the department finds that one or more
27 grounds exist for the revocation or suspension of a
28 certificate issued under this part, the department may, in
29 lieu of revocation or suspension, impose a fine upon the
30 provider sponsored organization. With respect to any
31 nonwillful violation, the fine must not exceed $2,500 per
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1 violation. Such fines may not exceed an aggregate amount of
2 $25,000 for all nonwillful violations arising out of the same
3 action. With respect to any knowing and willful violation of
4 a lawful order or rule of the department or a provision of
5 this part, the department may impose upon the organization a
6 fine in an amount not to exceed $20,000 for each such
7 violation. Such fines may not exceed an aggregate amount of
8 $250,000 for all knowing and willful violations arising out of
9 the same action. The department must adopt by rule by January
10 1, 1999, penalty categories that specify varying ranges of
11 monetary fines for willful violations and for nonwillful
12 violations.
13 641.831 Acquisition, merger, or consolidation.--Every
14 acquisition of a provider sponsored organization shall be
15 subject to the provisions of s. 628.4615. However, in the case
16 of a provider sponsored organization organized as a for-profit
17 corporation, the provisions of s. 628.451 govern with respect
18 to any merger or consolidation; and, in the case of a provider
19 sponsored organization organized as a not-for-profit
20 corporation, the provisions of s. 628.471 govern with respect
21 to any merger or consolidation.
22 641.833 Annual report.--
23 (1) Every provider sponsored organization shall,
24 annually within 3 months after the end of its fiscal year, or
25 within an extension of time therefor as the department, for
26 good cause, may grant, in a form prescribed by the department,
27 file a report with the department, verified by the oath of two
28 officers of the organization or, if not a corporation, of two
29 persons who are principal managing directors of the affairs of
30 the organization, properly notarized, showing its condition on
31
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1 the last day of the immediately preceding reporting period.
2 Such report shall include:
3 (a) A financial statement of the organization filed on
4 a computer diskette using a format acceptable to the
5 department;
6 (b) A financial statement of the organization filed on
7 forms acceptable to the department;
8 (c) An audited financial statement of the
9 organization, including its balance sheet and a statement of
10 operations for the preceding year certified by an independent
11 certified public accountant, prepared in accordance with
12 statutory accounting principles;
13 (d) The number of provider sponsored contracts issued
14 and outstanding and the number of provider sponsored contracts
15 terminated;
16 (e) The number and amount of damage claims for medical
17 injury initiated against the provider sponsored organization
18 and any of the providers engaged by it during the reporting
19 year, broken down into claims with and without formal legal
20 process, and the disposition, if any, of each such claim;
21 (f) An actuarial certification that:
22 1. The provider sponsored organization is actuarially
23 sound, which certification shall consider the rates, benefits,
24 and expenses of, and any other funds available for the payment
25 of obligations of, the organization; and
26 2. Incurred but not reported claims and claims
27 reported but not fully paid have been adequately provided for;
28 and
29 (g) Such other information relating to the performance
30 of provider sponsored organizations as is required by the
31 department.
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1 (2) Every provider sponsored organization shall file
2 quarterly, within 45 days after each of its quarterly
3 reporting periods, an unaudited financial statement of the
4 organization as described in paragraphs (1)(a) and (b). The
5 quarterly report shall be verified by the oath of two officers
6 of the organization, properly notarized.
7 (3) Any provider sponsored organization which neglects
8 to file an annual report or quarterly report in the form and
9 within the time required by this section shall forfeit up to
10 $1,000 for each day for the first 10 days during which the
11 neglect continues and shall forfeit up to $2,000 for each day
12 after the first 10 days during which the neglect continues;
13 and, upon notice by the department to that effect, the
14 organization's authority to enroll new subscribers or to do
15 business in this state shall cease while such default
16 continues. The department shall deposit all sums collected by
17 it under this section to the credit of the Insurance
18 Commissioner's Regulatory Trust Fund. The department shall not
19 collect more than $100,000 for each report.
20 (4) Each authorized provider sponsored organization
21 shall retain an independent certified public accountant,
22 hereinafter referred to as "CPA," who agrees by written
23 contract with the provider sponsored organization to comply
24 with the provisions of this part. The contract shall state:
25 (a) The CPA shall provide to the HMO audited financial
26 statements consistent with this part.
27 (b) Any determination by the CPA that the provider
28 sponsored organization does not meet minimum surplus
29 requirements as set forth in rules and regulations adopted by
30 the Secretary pursuant to s. 1856(a) of the Balanced Budget
31
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1 Act of 1997 shall be stated by the CPA, in writing, in the
2 audited financial statement.
3 (c) The completed work papers and any written
4 communications between the CPA firm and the provider sponsored
5 organization relating to the audit of the provider sponsored
6 organization shall be made available for review on a
7 visual-inspection-only basis by the department at the offices
8 of the provider sponsored organization, at the department, or
9 at any other reasonable place as mutually agreed between the
10 department and the provider sponsored organization. The CPA
11 must retain for review the work papers and written
12 communications for a period of not less than 6 years.
13 (5) To facilitate uniformity in financial statements
14 and to facilitate department analysis, the department may by
15 rule adopt the form for financial statements of a provider
16 sponsored organization, including supplements as approved by
17 the National Association of Insurance Commissioners in 1995,
18 and may adopt subsequent amendments thereto if the methodology
19 remains substantially consistent, and may by rule require each
20 provider sponsored organization to submit to the department
21 all or part of the information contained in the annual
22 statement in a computer-readable form compatible with the
23 electronic data processing system specified by the department.
24 641.835 Examination by the department.--
25 (1) The department shall examine the affairs,
26 transactions, accounts, business records, and assets of any
27 provider sponsored organization as often as it deems expedient
28 for the protection of the people of this state, but not less
29 frequently than once every 3 years. In lieu of making its own
30 financial examination, the department may accept an
31 independent certified public accountant's audit report
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1 prepared on a statutory accounting basis consistent with this
2 part. However, except when the medical records are requested
3 and copies furnished pursuant to s. 445.667, medical records
4 of individuals and records of physicians providing service
5 under contract to the provider sponsored organization shall
6 not be subject to audit, although they may be subject to
7 subpoena by court order upon a showing of good cause. For the
8 purpose of examinations, the department may administer oaths
9 to and examine the officers and agents of a provider sponsored
10 organization concerning its business and affairs. The
11 examination of each provider sponsored organization by the
12 department shall be subject to the same terms and conditions
13 as apply to insurers under chapter 624. In no event shall
14 expenses of all examinations exceed a maximum of $20,000 for
15 any 1-year period. Any rehabilitation, liquidation,
16 conservation, or dissolution of a provider sponsored
17 organization shall be conducted under the supervision of the
18 department, which shall have all power with respect thereto
19 granted to it under the laws governing the rehabilitation,
20 liquidation, reorganization, conservation, or dissolution of
21 life insurance companies.
22 (2) The department may contract, at reasonable fees
23 for work performed, with qualified, impartial outside sources
24 to perform audits or examinations or portions thereof
25 pertaining to the qualification of an entity for issuance of a
26 certificate of authority or to determine continued compliance
27 with the requirements of this part. Any contracted assistance
28 shall be under the direct supervision of the department. The
29 results of any contracted assistance shall be subject to the
30 review of, and approval, disapproval, or modification by, the
31 department.
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1 641.837 Civil remedy.--In any civil action brought to
2 enforce the terms and conditions of a provider sponsored
3 organization contract, the prevailing party is entitled to
4 recover reasonable attorney's fees and court costs. This
5 section shall not be construed to authorize a civil action
6 against the department, its employees, or the Insurance
7 Commissioner or against the Agency for Health Care
8 Administration, its employees, or the director of the agency.
9 641.839 Injunction.--In addition to the penalties and
10 other enforcement provisions of this part, the department is
11 vested with the power to seek both temporary and permanent
12 injunctive relief when:
13 (1) A provider sponsored organization is being
14 operated by any person or entity without a subsisting
15 certificate of authority, unless a waiver has been granted by
16 the Secretary pursuant to s. 1855(a)(2) of the Balanced Budget
17 Act of 1997.
18 (2) Any person, entity, or provider sponsored
19 organization has engaged in any activity prohibited by this
20 part or any rule adopted pursuant thereto.
21 (3) Any provider sponsored organization, person, or
22 entity is renewing, issuing, or delivering a provider
23 sponsored contract or contracts without a subsisting
24 certificate of authority, unless a waiver has been granted by
25 the Secretary pursuant to s. 1855(a)(2) of the Balanced Budget
26 Act of 1997.
27
28 The department's authority to seek injunctive relief shall not
29 be conditioned on having conducted any proceeding pursuant to
30 chapter 120.
31
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1 641.841 Payment of judgment by provider sponsored
2 organization.--Except as otherwise ordered by the court or
3 mutually agreed upon by the parties, every judgment or decree
4 entered in any of the courts of this state against any
5 provider sponsored organization for the recovery of money
6 shall be fully satisfied within 60 days from and after the
7 entry thereof or, in the case of an appeal from such judgment
8 or decree, within 60 days from and after the affirmance of the
9 same by the appellate court.
10 641.843 Liquidation, rehabilitation, reorganization,
11 and conservation; exclusive methods of remedy.--A delinquency
12 proceeding under part I of chapter 631 or supervision by the
13 department under ss. 624.80-624.87 constitutes the sole and
14 exclusive means of liquidating, reorganizing, rehabilitating,
15 or conserving a provider sponsored organization.
16 641.845 Fees.--Every provider sponsored organization
17 shall pay to the department the following fees:
18 (1) For filing a copy of its application for a
19 certificate of authority or amendment thereto, a nonrefundable
20 fee in the amount of $1,000.
21 (2) For filing each annual report, which must be filed
22 on computer diskettes, $150.
23 641.847 Construction and relationship to other laws.--
24 (1) Every provider sponsored organization shall accept
25 the standard health claim form prescribed pursuant to s.
26 627.647.
27 (2) Except as provided in this part, the Florida
28 Insurance Code does not apply to provider sponsored
29 organizations certificated under this part, and provider
30 sponsored organizations certificated under this part are not
31 subject to part I or part II of this chapter. Any person,
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1 entity, or provider sponsored organization operating without a
2 subsisting certificate of authority in violation of this part
3 or rules promulgated thereunder or renewing, issuing, or
4 delivering provider sponsored contracts without a subsisting
5 certificate of authority in violation of this part or rules
6 promulgated thereunder, in addition to being subject to the
7 provisions of this part, is subject to the provisions of the
8 Florida Insurance Code as defined in s. 624.01, unless a
9 waiver has been granted by the Secretary pursuant to s.
10 1855(a)(2) of the Balanced Budget Act of 1997.
11 (3) The solicitation of subscribers by a provider
12 sponsored organization or its representatives shall not be
13 construed to be violative of any provisions of law relating to
14 solicitation or advertising by health professionals if the
15 provider sponsored organization is operating pursuant to a
16 subsisting certificate of authority or operating pursuant to a
17 waiver granted by the Secretary pursuant to s. 1855(a)(2) of
18 the Balanced Budget Act of 1997.
19 (4) The Division of Insurance Fraud of the department
20 is vested with all powers granted to it under the Florida
21 Insurance Code with respect to the investigation of any
22 violation of this part.
23 (5) Every provider sponsored organization must comply
24 with s. 627.4301.
25 641.849 Human immunodeficiency virus infection and
26 acquired immune deficiency syndrome for contract purposes.--
27 (1) PURPOSE.--The purpose of this section is to
28 prohibit unfair practices in a provider sponsored organization
29 contract with respect to exposure to the human
30 immunodeficiency virus infection and related matters, and
31 thereby reduce the possibility that a provider sponsored
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1 organization subscriber or applicant may suffer unfair
2 discrimination when subscribing to or applying for the
3 contractual services of a provider sponsored organization.
4 (2) SCOPE.--This section applies to all provider
5 sponsored contracts which are issued in this state or which
6 are issued outside this state but cover residents of this
7 state to the extent the provisions of this section are not
8 inconsistent with rules and regulations established by the
9 Secretary for the Medicare+Choice program. This section shall
10 not prohibit a provider sponsored organization from contesting
11 a contract or claim to the extent allowed by law.
12 (3) DEFINITIONS.--As used in this section:
13 (a) "AIDS" means acquired immune deficiency syndrome.
14 (b) "ARC" means AIDS-related complex.
15 (c) "HIV" means human immunodeficiency virus
16 identified as the causative agent of AIDS.
17 (4) UTILIZATION OF MEDICAL TESTS.--
18 (a) With respect to the issuance of or the
19 underwriting of a provider sponsored organization contract
20 regarding exposure to the HIV infection and sickness or
21 medical conditions derived from such infection, a provider
22 sponsored organization shall only utilize medical tests which
23 are reliable predictors of risk. A test which is recommended
24 by the Centers for Disease Control or by the federal Food and
25 Drug Administration is deemed to be reliable for the purposes
26 of this section. A test which is rejected or not recommended
27 by the Centers for Disease Control or the federal Food and
28 Drug Administration is a test which is deemed to be not
29 reliable for the purposes of this section. If a specific
30 Centers for Disease Control or federal Food and Drug
31 Administration recommended test indicates the existence or
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1 potential existence of exposure by the HIV infection or a
2 sickness or medical condition related to the HIV infection,
3 before relying on a single test result to deny or limit
4 coverage or to rate the coverage, the provider sponsored
5 organization shall follow the applicable Centers for Disease
6 Control or federal Food and Drug Administration recommended
7 test protocol and shall utilize any applicable Centers for
8 Disease Control or federal Food and Drug Administration
9 recommended followup tests or series of tests to confirm the
10 indication.
11 (b) Prior to testing, the provider sponsored
12 organization must disclose its intent to test the person for
13 the HIV infection or for a specific sickness or medical
14 condition derived therefrom and must obtain the person's
15 written informed consent to administer the test. Written
16 informed consent shall include a fair explanation of the test,
17 including its purpose, potential uses, and limitations, and
18 the meaning of its results and the right to confidential
19 treatment of information. Use of a form approved by the
20 department shall raise a conclusive presumption of informed
21 consent.
22 (c) An applicant shall be notified of a positive test
23 result by a physician designated by the applicant or, in the
24 absence of such designation, by the Department of Health.
25 Such notification must include:
26 1. Face-to-face posttest counseling on the meaning of
27 the test results; the possible need for additional testing;
28 and the need to eliminate behavior which might spread the
29 disease to others;
30
31
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1 2. The availability in the geographic area of any
2 appropriate health care services, including mental health
3 care, and appropriate social and support services;
4 3. The benefits of locating and counseling any
5 individual by whom the infected individual may have been
6 exposed to human immunodeficiency virus and any individual
7 whom the infected individual may have exposed to the virus;
8 and
9 4. The availability, if any, of the services of public
10 health authorities with respect to locating and counseling any
11 individual described in subparagraph 3.
12 (d) A medical test for exposure to the HIV infection
13 or for a sickness or medical condition derived from such
14 infection shall only be required of or given to a person if
15 the test is required or given to all subscribers or applicants
16 or if the decision to require the test is based on the
17 person's medical history. Sexual orientation shall not be
18 used in the underwriting process or in the determination of
19 which subscribers or applicants for enrollment shall be tested
20 for exposure to the HIV infection. Neither the marital status,
21 the living arrangements, the occupation, the gender, the
22 beneficiary designation, nor the zip code or other territorial
23 classification of an applicant shall be used to establish the
24 applicant's sexual orientation.
25 (e) A provider sponsored organization may inquire
26 whether a person has been tested positive for exposure to the
27 HIV infection or been diagnosed as having AIDS or ARC caused
28 by the HIV infection or other sickness or medical condition
29 derived from such infection. A provider sponsored organization
30 shall not inquire whether a person has been tested for or has
31 received a negative result from a specific test for exposure
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1 to the HIV infection or for a sickness or medical condition
2 derived from such infection.
3 (f) A provider sponsored organization shall maintain
4 strict confidentiality regarding medical test results with
5 respect to the HIV infection or a specific sickness or medical
6 condition derived from such infection. Information regarding
7 specific test results shall not be disclosed outside the
8 provider sponsored organization, its employees, its marketing
9 representatives, or its insurance affiliates, except to the
10 person tested and to persons designated in writing by the
11 person tested. Specific test results shall not be furnished to
12 an insurance industry or provider sponsored organization data
13 bank if a review of the information would identify the
14 individual and the specific test results.
15 (g) No laboratory may be used by an insurer or
16 insurance support organization for the processing of
17 HIV-related tests unless it is certified by the United States
18 Department of Health and Human Services under the Clinical
19 Laboratories Improvement Act of 1967, permitting testing of
20 specimens obtained in interstate commerce, and subjects itself
21 to ongoing proficiency testing by the College of American
22 Pathologists, the American Association of Bio Analysts, or an
23 equivalent program approved by the Centers for Disease Control
24 of the United States Department of Health and Human Services.
25 (5) RESTRICTIONS ON CONTRACT EXCLUSIONS AND
26 LIMITATIONS.--
27 (a) A provider sponsored organization contract shall
28 not exclude coverage of a member of a subscriber group because
29 of a positive test result for exposure to the HIV infection or
30 a specific sickness or medical condition derived from such
31 infection, either as a condition for or subsequent to the
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1 issuance of the contract, provided that this prohibition shall
2 not apply to persons applying for enrollment where individual
3 underwriting is otherwise allowed by law.
4 (b) No provider sponsored organization contract shall
5 exclude or limit coverage for exposure to the HIV infection or
6 a specific sickness or medical condition derived from such
7 infection, except as provided in a preexisting condition
8 clause.
9 641.851 Language used in contracts and advertisements;
10 translations.--
11 (1)(a) All provider sponsored contracts or forms shall
12 be printed in English.
13 (b) If the negotiations by a provider sponsored
14 organization with a member leading up to the effectuation of a
15 provider sponsored contract are conducted in a language other
16 than English, the provider sponsored organization shall supply
17 to the member a written translation of the contract, which
18 translation accurately reflects the substance of the contract
19 and is in the language used to negotiate the contract. The
20 written translation shall be affixed to and shall become a
21 part of the contract or form. Any such translation shall be
22 furnished to the department as part of the filing of the
23 provider sponsored contract form. No translation of a
24 provider sponsored contract form shall be approved by the
25 department unless the translation accurately reflects the
26 substance of the provider sponsored contract form in
27 translation.
28 (2) The text of all advertisements by a provider
29 sponsored organization, if printed or broadcast in a language
30 other than English, also shall be available in English and
31 shall be furnished to the department upon request. As used in
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1 this subsection, the term "advertisement" means any
2 advertisement, circular, pamphlet, brochure, or other printed
3 material disclosing or disseminating advertising material or
4 information by a provider sponsored organization to
5 prospective or existing subscribers and includes any radio or
6 television transmittal of an advertisement or information.
7 641.853 Standards for marketing to persons eligible
8 for Medicare.--
9 (1) Every provider sponsored organization marketing
10 coverage to Medicare participants or persons eligible for
11 Medicare in this state, directly or through its agents, shall:
12 (a) Establish marketing procedures to assure that any
13 comparison of benefits between Medicare or any other provider
14 sponsored organization offering such coverage by its agents
15 will be fair and accurate.
16 (b) Establish marketing procedures to assure proper
17 notification to the Medicare participant of enrollment or
18 disenrollment from the provider sponsored organization. Such
19 notification shall be made in a timely manner.
20 (c) Display prominently by type, stamp, or other
21 appropriate means, on the first page of the application and
22 contract, the following:
23 "Notice to buyer: When you enroll in this provider
24 sponsored organization, you will be disenrolled from Medicare.
25 The buyer should be aware that in order to receive payment or
26 coverage for services such services must be rendered by
27 physicians, hospitals, and other health care providers
28 designated by the provider sponsored organization. If the
29 services are rendered by a nonparticipating physician,
30 hospital, or other health care provider, the purchaser may be
31
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1 liable for payment for such services except in very limited
2 circumstances."
3 (d) Inquire and otherwise make every reasonable effort
4 to identify whether a prospective Medicare participant has
5 previously been enrolled in either the same provider sponsored
6 organization as a Medicare participant or in another provider
7 sponsored organization as a Medicare participant.
8 (2) In addition to the practices prohibited in s.
9 641.881:
10 (a) No provider sponsored organization or person
11 representing such provider sponsored organization shall employ
12 any method of marketing having the effect of or tending to
13 induce the purchase of health care plans through fraud,
14 deceit, force, fright, threat whether explicit or implied,
15 intimidation, harassment, or undue pressure to purchase or
16 recommend the purchase of a provider sponsored organization
17 contract.
18 (b) No participating provider, employee, or agent of
19 such participating provider shall be an agent for or conduct
20 any sales activities for a provider sponsored organization
21 with whom they have a provider contract.
22 641.855 Provider sponsored contracts.--
23 (1) Any entity issued a certificate and otherwise in
24 compliance with this part may enter into contracts in this
25 state to provide Medicare+Choice benefits to subscribers in
26 exchange for a premium payment. Each subscriber shall be
27 given a copy of the applicable provider sponsored contract,
28 certificate, or member handbook. Whichever document is
29 provided to a subscriber shall contain all of the provisions
30 and disclosures required by this section.
31
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1 (2) Every provider sponsored contract, certificate, or
2 member handbook shall clearly state all of the services to
3 which a subscriber is entitled under the Medicare+Choice
4 contract and must include a clear and understandable statement
5 of any limitations on the services or kinds of services to be
6 provided, including any copayment feature or schedule of
7 benefits required by the contract or by any insurer or entity
8 which is underwriting any of the services offered by the
9 provider sponsored organization. The contract, certificate,
10 or member handbook shall also state where and in what manner
11 the comprehensive health care services may be obtained.
12 (3) Every subscriber shall receive a clear and
13 understandable description of the method of the provider
14 sponsored organization for resolving subscriber grievances,
15 and the method shall be set forth in the contract,
16 certificate, and member handbook. The organization shall also
17 furnish, at the time of initial enrollment and when necessary
18 due to substantial changes to the grievance process a separate
19 and additional communication prepared or approved by the
20 department notifying the Medicare+Choice subscriber of their
21 rights and responsibilities under the grievance process.
22 (4) A provider sponsored organization is entitled to
23 coordinate benefits on the same basis as an insurer under s.
24 627.4235.
25 (5) A provider sponsored organization providing
26 medical benefits or payments to a subscriber who suffers
27 injury, disease, or illness by virtue of the negligent act or
28 omission of a third party is entitled to reimbursement from
29 the subscriber in accordance with s. 768.76(4).
30 (6) No alteration of any written application for any
31 provider sponsored contract shall be made by any person other
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1 than the applicant without his or her written consent, except
2 that insertions may be made by the provider sponsored
3 organization, for administrative purposes only, in such manner
4 as to indicate clearly that such insertions are not to be
5 ascribed to the applicant.
6 (7) No contract shall contain any waiver of rights or
7 benefits provided to or available to subscribers under the
8 provisions of any law or rule applicable to provider sponsored
9 organizations.
10 (8) Each Medicare+Choice contract, certificate, or
11 member handbook shall state that emergency services and care
12 shall be provided to subscribers in emergency situations not
13 permitting treatment through the provider sponsored
14 organization's providers, without prior notification to and
15 approval of the organization. Not less than 75 percent of the
16 reasonable charges for covered services and supplies shall be
17 paid by the organization, up to the subscriber contract
18 benefit limits. Payment also may be subject to additional
19 applicable copayment provisions, not to exceed $100 per claim
20 if not inconsistent with rules and regulations established by
21 the Secretary governing Medicare+Choice benefits. The
22 Medicare+Choice contract, certificate, or member handbook
23 shall contain the definition of "emergency services and care"
24 as specified in s. 641.805(7), shall describe procedures for
25 determination by the provider sponsored organization of
26 whether the services qualify for reimbursement as emergency
27 services and care, and shall contain specific examples of what
28 does constitute an emergency. In providing for emergency
29 services and care as a covered service, a provider sponsored
30 organization shall be governed by s. 641.513.
31
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1 (9) In addition to the requirements of this section,
2 and if not inconsistent with the rules and regulations
3 established by the Secretary for the Medicare+Choice program,
4 with respect to a person who is entitled to have payments for
5 health care costs made under Medicare, Title XVIII of the
6 Social Security Act ("Medicare"), parts A and/or B:
7 (a) The provider sponsored organization shall mail or
8 deliver notification to the Medicare beneficiary of the date
9 of enrollment in the provider sponsored organization within 10
10 days after receiving notification of enrollment approval from
11 the United States Department of Health and Human Services,
12 Health Care Financing Administration. When a Medicare
13 beneficiary who is a subscriber of the provider sponsored
14 organization requests disenrollment from the organization, the
15 organization shall mail or deliver to the beneficiary notice
16 of the effective date of the disenrollment within 10 days
17 after receipt of the written disenrollment request. The
18 provider sponsored organization shall forward the
19 disenrollment request to the United States Department of
20 Health and Human Services, Health Care Financing
21 Administration, in a timely manner so as to effectuate the
22 next available disenrollment date, as prescribed by such
23 federal agency.
24 (b) The provider sponsored contract, certificate, or
25 member handbook shall be delivered to the subscriber no later
26 than the earlier of 10 working days after the provider
27 sponsored organization and the Health Care Financing
28 Administration of the United States Department of Health and
29 Human Services approve the subscriber's enrollment application
30 or the effective date of coverage of the subscriber under the
31 provider sponsored contract. However, if notice from the
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1 Health Care Financing Administration of its approval of the
2 subscriber's enrollment application is received by the
3 provider sponsored organization after the effective coverage
4 date prescribed by the Health Care Financing Administration,
5 the provider sponsored organization shall deliver the
6 contract, certificate, or member handbook to the subscriber
7 within 10 days after receiving such notice. When a Medicare
8 recipient is enrolled in a provider sponsored organization
9 program, the contract, certificate, or member handbook shall
10 be accompanied by a provider sponsored organization
11 identification sticker with instruction to the Medicare
12 beneficiary to place the sticker on the Medicare
13 identification card.
14 (10) Each provider sponsored organization that
15 provides for inpatient and outpatient services by allopathic
16 hospitals shall provide as an option of the subscriber similar
17 inpatient and outpatient services by hospitals accredited by
18 the American Osteopathic Association when such services are
19 available in the same service area of the provider sponsored
20 organization and the osteopathic hospital agrees to provide
21 the services as specified herein. As a condition precedent to
22 providing osteopathic inpatient and outpatient services
23 through an osteopathic hospital that has not entered into a
24 written contract with the provider sponsored organization, the
25 provider sponsored organization may require the subscriber or
26 any other person receiving osteopathic services to release the
27 provider sponsored organization from any liability arising
28 from any act of omission or commission constituting
29 malpractice in the delivery of osteopathic care from that
30 hospital. The osteopathic hospital providing the inpatient
31 and outpatient services for the provider sponsored
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1 organization shall charge rates that do not exceed the
2 osteopathic hospital's usual and customary rates less the
3 average discount provided by allopathic hospitals providing
4 the provider sponsored organization services in the same
5 service area of the provider sponsored organization.
6 (11) To the extent this subsection is not
7 inconsistent, under s. 1856(b)(3) of the Balanced Budget Act
8 of 1997, with rules and regulations established by the
9 Secretary for the Medicare+Choice program:
10 (a) Provider sponsored contracts that provide
11 coverage, benefits, or services for breast cancer treatment
12 may not limit inpatient hospital coverage for mastectomies to
13 any period that is less than that determined by the treating
14 physician under contract with the provider sponsored
15 organization to be medically necessary in accordance with
16 prevailing medical standards and after consultation with the
17 covered patient. Such contract must also provide coverage for
18 outpatient postsurgical followup care in keeping with
19 prevailing medical standards by a licensed health care
20 professional under contract with the provider sponsored
21 organization qualified to provide postsurgical mastectomy
22 care. The treating physician under contract with the provider
23 sponsored organization, after consultation with the covered
24 patient, may choose that the outpatient care be provided at
25 the most medically appropriate setting, which may include the
26 hospital, treating physician's office, outpatient center, or
27 home of the covered patient.
28 (b) A provider sponsored organization subject to this
29 subsection may not:
30 1. Deny to a covered person eligibility, or continued
31 eligibility, to enroll or to renew coverage under the terms of
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1 the contract for the purpose of avoiding the requirements of
2 this subsection;
3 2. Provide monetary payments or rebates to a covered
4 patient to accept less than the minimum protections available
5 under this subsection;
6 3. Penalize or otherwise reduce or limit the
7 reimbursement of an attending provider solely because the
8 attending provider provided care to a covered patient under
9 this subsection;
10 4. Provide incentives, monetary or otherwise, to an
11 attending provider solely to induce the provider to provide
12 care to a covered patient in a manner inconsistent with this
13 subsection; or
14 5. Subject to the other provisions of this subsection,
15 restrict benefits for any portion of a period within a
16 hospital length of stay or outpatient care as required by this
17 subsection in a manner that is less than favorable than the
18 benefits provided for any preceding portion of such stay.
19 (c)1. This subsection does not require a covered
20 patient to have the mastectomy in the hospital or stay in the
21 hospital for a fixed period of time following the mastectomy.
22 2. This subsection does not prevent a contract from
23 imposing deductibles, coinsurance, or other cost sharing in
24 relation to benefits pursuant to this subsection, except that
25 such cost sharing shall not exceed cost sharing with other
26 benefits.
27 (d) Except as provided in paragraph (b), this
28 subsection does not affect any agreement between a provider
29 sponsored organization and a hospital or other health care
30 provider with respect to reimbursement for health care
31 services provided, rate negotiations with providers, or
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1 capitation of providers, and does not prohibit appropriate
2 utilization review or case management by the provider
3 sponsored organization.
4 (e) As used in this subsection, the term "mastectomy"
5 means the removal of all or part of the breast for medically
6 necessary reasons as determined by a licensed physician.
7 (12) To the extent this subsection is not
8 inconsistent, under s. 1856(b)(3) of the Balanced Budget Act
9 of 1997, with rules and regulations established by the
10 Secretary for the Medicare+Choice program, a provider
11 sponsored contract that provides coverage for mastectomies
12 must also provide coverage for prosthetic devices and breast
13 reconstructive surgery incident to the mastectomy. As used in
14 this subsection, the term "breast reconstructive surgery"
15 means surgery to reestablish symmetry between the two breasts.
16 Such surgery must be in a manner chosen by the treating
17 physician under contract with the provider sponsored
18 organization, consistent with prevailing medical standards,
19 and in consultation with the patient. The provider sponsored
20 organization may charge an appropriate additional premium for
21 the coverage required by this subsection. The coverage for
22 prosthetic devices and breast reconstructive surgery shall be
23 subject to any deductible and coinsurance conditions.
24 641.857 Provider sponsored organization; disclosure of
25 terms and conditions of plan.--Each provider sponsored
26 organization shall provide prospective enrollees with written
27 information about the terms and conditions of the plan in
28 accordance with s. 641.855(2) so that the prospective
29 enrollees can make informed decisions about accepting a
30 managed-care system of health care delivery; however,
31 information about where, in what manner, and from whom the
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1 comprehensive health care services or specific health care
2 services can be obtained need be disclosed only upon request
3 by the prospective enrollee. All marketing materials
4 distributed by the provider sponsored organization must
5 contain a notice in boldfaced type which states that the
6 information required under this section is available to the
7 prospective enrollee upon request.
8 641.859 Coverage for mammograms.--
9 (1) To the extent this section is not inconsistent,
10 under s. 1856(b)(3) of the Balanced Budget Act of 1997, with
11 rules and regulations established by the Secretary for the
12 Medicare+Choice program, every provider sponsored contract
13 issued or renewed on or after October 1, 1998, shall provide
14 coverage for at least the following:
15 (a) A baseline mammogram for any woman who is 35 years
16 of age or older, but younger than 40 years of age.
17 (b) A mammogram every 2 years for any woman who is 40
18 years of age or older, but younger than 50 years of age, or
19 more frequently based on the patient's physician's
20 recommendations.
21 (c) A mammogram every year for any woman who is 50
22 years of age or older.
23 (d) One or more mammograms a year, based upon a
24 physician's recommendation for any woman who is at risk for
25 breast cancer because of a personal or family history of
26 breast cancer, because of having a history of biopsy-proven
27 benign breast disease, because of having a mother, sister, or
28 daughter who has had breast cancer, or because a woman has not
29 given birth before the age of 30.
30 (2) The coverage required by this section is subject
31 to the deductible and copayment provisions applicable to
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1 outpatient visits, and is also subject to all other terms and
2 conditions applicable to other benefits. A provider sponsored
3 organization shall make available to the subscriber as part of
4 the application, for an appropriate additional premium, the
5 coverage required in this section without such coverage being
6 subject to any deductible or copayment provisions in the
7 contract.
8 641.861 Requirements with respect to breast cancer and
9 routine followup care.--To the extent this section is not
10 inconsistent, under s. 1856(b)(3) of the Balanced Budget Act
11 of 1997, with rules and regulations established by the
12 Secretary for the Medicare+Choice program, routine followup
13 care to determine whether a breast cancer has recurred in a
14 person who has been previously determined to be free of breast
15 cancer does not constitute medical advice, diagnosis, care, or
16 treatment for purposes of determining preexisting conditions
17 unless evidence of breast cancer is found during or as a
18 result of the followup care.
19 641.863 Provider contracts.--
20 (1) Whenever a contract exists between a provider
21 sponsored organization and a provider and the organization
22 fails to meet its obligations to pay fees for services already
23 rendered to a subscriber, the provider sponsored organization
24 shall be liable for such fee or fees rather than the
25 subscriber; and the contract shall so state.
26 (2) No subscriber of a provider sponsored organization
27 shall be liable to any provider of health care services for
28 any services covered by the provider sponsored organization.
29 (3) No provider of services or any representative of
30 such provider shall collect or attempt to collect from a
31 provider sponsored organization subscriber any money for
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1 services covered by a provider sponsored organization and no
2 provider or representative of such provider may maintain any
3 action at law against a subscriber of a provider sponsored
4 organization to collect money owed to such provider by a
5 provider sponsored organization.
6 (4) Every contract between a provider sponsored
7 organization and a provider of health care services shall be
8 in writing and shall contain a provision that the subscriber
9 shall not be liable to the provider for any services covered
10 by the subscriber's contract with the provider sponsored
11 organization.
12 (5) The provisions of this section shall not be
13 construed to apply to the amount of any deductible or
14 copayment which is not covered by the contract of the provider
15 sponsored organization.
16 (6)(a) All provider contracts shall contain the
17 following provisions:
18 1. The contracts must provide that the provider shall
19 provide 60 days' advance written notice to the provider
20 sponsored organization and the department before canceling the
21 contract with the provider sponsored organization for any
22 reason; and
23 2. The contract must also provide that nonpayment for
24 goods or services rendered by the provider to the provider
25 sponsored organization shall not be a valid reason for
26 avoiding the 60-day advance notice of cancellation.
27 (b) The contracts must provide that the provider
28 sponsored organization will provide 60 days' advance written
29 notice to the provider and the department before canceling,
30 without cause, the contract with the provider, except in a
31 case in which a patient's health is subject to imminent danger
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1 or a physician's ability to practice medicine is effectively
2 impaired by an action by the Board of Medicine or other
3 governmental agency.
4 (7) Upon receipt by the provider sponsored
5 organization of a 60-day cancellation notice, the provider
6 sponsored organization may, if requested by the provider,
7 terminate the contract in less than 60 days if the provider
8 sponsored organization is not financially impaired or
9 insolvent.
10 (8) A contract between a provider sponsored
11 organization and a provider of health care services shall not
12 contain any provision restricting the provider's ability to
13 communicate information to the provider's patient regarding
14 medical care or treatment options for the patient when the
15 provider deems knowledge of such information by the patient to
16 be in the best interest of the health of the patient.
17 641.865 Certain words prohibited in name of
18 organization.--
19 (1) No entity certificated as a provider sponsored
20 organization, other than a licensed insurer insofar as its
21 name is concerned, shall use in its name, contracts, or
22 literature any of the words "insurance," "casualty," "surety,"
23 "mutual," or any other words descriptive of the insurance,
24 casualty, or surety business or deceptively similar to the
25 name or description of any insurance or surety corporation
26 doing business in the state.
27 (2) No person, entity, or health care plan not
28 certificated under the provisions of this part shall use in
29 its name, logo, contracts, or literature the phrase "provider
30 sponsored organization" or the initials "PSO"; imply, directly
31
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1 or indirectly, that it is a provider sponsored organization;
2 or hold itself out to be a provider sponsored organization.
3 641.867 Assets, liabilities, and investments.--Assets,
4 liabilities, and investments for provider sponsored
5 organizations offering the Medicare+Choice plan shall be
6 consistent with the federal rules and regulations on solvency
7 standards established by the Secretary pursuant to s. 1856(a)
8 of the Balanced Budget Act of 1997.
9 641.869 Adoption of rules; penalty for violation.--The
10 department shall adopt rules necessary to carry out the
11 provisions of this part which shall be consistent with rules
12 and regulations established by the Secretary pursuant to the
13 Balanced Budget Act of 1997 for Medicare+Choice plans. Any
14 violation of a rule adopted under this section shall subject
15 the violating entity to the provisions of s. 641.823.
16 641.871 Dividends.--
17 (1) A provider sponsored organization shall not pay
18 any dividend or distribute cash or other property to
19 stockholders except out of that part of its available and
20 accumulated surplus funds which is derived from realized net
21 operating profits on its business and net realized capital
22 gains. Dividend payments or distributions to stockholders
23 shall not exceed 10 percent of such surplus in any one year
24 unless otherwise approved by the department. In addition to
25 such limited payments, a provider sponsored organization may
26 make dividend payments or distributions out of the provider
27 sponsored organization's entire net operating profits and
28 realized net capital gains derived during the immediately
29 preceding calendar or fiscal year, as applicable.
30 (2) The department shall not approve a dividend or
31 distribution in excess of the maximum amount allowed in
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1 subsection (1) unless it determines that the distribution or
2 dividend would not jeopardize the financial condition of the
3 provider sponsored organization.
4 (3) Any director of a provider sponsored organization
5 who knowingly votes for or concurs in declaration or payment
6 of a dividend to stockholders when such declaration is in
7 violation of this section is guilty of a misdemeanor of the
8 second degree, punishable as provided in s. 775.082 or s.
9 775.083, and shall be jointly and severally liable, together
10 with other such directors likewise voting for or concurring,
11 for any loss thereby sustained by creditors of the provider
12 sponsored organization to the extent of such dividend.
13 (4) Any stockholder receiving such an illegal dividend
14 shall be liable in the amount thereof to the provider
15 sponsored organization.
16 (5) The department may revoke or suspend the
17 certificate of authority of a provider sponsored organization
18 which has declared or paid such an illegal dividend.
19 641.873 Prohibited activities; penalties.--
20 (1) Any person or entity which knowingly renews,
21 issues, or delivers any provider sponsored contract without
22 first obtaining and thereafter maintaining a certificate of
23 authority, unless a waiver has been granted by the Secretary
24 pursuant to s. 1855(a)(2) of the Balanced Budget Act of 1997,
25 commits a felony of the third degree, punishable as provided
26 in s. 775.082 or s. 775.083.
27 (2) Except as provided in subsection (1), any person,
28 entity, or provider sponsored organization which knowingly
29 violates the provisions of this part is guilty of a
30 misdemeanor of the first degree, punishable as provided in s.
31 775.082 or s. 775.083.
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1 (3) Any agent or representative, solicitor, examining
2 physician, applicant, or other person who knowingly makes any
3 false and fraudulent statements or representation in, or with
4 reference to, any application or negotiation for provider
5 sponsored organization coverage is, in addition to any other
6 penalty provided by law, guilty of a misdemeanor of the first
7 degree, punishable as provided in s. 775.082 or s. 775.083.
8 (4) Any agent, representative, solicitor, collector,
9 or other person who, while acting on behalf of a provider
10 sponsored organization, receives or collects its funds or
11 premium payments and fails to satisfactorily account for or
12 turn over, when required, all such funds or payments is, in
13 addition to the other penalties provided for by law, guilty of
14 a misdemeanor of the second degree, punishable as provided in
15 s. 775.082 or s. 775.083.
16 (5) Any person who, without authority granted by a
17 provider sponsored organization, collects or secures cash
18 advances, premium payments, or other funds owing to the
19 provider sponsored organization or otherwise conducts the
20 business of a provider sponsored organization without its
21 authority is, in addition to the other penalties provided for
22 by law, guilty of a misdemeanor of the second degree,
23 punishable as provided in s. 775.082 or s. 775.083.
24 641.875 Order to discontinue certain advertising.--If
25 in the opinion of the department any advertisement by a
26 provider sponsored organization violates any of the provisions
27 of this part, the department may enter an immediate order
28 requiring that the use of the advertisement be discontinued.
29 If requested by the provider sponsored organization, the
30 department shall conduct a hearing within 10 days of the entry
31 of such order. If, after the hearing or by agreement with the
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1 provider sponsored organization, a final determination is made
2 that the advertising was in fact violative of any provision of
3 this part, the department may, in lieu of revocation of the
4 certificate of authority, require the publication of a
5 corrective advertisement; impose an administrative penalty of
6 up to $10,000; and, in the case of an initial solicitation,
7 require that the provider sponsored organization, prior to
8 accepting any application received in response to the
9 advertisement, provide an acceptable clarification of the
10 advertisement to each individual applicant.
11 641.877 Agent licensing and appointment required;
12 exceptions.--
13 (1) With respect to a provider sponsored contract, no
14 person shall, unless licensed and appointed as a health
15 insurance agent in accordance with the applicable provisions
16 of the Florida Insurance Code:
17 (a) Solicit contracts or procure applications; or
18 (b) Engage or hold himself or herself out as engaging
19 in the business of analyzing or abstracting provider sponsored
20 contracts or of counseling, advising, or giving opinions to
21 persons relative to such contracts other than as a consulting
22 actuary advising a provider sponsored organization or as a
23 salaried bona fide full-time employee so counseling and
24 advising his or her employer relative to coverage for the
25 employer and his or her employees.
26 (2) All qualifications, disciplinary provisions,
27 licensing and appointment procedures, fees, and related
28 matters contained in the Florida Insurance Code which apply to
29 the licensing and appointment of health insurance agents by
30 insurers shall apply to provider sponsored organizations and
31
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1 to persons licensed or appointed by the provider sponsored
2 organization as their agents.
3 (3) An examination, license, or appointment is not
4 required of any regular salaried officer or employee of a
5 provider sponsored organization who devotes substantially all
6 of his or her services to activities other than the
7 solicitation of provider sponsored organization contracts from
8 the public and who receives no commission or other
9 compensation directly dependent upon the solicitation of such
10 contracts. This exemption does not apply to the solicitation
11 of Medicaid eligible subscribers.
12 (4) All agents and provider sponsored organizations
13 shall comply with and be subject to the applicable provisions
14 of this section and s. 409.912(18), and all companies and
15 entities appointing agents shall comply with s. 626.451, when
16 marketing for any provider sponsored organization licensed
17 pursuant to this part, including those organizations under
18 contract with the Agency for Health Care Administration to
19 provide health care services to Medicaid recipients or any
20 private entity providing health care services to Medicaid
21 recipients pursuant to a prepaid health plan contract with the
22 Agency for Health Care Administration.
23 641.879 Unfair methods of competition and unfair or
24 deceptive acts or practices prohibited.--No person, entity, or
25 provider sponsored organization shall engage in this state in
26 any trade practice which is defined in this part as, or
27 determined pursuant to s. 641.883 to be, an unfair method of
28 competition or an unfair or deceptive act or practice
29 involving the business of provider sponsored organizations.
30 641.881 Unfair methods of competition and unfair or
31 deceptive acts or practices defined.--The following are
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1 defined as unfair methods of competition and unfair or
2 deceptive acts or practices:
3 (1) MISREPRESENTATION AND FALSE ADVERTISING OF
4 PROVIDER SPONSORED CONTRACTS.--Knowingly making, issuing, or
5 circulating, or causing to be made, issued, or circulated, any
6 estimate, illustration, circular, statement, sales
7 presentation, omission, or comparison which:
8 (a) Misrepresents the benefits, advantages,
9 conditions, or terms of any provider sponsored contract.
10 (b) Is misleading, or is a misrepresentation as to the
11 financial condition of any person.
12 (c) Uses any name or title of any contract
13 misrepresenting the true nature thereof.
14 (d) Is a misrepresentation for the purpose of
15 inducing, or tending to induce, the lapse, forfeiture,
16 exchange, conversion, or surrender of any provider sponsored
17 contract under the Medicare+Choice program.
18 (e) Misrepresents the benefits, nature,
19 characteristics, uses, standard, quantity, quality, cost,
20 rate, scope, source, or geographic origin or location of any
21 goods or services available from or provided by, directly or
22 indirectly, any provider sponsored organization.
23 (f) Misrepresents the affiliation, connection, or
24 association of any goods, services, or business establishment.
25 (g) Advertises goods or services with intent not to
26 sell them as advertised.
27 (h) Disparages the goods, services, or business of
28 another person by any false or misleading representation.
29 (i) Misrepresents the sponsorship, endorsement,
30 approval, or certification of goods or services.
31
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1 (j) Uses an advertising format which, by virtue of the
2 design, location, or size of printed matter, is deceptive or
3 misleading or which would be deceptive or misleading to any
4 reasonable person.
5 (k) Offers to provide a service which the provider
6 sponsored organization is unable to provide.
7 (l) Misrepresents the availability of a service
8 provided by the provider sponsored organization, either
9 directly or indirectly, including the availability of the
10 service as to location.
11 (2) FALSE INFORMATION AND ADVERTISING
12 GENERALLY.--Knowingly making, publishing, disseminating,
13 circulating, or placing before the public, or causing,
14 directly or indirectly, to be made, published, disseminated,
15 circulated, or placed before the public:
16 (a) In a newspaper, magazine, or other publication;
17 (b) In the form of a notice, circular, pamphlet,
18 letter, or poster;
19 (c) Over any radio or television station; or
20 (d) In any other way,
21
22 an advertisement, announcement, or statement containing any
23 assertion, representation, or statement with respect to the
24 business of the provider sponsored organization which is
25 untrue, deceptive, or misleading.
26 (3) DEFAMATION.--Knowingly making, publishing,
27 disseminating, or circulating, directly or indirectly, or
28 aiding, abetting, or encouraging the making, publishing,
29 disseminating, or circulating of, any oral or written
30 statement, or any pamphlet, circular, article, or literature,
31
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1 which is false or maliciously critical of any person and which
2 is calculated to injure such person.
3 (4) FALSE STATEMENTS AND ENTRIES.--
4 (a) Knowingly:
5 1. Filing with any supervisory or other public
6 official,
7 2. Making, publishing, disseminating, or circulating,
8 3. Delivering to any person,
9 4. Placing before the public, or
10 5. Causing, directly or indirectly, to be made,
11 published, disseminated, circulated, or delivered to any
12 person, or place before the public,
13
14 any material false statement.
15 (b) Knowingly making any false entry of a material
16 fact in any book, report, or statement of any person.
17 (5) UNFAIR CLAIM SETTLEMENT PRACTICES.--
18 (a) Attempting to settle claims on the basis of an
19 application or any other material document which was altered
20 without notice to, or knowledge or consent of, the subscriber
21 or group of subscribers to a provider sponsored organization;
22 (b) Making a material misrepresentation to the
23 subscriber for the purpose and with the intent of effecting
24 settlement of claims, loss, or damage under a provider
25 sponsored contract on less favorable terms than those provided
26 in, and contemplated by, the contract; or
27 (c) Committing or performing with such frequency as to
28 indicate a general business practice any of the following:
29 1. Failing to adopt and implement standards for the
30 proper investigation of claims;
31
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1 2. Misrepresenting pertinent facts or contract
2 provisions relating to coverage at issue;
3 3. Failing to acknowledge and act promptly upon
4 communications with respect to claims;
5 4. Denying of claims without conducting reasonable
6 investigations based upon available information;
7 5. Failing to affirm or deny coverage of claims upon
8 written request of the subscriber within a reasonable time not
9 to exceed 30 days after a claim or proof-of-loss statements
10 have been completed and documents pertinent to the claim have
11 been requested in a timely manner and received by the provider
12 sponsored organization;
13 6. Failing to provide promptly a reasonable
14 explanation in writing to the subscriber of the basis in the
15 provider sponsored contract in relation to the facts or
16 applicable law for denial of a claim or for the offer of a
17 compromise settlement;
18 7. Failing to provide, upon written request of a
19 subscriber, itemized statements verifying that services and
20 supplies were furnished, where such statement is necessary for
21 the submission of other insurance claims covered by individual
22 specified disease or limited benefit policies, provided that
23 the organization may receive from the subscriber a reasonable
24 administrative charge for the cost of preparing such
25 statement; or
26 8. Failing to provide any subscriber with services,
27 care, or treatment contracted for pursuant to any provider
28 sponsored contract without a reasonable basis to believe that
29 a legitimate defense exists for not providing such services,
30 care, or treatment. To the extent that a national disaster,
31 war, riot, civil insurrection, epidemic, or any other
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1 emergency or similar event not within the control of the
2 provider sponsored organization results in the inability of
3 the facilities, personnel, or financial resources of the
4 provider sponsored organization to provide or arrange for
5 provision of a health service in accordance with requirements
6 of this part, the provider sponsored organization is required
7 only to make a good faith effort to provide or arrange for
8 provision of the service, taking into account the impact of
9 the event. For the purposes of this paragraph, an event is
10 not within the control of the provider sponsored organization
11 if the provider sponsored organization cannot exercise
12 influence or dominion over its occurrence.
13 (6) FAILURE TO MAINTAIN COMPLAINT-HANDLING
14 PROCEDURES.--Failure of any person to maintain a complete
15 record of all the complaints received since the date of the
16 most recent examination of the provider sponsored organization
17 by the department. For the purposes of this subsection, the
18 term "complaint" means any written communication primarily
19 expressing a grievance and requesting a remedy to the
20 grievance.
21 (7) OPERATION WITHOUT A SUBSISTING CERTIFICATE OF
22 AUTHORITY.--Operation of a provider sponsored organization by
23 any person or entity without a subsisting certificate of
24 authority therefor or renewal, issuance, or delivery of any
25 provider sponsored contract by a provider sponsored
26 organization, person, or entity without a subsisting
27 certificate of authority.
28 (8) MISREPRESENTATION IN PROVIDER SPONSORED
29 ORGANIZATION APPLICATIONS.--Knowingly making false or
30 fraudulent statements or representations on, or relative to,
31 an application for a provider sponsored contract for the
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1 purpose of obtaining a fee, commission, money, or other
2 benefits from any provider sponsored organization; agent; or
3 representative, broker, or individual.
4 (9) TWISTING.--Knowingly making any misleading
5 representations or incomplete or fraudulent comparisons of any
6 provider sponsored contracts or provider sponsored
7 organizations or of any insurance policies or insurers for the
8 purpose of inducing, or intending to induce, any person to
9 lapse, forfeit, surrender, terminate, retain, pledge, assign,
10 borrow on, or convert any insurance policy or provider
11 sponsored contract or to take out a provider sponsored
12 contract or policy of insurance in another provider sponsored
13 organization or insurer.
14 (10) ILLEGAL DEALINGS IN PREMIUMS; EXCESS OR REDUCED
15 CHARGES FOR PROVIDER SPONSORED COVERAGE.--
16 (a) Knowingly collecting any sum as a premium or
17 charge for provider sponsored coverage which is not then
18 provided or is not in due course to be provided, subject to
19 acceptance of the risk by the provider sponsored organization,
20 by a provider sponsored contract issued by a provider
21 sponsored organization as permitted by this part.
22 (b) Knowingly collecting as a premium or charge for
23 provider sponsored coverage any sum in excess of or less than
24 the premium or charge applicable to provider sponsored
25 coverage, in accordance with the applicable classifications
26 and rates as filed with the department, and as specified in
27 the provider sponsored contract.
28 (11) FALSE CLAIMS; OBTAINING OR RETAINING MONEY
29 DISHONESTLY.--Any agent or representative, physician,
30 claimant, or other person who causes to be presented to any
31
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1 provider sponsored organization a false claim for payment
2 knowing the same to be false.
3 (12) PROHIBITED DISCRIMINATORY PRACTICES.--A provider
4 sponsored organization may not refuse to provide services or
5 care to a subscriber solely because medical services may be or
6 have been sought for injuries resulting from an assault,
7 battery, sexual assault, sexual battery, or any other offense
8 by a family or household member, as defined in s. 741.28(2),
9 or by another who is or was residing in the same dwelling
10 unit.
11 (13) MISREPRESENTATION IN PROVIDER SPONSORED
12 ORGANIZATION; AVAILABILITY OF PROVIDERS.--Knowingly misleading
13 potential enrollees as to the availability of providers.
14 641.883 General powers and duties of the
15 department.--In addition to the powers and duties set forth in
16 s. 624.307, the department shall have the power to examine and
17 investigate the affairs of every person, entity, or provider
18 sponsored organization in order to determine whether the
19 person, entity, or provider sponsored organization is
20 operating in accordance with the provisions of this part or
21 has been or is engaged in any unfair method of competition or
22 in any unfair or deceptive act or practice prohibited by s.
23 641.879.
24 641.885 Defined unfair practices; hearings, witnesses,
25 appearances, production of books, and service of process.--
26 (1) Whenever the department has reason to believe that
27 any person, entity, or provider sponsored organization has
28 engaged, or is engaging, in this state in any unfair method of
29 competition or any unfair or deceptive act or practice as
30 defined in s. 641.881 or is operating a provider sponsored
31 organization without a certificate of authority as required by
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1 this part, unless a waiver has been granted by the Secretary
2 pursuant to s. 1856(a)(2) of the Balanced Budget Act of 1997,
3 and that a proceeding by it in respect thereto would be to the
4 interest of the public, the department shall conduct or cause
5 to have conducted a hearing in accordance with chapter 120.
6 (2) The department, a duly empowered hearing officer,
7 or an administrative law judge, during the conduct of such
8 hearing, shall have those powers enumerated in s. 120.569;
9 however, the penalties for failure to comply with a subpoena
10 or with an order directing discovery shall be limited to a
11 fine not to exceed $1,000 per violation.
12 (3) Statements of charges, notices, and orders under
13 this part may be served by anyone duly authorized by the
14 department, either in the manner provided by law for service
15 of process in civil actions or by certifying and mailing a
16 copy thereof to the person, entity, or provider sponsored
17 organization affected by the statement, notice, order, or
18 other process at her or his or its residence or principal
19 office or place of business. The verified return by the
20 person so serving such statement, notice, order, or other
21 process, setting forth the manner of the service, shall be
22 proof of the same, and the return postcard receipt for such
23 statement, notice, order, or other process, certified and
24 mailed as aforesaid, shall be proof of service of the same.
25 641.887 Cease and desist and penalty orders.--After
26 the hearing provided in s. 641.885, the department shall enter
27 a final order in accordance with s. 120.569. If it is
28 determined that the person, entity, or provider sponsored
29 organization charged has engaged in an unfair or deceptive act
30 or practice or the unlawful operation of a provider sponsored
31 organization without a subsisting certificate of authority,
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1 the department shall also issue an order requiring the
2 violator to cease and desist from engaging in such method of
3 competition, act, or practice or unlawful operation of a
4 provider sponsored organization. Further, if the act or
5 practice constitutes a violation of s. 641.879 or s. 641.881,
6 the department may, at its discretion, order any one or more
7 of the following:
8 (1) Suspension or revocation of the provider sponsored
9 organization's certificate of authority if it knew, or
10 reasonably should have known, it was in violation of this
11 part.
12 (2) If it is determined that the person or entity
13 charged has engaged in the business of operating a provider
14 sponsored organization without a certificate of authority,
15 unless a waiver has been granted by the Secretary pursuant to
16 s. 1856(a)(2) of the Balanced Budget Act of 1997, an
17 administrative penalty not to exceed $1,000 for each provider
18 sponsored contract offered or effectuated.
19 641.889 Appeals from the department.--Any person,
20 entity, or provider sponsored organization subject to an order
21 of the department under s. 641.887 or s. 641.891 may obtain a
22 review of the order by filing an appeal therefrom in
23 accordance with the provisions and procedures for appeal under
24 s. 120.68.
25 641.891 Penalty for violation of cease and desist
26 orders.--Any person, entity, or provider sponsored
27 organization which violates a cease and desist order of the
28 department under s. 641.887 while such order is in effect,
29 after notice and hearing as provided in s. 641.885, shall be
30 subject, at the discretion of the department, to any one or
31 more of the following:
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1 (1) A monetary penalty of not more than $200,000 as to
2 all matters determined in such hearing.
3 (2) Suspension or revocation of the provider sponsored
4 organization's certificate of authority.
5 641.893 Civil liability.--The provisions of this part
6 are cumulative to rights under the general civil and common
7 law, and no action of the department shall abrogate such
8 rights to damage or other relief in any court.
9 641.895 Exemption.--Provider service organizations are
10 exempt from s. 455.654 in providing health care services for
11 Medicare+Choice enrollees.
12 Section 3. Subsections (2) and (5) of section 641.316,
13 Florida Statutes, are amended to read:
14 641.316 Fiscal intermediary services.--
15 (2)(a) The term "fiduciary" or "fiscal intermediary
16 services" means reimbursements received or collected on behalf
17 of health care professionals for services rendered, patient
18 and provider accounting, financial reporting and auditing,
19 receipts and collections management, compensation and
20 reimbursement disbursement services, or other related
21 fiduciary services pursuant to health care professional
22 contracts with health maintenance organizations or provider
23 sponsored organizations.
24 (b) The term "fiscal intermediary services
25 organization" means a person or entity which performs
26 fiduciary or fiscal intermediary services to health care
27 professionals who contract with health maintenance
28 organizations or provider sponsored organizations other than a
29 fiscal intermediary services organization owned, operated, or
30 controlled by a hospital licensed under chapter 395, an
31 insurer licensed under chapter 624, a third-party
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1 administrator licensed under chapter 626, a prepaid limited
2 health organization licensed under chapter 636, a health
3 maintenance organization or a provider sponsored organization
4 licensed under this chapter, or physician group practices as
5 defined in s. 455.236(3)(f).
6 (5) Any fiscal intermediary services organization,
7 other than a fiscal intermediary services organization owned,
8 operated, or controlled by a hospital licensed under chapter
9 395, an insurer licensed under chapter 624, a third-party
10 administrator licensed under chapter 626, a prepaid limited
11 health organization or a provider sponsored organization
12 licensed under chapter 636, a health maintenance organization
13 licensed under this chapter, or physician group practices as
14 defined in s. 455.236(3)(f), must register with the department
15 and meet the requirements of this section. In order to
16 register as a fiscal intermediary services organization, the
17 organization must comply with ss. 641.21(1)(c) and (d) and
18 641.22(6). Should the department determine that the fiscal
19 intermediary services organization does not meet the
20 requirements of this section, the registration shall be
21 denied. In the event that the registrant fails to maintain
22 compliance with the provisions of this section, the department
23 may revoke or suspend the registration. In lieu of revocation
24 or suspension of the registration, the department may levy an
25 administrative penalty in accordance with s. 641.25.
26 Section 4. Section 641.227, Florida Statutes, is
27 amended to read:
28 641.227 Rehabilitation Administrative Expense Fund.--
29 (1) The department shall not issue or permit to exist
30 a certificate of authority to operate a health maintenance
31 organization or a provider sponsored organization in this
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1 state unless the organization has deposited with the
2 department $10,000 in cash for use in the Rehabilitation
3 Administrative Expense Fund as established in subsection (2).
4 (2) The department shall maintain all deposits
5 received under this section and all income from such deposits
6 in trust in an account titled "Rehabilitation Administrative
7 Expense Fund." The fund shall be administered by the
8 department and shall be used for the purpose of payment of the
9 administrative expenses of the department during any
10 rehabilitation of a health maintenance organization or a
11 provider sponsored organization, when rehabilitation is
12 ordered by a court of competent jurisdiction.
13 (3) Upon successful rehabilitation of a health
14 maintenance organization or a provider sponsored organization,
15 the organization shall reimburse the fund for the amount of
16 expenses incurred by the department during the court-ordered
17 rehabilitation period.
18 (4) If a court of competent jurisdiction orders
19 liquidation of a health maintenance organization or a provider
20 sponsored organization, the fund shall be reimbursed for
21 expenses incurred by the department as provided for in chapter
22 631.
23 (5) Each deposit made under this section shall be
24 allowed as an asset for purposes of determination of the
25 financial condition of the health maintenance organization or
26 the provider sponsored organization. The deposit shall be
27 refunded to the organization only when the organization both
28 ceases operation as a health maintenance organization or a
29 provider sponsored organization and no longer holds a
30 subsisting certificate of authority.
31
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1 Section 5. Subsections (9), (10), (11), (13), and (16)
2 of section 641.47, Florida Statutes, are amended to read:
3 641.47 Definitions.--As used in this part, the term:
4 (9) "Geographic area" means the county or counties, or
5 any portion of a county or counties, within which the health
6 maintenance organization or provider sponsored organization
7 provides or arranges for comprehensive health care services to
8 be available to its subscribers.
9 (10) "Grievance" means a written complaint submitted
10 by or on behalf of a subscriber to an organization or a state
11 agency regarding the:
12 (a) Availability, coverage for the delivery, or
13 quality of health care services, including a complaint
14 regarding an adverse determination made pursuant to
15 utilization review;
16 (b) Claims payment, handling, or reimbursement for
17 health care services; or
18 (c) Matters pertaining to the contractual relationship
19 between a subscriber and an organization.
20
21 A grievance does not include a written complaint submitted by
22 or on behalf of a subscriber eligible for a grievance and
23 appeals procedure provided by an organization pursuant to
24 contract with the Federal Government under Title XVIII of the
25 Social Security Act, which contract is governed by the rules
26 and regulations established by the Secretary of the United
27 States Department of Health and Human Services pursuant to the
28 Balanced Budget Act of 1997 as it applies to provider
29 sponsored organizations offering Medicare+Choice plans.
30 (11) "Health care services" means comprehensive health
31 care services, as defined in s. 641.19, when applicable to a
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1 health maintenance organization, the benefit package for
2 Medicare beneficiaries established by the federal government
3 when applicable to provider sponsored organizations, and means
4 basic services, as defined in s. 641.402, when applicable to a
5 prepaid health clinic.
6 (13) "Organization" means any health maintenance
7 organization as defined in s. 641.19, any provider sponsored
8 organization as defined in s. 641.805, and any prepaid health
9 clinic as defined in s. 641.402.
10 (16) "Subscriber" means an individual who has
11 contracted, or on whose behalf a contract has been entered
12 into, with a health maintenance organization for health care
13 services, or in the case of a provider sponsored organization,
14 a Medicare beneficiary.
15 Section 6. Section 641.48, Florida Statutes, is
16 amended to read:
17 641.48 Purpose and application of part.--The purpose
18 of this part is to ensure that health maintenance
19 organizations, provider sponsored organizations, and prepaid
20 health clinics deliver high-quality health care to their
21 subscribers. To achieve this purpose, this part requires all
22 such organizations to obtain a health care provider
23 certificate from the agency as a condition precedent to
24 obtaining a certificate of authority to do business in Florida
25 from the Department of Insurance, under part I, or part II, or
26 part IV of this chapter.
27 Section 7. Subsections (1) and (2) and paragraphs (q)
28 and (r) of subsection (3) of section 641.49, Florida Statutes,
29 are amended to read:
30 641.49 Certification of health maintenance
31 organization, provider sponsored organization, and prepaid
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1 health clinic as health care providers; application
2 procedure.--
3 (1) No person or governmental unit shall establish,
4 conduct, or maintain a health maintenance organization,
5 provider sponsored organization, or a prepaid health clinic in
6 this state without first obtaining a health care provider
7 certificate under this part.
8 (2) The Department of Insurance shall not issue a
9 certificate of authority under part I, or part II, or part IV
10 of this chapter to any applicant which does not possess a
11 valid health care provider certificate issued by the agency
12 under this part.
13 (3) Each application for a health care provider
14 certificate shall be on a form prescribed by the agency. The
15 following information and documents shall be submitted by an
16 applicant and maintained, after certification under this part,
17 by each organization and shall be available for inspection or
18 examination by the agency at the offices of an organization at
19 any time during regular business hours. The agency shall give
20 reasonable notice to an organization prior to any onsite
21 inspection or examination of its records or premises conducted
22 under this section. The agency may require that the following
23 information or documents be submitted with the application:
24 (q) A description and supporting documentation
25 concerning how the applicant, or health maintenance
26 organization, or provider sponsored organization will comply
27 with internal risk management program requirements under s.
28 641.55.
29 (r) An explanation of how coverage for emergency
30 services and care is to be effected outside the applicant's,
31
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1 or health maintenance organization's, or provider sponsored
2 organization's stated geographic area.
3 Section 8. Subsections (1) and (3) of section 641.495,
4 Florida Statutes, are amended to read:
5 641.495 Requirements for issuance and maintenance of
6 certificate.--
7 (1) Within 90 days after receiving an application for
8 a health care provider certificate, the agency shall issue a
9 health care provider certificate to an applicant filing a
10 completed application in conformity with ss. 641.48 and
11 641.49, upon payment of the prescribed fee, and upon the
12 agency's being satisfied that the applicant has the ability to
13 provide quality of care consistent with the prevailing
14 professional standards of care and which applicant otherwise
15 meets the requirements of this part.
16 (3) The organization shall demonstrate its capability
17 to provide health care services in the geographic area that it
18 proposes to service. In addition, each health maintenance
19 organization or provider sponsored organization shall notify
20 the agency of its intent to expand its geographic area at
21 least 60 days prior to the date it plans to begin providing
22 health care services in the new area. Prior to the date the
23 health maintenance organization or provider sponsored
24 organization begins enrolling members in the new area, it must
25 submit a notarized affidavit, signed by two officers of the
26 organization who have the authority to legally bind the
27 organization, to the agency describing and affirming its
28 existing and projected capability to provide health care
29 services to its projected number of subscribers in the new
30 area. The notarized affidavit shall further assure that, 15
31 days prior to providing health care services in the new area,
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1 the health maintenance organization or provider sponsored
2 organization shall be able, through documentation or
3 otherwise, to demonstrate that it shall be capable of
4 providing services to its projected subscribers for at least
5 the first 60 days of operation. If the agency determines that
6 the organization is not capable of providing health care
7 services to its projected number of subscribers in the new
8 area, the agency may issue an order as required under chapter
9 120 prohibiting the organization from expanding into the new
10 area. In any proceeding under chapter 120, the agency shall
11 have the burden of establishing that the organization is not
12 capable of providing health care services to its projected
13 number of subscribers in the new area.
14 Section 9. Paragraph (c) of subsection (4) of section
15 641.51, Florida Statutes, is amended to read:
16 641.51 Quality assurance program; second medical
17 opinion requirement.--
18 (4)
19 (c) For second opinions provided by contract
20 physicians the organization is prohibited from charging a fee
21 to the subscriber in an amount in excess of the subscriber
22 fees established by contract for referral contract physicians.
23 The organization shall pay the amount of all charges, which
24 are usual, reasonable, and customary in the community, for
25 second opinion services performed by a physician not under
26 contract with the organization, but may require the subscriber
27 to be responsible for up to 40 percent of such amount. The
28 organization may require that any tests deemed necessary by a
29 noncontract physician shall be conducted by the organization.
30 The organization may deny reimbursement rights granted under
31 this section in the event the subscriber seeks in excess of
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1 three such referrals per year if such subsequent referral
2 costs are deemed by the organization to be evidence that the
3 subscriber has unreasonably overutilized the second opinion
4 privilege. A subscriber thus denied reimbursement under this
5 section shall have recourse to grievance procedures as
6 specified in ss. 408.7056, 641.495, and 641.511. The
7 organization's physician's professional judgment concerning
8 the treatment of a subscriber derived after review of a second
9 opinion shall be controlling as to the treatment obligations
10 of the health maintenance organization or provider sponsored
11 organization. Treatment not authorized by the health
12 maintenance organization or provider sponsored organization
13 shall be at the subscriber's expense.
14 Section 10. Section 641.512, Florida Statutes, is
15 amended to read:
16 641.512 Accreditation and external quality assurance
17 assessment.--
18 (1)(a) To promote the quality of health care services
19 provided by health maintenance organizations, provider
20 sponsored organizations, and prepaid health clinics in this
21 state, the department shall require each health maintenance
22 organization, provider sponsored organization, and prepaid
23 health clinic to be accredited within 1 year of the
24 organization's receipt of its certificate of authority and to
25 maintain accreditation by an accreditation organization
26 approved by the department, as a condition of doing business
27 in the state.
28 (b) In the event that no accreditation organization
29 can be approved by the department, the department shall
30 require each health maintenance organization, provider
31 sponsored organization, and prepaid health clinic to have an
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1 external quality assurance assessment performed by a review
2 organization approved by the department, as a condition of
3 doing business in the state. The assessment shall be
4 conducted within 1 year of the organization's receipt of its
5 certificate of authority and every 2 years thereafter, or when
6 the department deems additional assessments necessary.
7 (2) The accreditation or review organization must have
8 nationally recognized experience in health maintenance
9 organization or provider sponsored organization activities and
10 in the appraisal of medical practice and quality assurance in
11 a health maintenance organization setting or, in the case of
12 provider sponsored organizations, in the appraisal of medical
13 practice and quality assurance in the provider sponsored
14 organization setting. The accreditation or review organization
15 shall not currently be involved in the operation of the health
16 maintenance organization, provider sponsored organization, or
17 prepaid health clinic, nor in the delivery of health care
18 services to its subscribers. The accreditation or review
19 organization shall not have contracted or conducted
20 consultations within the last 2 years for other than
21 accreditation purposes of the health maintenance organization,
22 provider sponsored organization, or prepaid health clinic
23 seeking accreditation or under quality assurance assessment.
24 (3) A representative of the department shall accompany
25 the accreditation or review organization throughout the
26 accreditation or assessment process, but shall not participate
27 in the final accreditation or assessment determination. The
28 accreditation or review organization shall monitor and
29 evaluate the quality and appropriateness of patient care, the
30 organization's pursuance of opportunities to improve patient
31 care and resolve identified problems, and the effectiveness of
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1 the internal quality assurance program required for health
2 maintenance organization, provider sponsored organization, and
3 prepaid health clinic certification pursuant to s.
4 641.49(3)(o).
5 (4) The accreditation or assessment process shall
6 include a review of:
7 (a) All documentation necessary to determine the
8 current professional credentials of employed health care
9 providers or physicians providing service under contract to
10 the health maintenance organization, provider sponsored
11 organization, or prepaid health clinic.
12 (b) At least a representative sample of not fewer than
13 50 medical records of individual subscribers. When selecting
14 a sample, any and all medical records may be subject to
15 review. The sample of medical records shall be representative
16 of all subscribers' records.
17 (5) Every organization shall submit its books,
18 documentations, and medical records and take appropriate
19 action as may be necessary to facilitate the accreditation or
20 assessment process.
21 (6) The accreditation or review organization shall
22 issue a written report of its findings to the health
23 maintenance organization's, provider sponsored organization's,
24 or prepaid health clinic's board of directors. A copy of the
25 report shall be submitted to the department by the
26 organization within 30 business days of its receipt by the
27 health maintenance organization, provider sponsored
28 organization, or prepaid health clinic.
29 (7) The expenses of the accreditation or assessment
30 process of each organization, including any expenses incurred
31 pursuant to this section, shall be paid by the organization.
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1 Section 11. Section 641.513, Florida Statutes, is
2 amended to read:
3 641.513 Requirements for providing emergency services
4 and care.--
5 (1) In providing for emergency services and care as a
6 covered service, a health maintenance organization or provider
7 sponsored organization may not:
8 (a) Require prior authorization for the receipt of
9 prehospital transport or treatment or for emergency services
10 and care.
11 (b) Indicate that emergencies are covered only if care
12 is secured within a certain period of time.
13 (c) Use terms such as "life threatening" or "bona
14 fide" to qualify the kind of emergency that is covered.
15 (d) Deny payment based on the subscriber's failure to
16 notify the health maintenance organization or provider
17 sponsored organization in advance of seeking treatment or
18 within a certain period of time after the care is given.
19 (2) Prehospital and hospital-based trauma services and
20 emergency services and care must be provided to a subscriber
21 of a health maintenance organization or provider sponsored
22 organization as required under ss. 395.1041, 395.4045, and
23 401.45.
24 (3)(a) When a subscriber is present at a hospital
25 seeking emergency services and care, the determination as to
26 whether an emergency medical condition, as defined in s.
27 641.47 exists shall be made, for the purposes of treatment, by
28 a physician of the hospital or, to the extent permitted by
29 applicable law, by other appropriate licensed professional
30 hospital personnel under the supervision of the hospital
31 physician. The physician or the appropriate personnel shall
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1 indicate in the patient's chart the results of the screening,
2 examination, and evaluation. The health maintenance
3 organization or provider sponsored organization shall
4 compensate the provider for the screening, evaluation, and
5 examination that is reasonably calculated to assist the health
6 care provider in arriving at a determination as to whether the
7 patient's condition is an emergency medical condition. The
8 health maintenance organization or provider sponsored
9 organization shall compensate the provider for emergency
10 services and care. If a determination is made that an
11 emergency medical condition does not exist, payment for
12 services rendered subsequent to that determination is governed
13 by the contract under which the subscriber is covered.
14 (b) If a determination has been made that an emergency
15 medical condition exists and the subscriber has notified the
16 hospital, or the hospital emergency personnel otherwise have
17 knowledge that the patient is a subscriber of the health
18 maintenance organization or provider sponsored organization,
19 the hospital must make a reasonable attempt to notify the
20 subscriber's primary care physician, if known, or the health
21 maintenance organization or provider sponsored organization,
22 if the health maintenance organization or provider sponsored
23 organization had previously requested in writing that the
24 notification be made directly to the health maintenance
25 organization or provider sponsored organization, of the
26 existence of the emergency medical condition. If the primary
27 care physician is not known, or has not been contacted, the
28 hospital must:
29 1. Notify the health maintenance organization or
30 provider sponsored organization as soon as possible prior to
31 discharge of the subscriber from the emergency care area; or
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1 2. Notify the health maintenance organization or
2 provider sponsored organization within 24 hours or on the next
3 business day after admission of the subscriber as an inpatient
4 to the hospital.
5
6 If notification required by this paragraph is not
7 accomplished, the hospital must document its attempts to
8 notify the health maintenance organization or provider
9 sponsored organization of the circumstances that precluded
10 attempts to notify the health maintenance organization or
11 provider sponsored organization. A health maintenance
12 organization or provider sponsored organization may not deny
13 payment for emergency services and care based on a hospital's
14 failure to comply with the notification requirements of this
15 paragraph. Nothing in this paragraph shall alter any
16 contractual responsibility of a subscriber to make contact
17 with the health maintenance organization or provider sponsored
18 organization, subsequent to receiving treatment for the
19 emergency medical condition.
20 (c) If the subscriber's primary care physician
21 responds to the notification, the hospital physician and the
22 primary care physician may discuss the appropriate care and
23 treatment of the subscriber. The health maintenance
24 organization may have a member of the hospital staff with whom
25 it has a contract participate in the treatment of the
26 subscriber within the scope of the physician's hospital staff
27 privileges. The subscriber may be transferred, in accordance
28 with state and federal law, to a hospital that has a contract
29 with the health maintenance organization or provider sponsored
30 organization and has the service capability to treat the
31 subscriber's emergency medical condition. Notwithstanding any
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1 other state law, a hospital may request and collect insurance
2 or financial information from a patient in accordance with
3 federal law, which is necessary to determine if the patient is
4 a subscriber of a health maintenance organization or provider
5 sponsored organization, if emergency services and care are not
6 delayed.
7 (4) A subscriber may be charged a reasonable
8 copayment, as provided in s. 641.31(12), for the use of an
9 emergency room.
10 (5) Reimbursement for services pursuant to this
11 section by a provider who does not have a contract with the
12 health maintenance organization or provider sponsored
13 organization shall be the lesser of:
14 (a) The provider's charges;
15 (b) The usual and customary provider charges for
16 similar services in the community where the services were
17 provided; or
18 (c) The charge mutually agreed to by the health
19 maintenance organization or provider sponsored organization
20 and the provider within 60 days of the submittal of the claim.
21
22 Such reimbursement shall be net of any applicable copayment
23 authorized pursuant to subsection (4).
24 (6) Reimbursement for services under this section
25 provided to subscribers who are Medicaid recipients by a
26 provider for whom no contract exists between the provider and
27 the health maintenance organization or provider sponsored
28 organization shall be the lesser of:
29 (a) The provider's charges;
30
31
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1 (b) The usual and customary provider charges for
2 similar services in the community where the services were
3 provided;
4 (c) The charge mutually agreed to by the entity and
5 the provider within 60 days after submittal of the claim; or
6 (d) The Medicaid rate.
7 Section 12. Subsection (4) of section 641.515, Florida
8 Statutes, is amended to read:
9 641.515 Investigation by the agency.--
10 (4) The agency shall promulgate rules imposing upon
11 physicians and hospitals performing services for a health
12 maintenance organization or provider sponsored organization
13 standards of care generally applicable to physicians and
14 hospitals.
15 Section 13. Subsection (1) and paragraph (b) of
16 subsection (2) of section 641.54, Florida Statutes, are
17 amended to read:
18 641.54 Information disclosure.--
19 (1) Every health maintenance organization or provider
20 sponsored organization shall maintain a current list, by
21 geographic area, of all hospitals which are routinely and
22 regularly used by the organization, indicating to which
23 hospitals the organization may refer particular subscribers
24 for nonemergency services. The list shall also include all
25 physicians under the organization's direct employ or who are
26 under contract or other arrangement with the organization to
27 provide health care services to subscribers. The list shall
28 contain the following information for each physician:
29 (a) Name.
30 (b) Office location.
31 (c) Medical area or areas of specialty.
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1 (d) Board certification or eligibility in any area.
2 (e) License number.
3 (2) The list shall be made available, upon request, to
4 the department. The list shall also be made available, upon
5 request:
6 (b) With respect to an individual health maintenance
7 contract or any contract offered to a person who is entitled
8 to have payments for health care costs made under Medicare, to
9 the person considering or making application to, or under
10 contract with, the health maintenance organization or the
11 provider sponsored organization. The list may be restricted
12 to include only physicians and hospitals in the person's
13 geographic area.
14 Section 14. Section 641.59, Florida Statutes, is
15 amended to read:
16 641.59 Psychotherapeutic services; records and
17 reports.--A health maintenance organization, provider
18 sponsored organization, or prepaid health clinic, as defined
19 in this chapter, must maintain strict confidentiality against
20 unauthorized or inadvertent disclosure of confidential
21 information to persons inside or outside the health
22 maintenance organization, provider sponsored organization, or
23 prepaid health clinic regarding psychotherapeutic services
24 provided to subscribers by psychotherapists licensed under
25 chapter 490 or chapter 491 and psychotherapeutic records and
26 reports related to the services. A report, in lieu of records,
27 may be submitted by a psychotherapist in support of the
28 services. Such report must include clear statements
29 summarizing the subscriber's presenting symptoms, what
30 transpired in any provided therapy, what progress, if any, was
31 made by the subscriber, and results obtained. However, the
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1 health maintenance organization, provider sponsored
2 organization, or prepaid health clinic may require the records
3 upon which the report is based, if the report does not contain
4 sufficient information supporting the services. A
5 psychotherapist submitting records in support of services may
6 obscure portions to conceal the names, identities, or
7 identifying information of people other than the subscriber if
8 this information is unnecessary to utilization review, quality
9 management, discharge planning, case management, or claims
10 processing conducted by the health maintenance organization or
11 prepaid health clinic. A health maintenance organization,
12 provider sponsored organization, or prepaid health clinic may
13 provide aggregate data which does not disclose subscriber
14 identities or identities of other persons to entities such as
15 payors, sponsors, researchers, and accreditation bodies.
16 Section 15. Paragraph (f) of subsection (1) of section
17 641.60, Florida Statutes, is amended to read:
18 641.60 Statewide Managed Care Ombudsman Committee.--
19 (1) As used in ss. 641.60-641.75:
20 (f) "Managed care program" means a health care
21 delivery system that emphasizes primary care and integrates
22 the financing and delivery of services to enrolled individuals
23 through arrangements with selected providers, formal quality
24 assurance and utilization review, and financial incentives for
25 enrollees to use the program's providers. Such a health care
26 delivery system may include arrangements in which providers
27 receive prepaid set payments to coordinate and deliver all
28 inpatient and outpatient services to enrollees or arrangements
29 in which providers receive a case management fee to coordinate
30 services and are reimbursed on a fee-for-service basis for the
31 services they provide. A managed care program may include a
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1 state-licensed health maintenance organization, a provider
2 sponsored organization, a Medicaid prepaid health plan, a
3 Medicaid primary care case management program, or other
4 similar program.
5 Section 16. This act shall take effect October 1 of
6 the year in which enacted.
7
8 *****************************************
9 HOUSE SUMMARY
10
Creates pt. IV of ch. 641, F.S., to provide for
11 establishing, licensing, regulating, administering, and
enforcing compliance by provider sponsored organizations,
12 which provide a substantial proportion of the health care
items and services required in Medicare+Choice contract
13 under the Medicare+Choice program, as an alternative to
health maintenance organizations.
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