PART I HEALTH MAINTENANCE ORGANIZATIONS

PART II PREPAID HEALTH CLINICS

PART III HEALTH CARE SERVICES

CHAPTER 641

641.17

Short title.

History. — s. 1, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 778, 804, 809(1st), ch. 82-243; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.18 Declaration of legislative intent, findings, and purposes.

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

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

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

(4) It shall be the policy of this state to:

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

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

History. — s. 2, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 779, 804, 809(1st), ch. 82-243; s. 5, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.183 Statutory accounting procedures; transition provisions.

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

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

History. — s. 21, ch. 2001-213.

641.185 Health maintenance organization subscriber protections.

(1) With respect to the provisions of this part and

part III, the principles expressed in the following statements serve as standards to be followed by the commission, the office, the department, and the Agency for Health Care Administration in exercising their powers and duties, in exercising administrative discretion, in administrative

interpretations of the law, in enforcing its provisions, and in adopting rules:

(2) This

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

History. — s. 44, ch. 2000-256; s. 6, ch. 2001-64; s. 8, ch. 2002-389; s. 1554, ch. 2003-261; s. 110, ch. 2018-24.

641.19

Definitions.

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

(2) “Agency” means the Agency for Health Care Administration.

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

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

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

(6) “Emergency medical condition” means:

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

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

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

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

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

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

(13) “Insolvent” or “insolvency” means that all the statutory assets of the health maintenance organization, if made immediately available, would not be sufficient to discharge all of its liabilities or that the health maintenance organization is unable to pay its debts as they become due in the usual course of business.

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

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

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

(16) “Schedule of reimbursements” means a

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

schedule may be stated as:

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

(18) “Subscriber” means an entity or individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract.

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

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

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

(22) “Provider service network” means a network authorized under s. 409.912(1), reimbursed on a prepaid basis, operated by a health care provider or group of affiliated health care providers, and which directly provides health care services under a Medicare, Medicaid, or Healthy Kids contract.

History. — s. 3, ch. 72-264; s. 1, ch. 76-33; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 780, 804, 809(1st), ch. 82-243; s. 1, ch. 83-198; s. 137, ch. 83-216; s. 2, ch. 84-313; s. 6, ch. 85-177; s. 1, ch. 87-236; s. 1, ch. 87-273; s. 2, ch. 88-126; s. 2, ch. 88-388; s. 2, ch. 89-357; s. 74, ch. 89-360; ss. 111, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 2, ch. 95-281; s. 13, ch. 96-199; s. 3, ch. 96-223; s. 22, ch. 2001-213; s. 10, ch. 2002-247; s. 1555, ch. 2003-261; s. 46, ch. 2003-416; s. 1, ch. 2004-321; s. 33, ch. 2011-135; s. 30, ch. 2015-3; s. 18, ch. 2017-4; s. 14, ch. 2022-42.

641.201 Applicability of other laws.

History. — ss. 25, 50, ch. 85-321; s. 3, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 40, ch. 95-211; s. 71, ch. 2000-318.

641.2011 Insurance holding companies.

History. — s. 76, ch. 2000-318.

641.2015 Incorporation required.

History. — ss. 7, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 14, ch. 96-199; s. 58, ch. 2014-209.

641.2017 Insurance business not authorized.

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

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

History. — ss. 26, 50, ch. 85-321; s. 9, ch. 90-248; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1556, ch. 2003-261.

641.2018 Limited coverage for home health care authorized.

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

(2) Notwithstanding the other provisions of this chapter, a health maintenance organization may apply for and obtain a certificate of authority from the office pursuant to this part and a health care provider certificate pursuant to

part III, which certificate limits the authority of the organization to the issuance of contracts that limit coverage to home health care services pursuant to subsection (1). In addition to all applicable requirements of this part, as specified in subsection (1), all of the requirements of

part III apply to an organization applying for such a limited certificate, except to the extent that such requirements directly conflict with the limited nature of the coverage provided.

(3) Any contract that limits coverage to home health care benefits as provided in this

section must also meet all of the requirements of ss. 627.9403-627.9408 of the Long-Term Care Insurance Act, except s. 627.9407(3)(

c) and (9).

History. — s. 6, ch. 96-275; s. 51, ch. 99-3; s. 1557, ch. 2003-261; s. 10, ch. 2006-254.

641.20185 High-deductible contracts for medical savings accounts.

History. — s. 22, ch. 97-179; s. 52, ch. 99-3.

641.2019 Provider service network certificate of authority.

History. — s. 34, ch. 2011-135.

641.21 Application for certificate.

(1) Before any entity may operate a health maintenance organization, it shall obtain a certificate of authority from the office. The office shall accept and shall begin its review of an application for a certificate of authority anytime after an organization has filed an application for a health care provider certificate pursuant to

part III of this chapter. However, the office may not issue a certificate of authority to any applicant which does not possess a valid health care provider certificate issued by the agency. Each application for a certificate shall be on such form as the commission shall prescribe, shall be verified by the oath of two officers of the corporation and properly notarized, and shall be accompanied by the following:

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

Any such activities, oral or written, shall include a statement that the entity does not possess a valid certificate of authority and cannot enter into health maintenance contracts until such time as it has been issued a certificate of authority by the office.

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

History. — s. 5, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 782, 804, 809(1st), ch. 82-243; s. 2, ch. 83-198; s. 8, ch. 85-177; s. 4, ch. 87-236; s. 3, ch. 88-388; ss. 112, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 41, ch. 95-211; s. 15, ch. 96-199; s. 1558, ch. 2003-261; s. 133, ch. 2004-5.

641.215 Conditions precedent to issuance or maintenance of certificate of authority; effect of bankruptcy proceedings.

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

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

History. — ss. 113, 188, ch. 91-108; s. 4, ch. 91-429; s. 1559, ch. 2003-261.

641.217 Minority recruitment and retention plans required.

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

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

History. — s. 16, ch. 96-199; s. 434, ch. 2011-142.

641.22 Issuance of certificate of authority.

(1) As a condition precedent to the issuance of any certificate, the entity has obtained a health care provider certificate from the Agency for Health Care Administration pursuant to

part III of this chapter.

(2) The health maintenance organization is actuarially sound.

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

(4) The procedures for offering comprehensive health care services and offering and terminating contracts to subscribers will not unfairly discriminate on the basis of age, sex, race, health, or economic status. However, this

section does not prohibit reasonable underwriting classifications for the purposes of establishing contract rates, nor does it prohibit experience rating.

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

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

(7) The entity has a blanket fidelity bond in the amount of $100,000, issued by a licensed insurance carrier in this state, that will reimburse the entity in the event that anyone handling the funds of the entity either misappropriates or absconds with the funds. All employees handling the funds shall be covered by the blanket fidelity bond.

An agent licensed under the provisions of the Florida Insurance Code may either directly or indirectly represent the health maintenance organization in the solicitation, negotiation, effectuation, procurement, receipt, delivery, or forwarding of any health maintenance organization subscriber’s contract or collect or forward any consideration paid by the subscriber to the health maintenance organization; and the licensed agent shall not be required to post the bond required by this subsection.

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

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

History. — s. 6, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 783, 804, 809(1st), ch. 82-243; s. 3, ch. 83-198; s. 3, ch. 84-313; s. 9, ch. 85-177; s. 5, ch. 87-236; s. 4, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 42, ch. 95-211; s. 17, ch. 96-199; s. 21, ch. 97-93; s. 264, ch. 99-8; s. 1560, ch. 2003-261.

641.221 Continued eligibility for certificate of authority.

(1) In order to maintain its eligibility for a certificate of authority, a health maintenance organization shall continue to meet all conditions required to be met under this part and the rules promulgated thereunder for the initial application for and issuance of its certificate of authority under s. 641.22.

(2) In order to maintain eligibility for a certificate of authority, a health maintenance organization authorized under the Florida Insurance Code to exclusively market, sell, or offer to sell Medicare Advantage plans in this state shall be actively engaged in managed care within 24 months after licensure, shall designate and maintain at least one primary anti-fraud employee, and shall adopt an anti-fraud plan. The Office of Insurance Regulation may extend the period of eligibility upon written request.

History. — ss. 10, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 3, ch. 2017-178.

641.225 Surplus requirements.

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

(2) The office shall not issue a certificate of authority unless the health maintenance organization has a minimum surplus in an amount which is the greater of:

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

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

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

(6) A health maintenance organization that is authorized in this state and one or more other states, jurisdictions, or countries is subject to ss. 624.4085 and 624.40851.

History. — s. 4, ch. 83-198; s. 4, ch. 84-313; s. 28, ch. 85-62; s. 11, ch. 85-177; s. 1, ch. 86-286; s. 5, ch. 88-388; s. 24, ch. 90-295; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 18, ch. 96-199; s. 20, ch. 98-159; s. 7, ch. 2001-64; s. 1561, ch. 2003-261; s. 134, ch. 2004-5; s. 27, ch. 2004-344; s. 16, ch. 2014-101; s. 31, ch. 2015-3; s. 81, ch. 2016-10.

641.2261 Application of solvency requirements to provider-sponsored organizations and Medicaid provider service networks.

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

(2) Except for a provider service network seeking to obtain a certificate of authority under s. 641.2019, the solvency requirements in 42 C.F.R. s. 422.350, subpart H, and the solvency requirements established in approved federal waivers pursuant to

chapter 409 apply to a Medicaid provider service network rather than the solvency requirements of this part.

History. — s. 74, ch. 2000-318; s. 5, ch. 2005-358; s. 35, ch. 2011-135.

641.227 Rehabilitation Administrative Expense Fund.

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

(2) The department shall maintain all deposits received under this

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

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

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

chapter 631.

(5) Each deposit made under this

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

History. — ss. 12, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1562, ch. 2003-261.

641.228 Florida Health Maintenance Organization Consumer Assistance Plan.

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

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

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

History. — ss. 6, 24, ch. 88-388; ss. 114, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1563, ch. 2003-261.

641.23 Revocation or cancellation of certificate of authority; suspension of enrollment of new subscribers; terms of suspension.

(1) The maintenance of a valid and current health care provider certificate issued pursuant to

part III of this

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

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

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

(4) The office shall, in its order suspending the authority of a health maintenance organization to enroll new subscribers, specify the period during which the suspension is to be in effect and the conditions, if any, which must be met by the health maintenance organization prior to reinstatement of its authority to enroll new subscribers. The order of suspension is subject to rescission or modification by further order of the office prior to the expiration of the suspension period.

Reinstatement shall not be made unless requested by the health maintenance organization; however, the office shall not grant reinstatement if it finds that the circumstances for which the suspension occurred still exist or are likely to recur.

(5) The commission shall adopt rules establishing an actuarially sound medical loss ratio for Medicaid.

In determining the appropriate medical loss ratio, the commission shall consider factors, including but not limited to, plan age, plan structure, geographic service area, product mix, provider network, medical inflation, provider services, other professional services, out of network referrals and expenditures, in and out of network emergency room expenditures, inpatient expenditures, other medical expenditures, incentive pool adjustments, copayments, coordination of benefits, subrogation, and any other expenses associated with the delivery of medical benefits.

The commission shall utilize assistance from the Agency for Health Care Administration, the State University System, an independent actuary, and representatives from health maintenance organizations in developing the rule for appropriate medical loss ratios.

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

History. — s. 7, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 784, 804, 809(1st), ch. 82-243; s. 5, ch. 83-198; s. 6, ch. 84-313; s. 6, ch. 87-236; s. 7, ch. 88-388; ss. 115, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 43, ch. 95-211; s. 19, ch. 96-199; s. 265, ch. 99-8; s. 2, ch. 2000-155; s. 1564, ch. 2003-261.

641.234 Administrative, provider, and management contracts.

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

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

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

(4)(

a) If a health maintenance organization, through a health care risk contract, transfers to any entity the obligations to pay any provider for any claims arising from services provided to or for the benefit of any subscriber of the organization, the health maintenance organization shall remain responsible for any violations of ss. 641.3155, 641.3156, and 641.51(4). The provisions of ss. 624.418-624.4211 and 641.52 shall apply to any such violations.

History. — ss. 8, 24, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 20, ch. 96-199; s. 72, ch. 2000-318; s. 9, ch. 2002-389; s. 1565, ch. 2003-261.

641.2342 Contract providers.

History. — ss. 9, 24, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1566, ch. 2003-261.

641.25 Administrative penalty in lieu of suspension or revocation.

History. — s. 9, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 786, 804, 809(1st), ch. 82-243; s. 6, ch. 83-198; s. 7, ch. 87-236; s. 10, ch. 88-388; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 21, ch. 96-199; s. 1567, ch. 2003-261.

641.255 Acquisition, merger, or consolidation.

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

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

(3) A health maintenance organization that is a member of a holding company system is subject to s. 628.461 but not s. 628.4615.

History. — ss. 787, 809(1st), ch. 82-243; ss. 13, 17, ch. 86-250; s. 4, ch. 87-50; s. 10, ch. 90-248; ss. 184, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 22, ch. 96-199; s. 1568, ch. 2003-261; s. 17, ch. 2014-101.

641.26 Annual and quarterly reports.

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

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

(3) Every health maintenance organization shall file quarterly, for the first three calendar quarters of each year, an unaudited financial statement of the organization as described in paragraphs (1)(

a) and (b). The statement for the quarter ending March 31 shall be filed on or before May 15, the statement for the quarter ending June 30 shall be filed on or before August 15, and the statement for the quarter ending September 30 shall be filed on or before November 15. The quarterly report shall be verified by the oath of two officers of the organization, properly notarized.

(4) Any health maintenance organization that neglects to file an annual report or quarterly report in the form and within the time required by this

section shall forfeit up to $1,000 for each day for the first 10 days during which the neglect continues and shall forfeit up to $2,000 for each day after the first 10 days during which the neglect continues; and, upon notice by the office to that effect, the organization’s authority to enroll new subscribers or to do business in this state shall cease while such default continues. The office shall deposit all sums collected by it under this

section to the credit of the Insurance Regulatory Trust Fund. The office shall not collect more than $100,000 for each report.

(5) Each authorized health maintenance organization shall retain an independent certified public accountant, referred to in this

section as “CPA,” who agrees by written contract with the health maintenance organization to comply with the provisions of this part.

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

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

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

History. — s. 10, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 788, 804, 809(1st), ch. 82-243; s. 7, ch. 83-198; s. 13, ch. 85-177; s. 8, ch. 87-236; s. 11, ch. 88-388; s. 75, ch. 89-360; ss. 116, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 23, ch. 96-199; s. 22, ch. 98-159; s. 7, ch. 2002-247; s. 1569, ch. 2003-261.

641.261 Other reporting requirements.

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

(2) Any information provided by a health maintenance organization under this

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

History. — s. 6, ch. 87-377; s. 1, ch. 88-303; s. 8, ch. 90-232; s. 37, ch. 90-295; ss. 187, 188, ch. 91-108; s. 68, ch. 91-282; s. 4, ch. 91-429; s. 44, ch. 95-211; s. 266, ch. 99-8; s. 189, ch. 99-397.

641.27 Examination by the department.

(1) The office shall examine the affairs, transactions, accounts, business records, and assets of any health maintenance organization as often as it deems it expedient for the protection of the people of this state, but not less frequently than once every 5 years. However, except when the medical records are requested and copies furnished pursuant to s. 456.057, medical records of individuals and records of physicians providing service under contract to the health maintenance organization shall not be subject to audit, although they may be subject to subpoena by court order upon a showing of good cause.

For the purpose of examinations, the office may administer oaths to and examine the officers and agents of a health maintenance organization concerning its business and affairs. The examination of each health maintenance organization by the office shall be subject to the same terms and conditions as apply to insurers under

chapter 624. In no event shall expenses of all examinations exceed a maximum of $50,000 for any 1-year period. Any rehabilitation, liquidation, conservation, or dissolution of a health maintenance organization shall be conducted under the supervision of the department, which shall have all power with respect thereto granted to it under the laws governing the rehabilitation, liquidation, reorganization, conservation, or dissolution of life insurance companies.

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

The results of any contracted assistance shall be subject to the review of, and approval, disapproval, or modification by, the office.

History. — s. 11, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 789, 804, 809(1st), ch. 82-243; s. 8, ch. 83-198; s. 14, ch. 85-177; s. 9, ch. 87-236; s. 12, ch. 88-388; ss. 117, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 161, ch. 98-166; s. 222, ch. 2000-160; s. 73, ch. 2000-318; s. 1570, ch. 2003-261; s. 9, ch. 2005-231.

641.28 Civil remedy.

History. — s. 12, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 790, 804, 809(1st), ch. 82-243; s. 9, ch. 83-198; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 24, ch. 96-199; s. 1571, ch. 2003-261.

641.281 Injunction.

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

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

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

History. — ss. 15, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1572, ch. 2003-261.

641.282 Payment of judgment by health maintenance organization.

History. — ss. 16, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.284 Liquidation, rehabilitation, reorganization, and conservation; exclusive methods of remedy.

History. — ss. 118, 188, ch. 91-108; s. 4, ch. 91-429; s. 1573, ch. 2003-261.

641.285 Insolvency protection.

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

(2) If securities or assets deposited by a health maintenance organization under this part are subject to material fluctuations in market value, the office may, in its discretion, require the organization to deposit and maintain on deposit additional securities or assets in an amount as may be reasonably necessary to assure that the deposit will at all times have a market value of not less than the amount specified under this section.

If for any reason the market value of assets and securities of a health maintenance organization held on deposit in this state under this code falls below the amount required, the organization shall promptly deposit other or additional assets or securities eligible for deposit sufficient to cure the deficiency. If the health maintenance organization has failed to cure the deficiency within 30 days after receipt of notice thereof by registered or certified mail from the office, the office may revoke the certificate of authority of the health maintenance organization.

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

The deposit required under this subsection is in addition to any other deposits required of a health maintenance organization pursuant to subsections (1) and (2).

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

History. — ss. 791, 809(1st), ch. 82-243; s. 10, ch. 83-198; s. 17, ch. 85-177; ss. 184, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 21, ch. 98-159; s. 1574, ch. 2003-261.

641.286 Levy upon deposit limited.

History. — ss. 18, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.29 Fees.

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

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

History. — s. 13, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 792, 804, 809(1st), ch. 82-243; s. 19, ch. 85-177; s. 10, ch. 87-236; s. 13, ch. 88-388; ss. 119, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1575, ch. 2003-261.

641.30 Construction and relationship to other laws.

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

(2) Except as provided in this part, the Florida Insurance Code does not apply to health maintenance organizations certificated under this part, and health maintenance organizations certificated under this part are not subject to

part II of this chapter. Any person, entity, or health maintenance organization operating without a subsisting certificate of authority in violation of this part or rules promulgated thereunder or renewing, issuing, or delivering health maintenance contracts without a subsisting certificate of authority in violation of this part or rules promulgated thereunder, in addition to being subject to the provisions of this part, is subject to the provisions of the Florida Insurance Code as defined in s. 624.01.

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

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

(5) Every health maintenance organization must comply with s. 627.4301.

History. — s. 14, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 793, 804, 809(1st), ch. 82-243; s. 7, ch. 84-313; s. 20, ch. 85-177; s. 11, ch. 87-236; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 5, ch. 97-182; s. 53, ch. 99-3; s. 10, ch. 2002-389; s. 26, ch. 2016-165; s. 24, ch. 2025-4.

641.3005 Application of ch. 85-177.

History. — s. 48, ch. 85-177; s. 1, ch. 86-286; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.3007 HIV infection and AIDS for contract purposes.

(1) PURPOSE. —

(2) SCOPE. —

(3) DEFINITIONS. —

(4) UTILIZATION OF MEDICAL TESTS. —

(5) RESTRICTIONS ON CONTRACT EXCLUSIONS AND LIMITATIONS. —

History. — ss. 51, 54, ch. 88-380; s. 188, ch. 91-108; s. 4, ch. 91-429; s. 45, ch. 95-211; s. 54, ch. 99-3; s. 267, ch. 99-8; s. 1576, ch. 2003-261.

641.305 Language used in contracts and advertisements; translations.

(1)(

a) All health maintenance contracts or forms shall be printed in English.

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

History. — ss. 22, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1577, ch. 2003-261.

641.309 Standards for marketing to persons eligible for Medicare.

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

(2) In addition to the practices prohibited in s. 641.3903:

History. — ss. 120, 188, ch. 91-108; s. 4, ch. 91-429.

641.31 Health maintenance contracts.

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

(2) The rates charged by any health maintenance organization to its subscribers shall not be excessive, inadequate, or unfairly discriminatory or follow a rating methodology that is inconsistent, indeterminate, or ambiguous or encourages misrepresentation or misunderstanding. The commission, in accordance with generally accepted actuarial practice as applied to health maintenance organizations, may define by rule what constitutes excessive, inadequate, or unfairly discriminatory rates and may require whatever information it deems necessary to determine that a rate or proposed rate meets the requirements of this subsection.

(3)(

a) If a health maintenance organization desires to amend any contract with its subscribers or any certificate or member handbook, or desires to change any basic health maintenance contract, certificate, grievance procedure, or member handbook form, or application form where written application is required and is to be made a part of the contract, or printed amendment, addendum, rider, or endorsement form or form of renewal certificate, it may do so, upon filing with the office the proposed change or amendment. Any proposed change shall be effective immediately, subject to disapproval by the office.

Following receipt of notice of such disapproval or withdrawal of approval, no health maintenance organization shall issue or use any form disapproved by the office or as to which the office has withdrawn approval.

(4) Every health maintenance contract, certificate, or member handbook shall clearly state all of the services to which a subscriber is entitled under the contract and must include a clear and understandable statement of any limitations on the services or kinds of services to be provided, including any copayment feature or

schedule of benefits required by the contract or by any insurer or entity which is underwriting any of the services offered by the health maintenance organization. The contract, certificate, or member handbook shall also state where and in what manner the comprehensive health care services may be obtained.

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

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

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

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

(9) All health maintenance contracts that provide coverage, benefits, or services for a member of the family of the subscriber must, as to such family member’s coverage, benefits, or services, provide also that the coverage, benefits, or services applicable for children must be provided with respect to a newborn child of the subscriber, or covered family member of the subscriber, from the moment of birth.

However, with respect to a newborn child of a covered family member other than the spouse of the insured or subscriber, the coverage for the newborn child terminates 18 months after the birth of the newborn child.

The coverage, benefits, or services for newborn children must consist of coverage for injury or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and transportation costs of the newborn to and from the nearest appropriate facility appropriately staffed and equipped to treat the newborn’s condition, when such transportation is certified by the attending physician as medically necessary to protect the health and safety of the newborn child.

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

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

(12) Each health maintenance contract, certificate, or member handbook shall state that emergency services and care shall be provided to subscribers in emergency situations not permitting treatment through the health maintenance organization’s providers, without prior notification to and approval of the organization. Not less than 75 percent of the reasonable charges for covered services and supplies shall be paid by the organization, up to the subscriber contract benefit limits. Payment also may be subject to additional applicable copayment provisions, not to exceed $100 per claim. The health maintenance contract, certificate, or member handbook shall contain the

definitions of “emergency services and care” and “emergency medical condition” as specified in s. 641.19(6) and (7), shall describe procedures for determination by the health maintenance organization of whether the services qualify for reimbursement as emergency services and care, and shall contain specific examples of what does constitute an emergency. In providing for emergency services and care as a covered service, a health maintenance organization shall be governed by s. 641.513.

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

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

(15)(

a) All health maintenance contracts, certificates, and member handbooks shall contain the following provision:

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

(17) All health maintenance contracts that provide coverage for a member of the family of the subscriber, shall, as to such family member’s coverage, provide that coverage, benefits, or services applicable for children shall be provided with respect to an adopted child of the subscriber, which child is placed in compliance with

chapter 63, from the moment of placement in the residence of the subscriber. Such contracts may not exclude coverage for any preexisting condition of the child. In the case of a newborn child, coverage shall begin from the moment of birth if a written agreement to adopt such child has been entered into by the subscriber prior to the birth of the child, whether or not such agreement is enforceable. However, coverage for such child shall not be required in the event that the child is not ultimately placed in the residence of the subscriber in compliance with

chapter 63.

(18)(

a) Health maintenance contracts that provide coverage, benefits, or services for maternity care must provide, as an option to the subscriber, the services of nurse-midwives and midwives licensed pursuant to

chapter 467, and the services of birth centers licensed pursuant to ss. 383.30-383.332, if such services are available within the service area.

(19) Notwithstanding any other provision of law, health maintenance policies or contracts which provide coverage, benefits, or services as described in s. 463.002(7), shall offer to the subscriber the services of an optometrist licensed pursuant to

chapter 463.

(20) Notwithstanding any other provision of law, health maintenance policies or contracts which provide coverage, benefits, or services which are performed by physicians who are ophthalmologists, licensed pursuant to

chapter 458 or

chapter 459, shall offer the subscriber the services of an ophthalmologist. For purposes of this subsection, ophthalmologists are physicians specializing in the diagnosis and treatment of diseases and injuries of the eye.

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

part I of

chapter 464.

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

(23) The contract shall include the following provision:

(24) Each health maintenance organization that provides for inpatient and outpatient services by allopathic hospitals shall provide as an option of the subscriber similar inpatient and outpatient services by hospitals accredited by the American Osteopathic Association when such services are available in the same service area of the HMO and the osteopathic hospital agrees to provide the services as specified herein.

As a condition precedent to providing osteopathic inpatient and outpatient services through an osteopathic hospital that has not entered into a written contract with the HMO, the HMO may require the subscriber or any other person receiving osteopathic services to release the HMO from any liability arising from any act of omission or commission constituting malpractice in the delivery of osteopathic care from that hospital.

The osteopathic hospital providing the inpatient and outpatient services for the HMO shall charge rates that do not exceed the osteopathic hospital’s usual and customary rates less the average discount provided by allopathic hospitals providing the HMO services in the same service area of the HMO.

(25) If a subscriber is a resident of a continuing care facility certified under

chapter 651 or a retirement facility consisting of a nursing home or assisted living facility and residential apartments, the subscriber’s primary care physician must refer the subscriber to that facility’s skilled nursing unit or assisted living facility if requested by the subscriber and agreed to by the facility; if the primary care physician finds that such care is medically necessary; if the facility agrees to be reimbursed at the health maintenance organization’s contract rate negotiated with similar providers for the same services and supplies; and if the facility meets all guidelines established by the health maintenance organization related to quality of care, utilization, referral authorization, risk assumption, use of the health maintenance organization’s network, and other criteria applicable to providers under contract for the same services and supplies.

If a health maintenance organization enrolls a new subscriber who already resides in a continuing care facility or a retirement facility as described in this subsection, the health maintenance organization must provide in writing a disclosure of the subscriber’s rights under this subsection. If a subscriber’s request to be referred to the skilled nursing unit or assisted living facility that is part of the subscriber’s place of residence is not honored, the subscriber may use the grievance process provided in s. 641.511.

(26)(

a) Each health maintenance organization and prepaid health plan shall provide coverage for all medically appropriate and necessary equipment, supplies, and services used to treat diabetes, including outpatient self-management training and educational services, if the patient’s primary care physician, or the physician to whom the patient has been referred who specializes in treating diabetes, certifies that the equipment, supplies, or services are necessary.

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

(28) A health maintenance organization may not discriminate against or fail to contract with a hospital, based solely on the fact that the hospital’s medical staff is comprised of physicians licensed under

chapter 459. Nothing in this subsection shall mandate that a health maintenance organization contract with a hospital.

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

(30)(

a) All health maintenance contracts which provide coverage, benefits, or services for a member of the family of the subscriber must, as to such family member’s coverage, benefits, or services, also provide that the benefits applicable for children include coverage for child health supervision services from the moment of birth to age 16 years.

(31)(

a) Health maintenance contracts that provide coverage, benefits, or services for breast cancer treatment may not limit inpatient hospital coverage for mastectomies to any period that is less than that determined by the treating physician under contract with the health maintenance organization to be medically necessary in accordance with prevailing medical standards and after consultation with the covered patient.

Such contract must also provide coverage for outpatient postsurgical followup care in keeping with prevailing medical standards by a licensed health care professional under contract with the health maintenance organization qualified to provide postsurgical mastectomy care. The treating physician under contract with the health maintenance organization, after consultation with the covered patient, may choose that the outpatient care be provided at the most medically appropriate setting, which may include the hospital, treating physician’s office, outpatient center, or home of the covered patient.

(32) A health maintenance contract that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy. As used in this subsection, the term “breast reconstructive surgery” means surgery to reestablish symmetry between the two breasts. Such surgery must be in a manner chosen by the treating physician under contract with the health maintenance organization, consistent with prevailing medical standards, and in consultation with the patient.

The health maintenance organization may charge an appropriate additional premium for the coverage required by this subsection. The coverage for prosthetic devices and breast reconstructive surgery shall be subject to any deductible and coinsurance conditions.

(33) Notwithstanding any provision of this

section to the contrary, a health maintenance organization which offers dermatological services shall provide direct patient access, for office visits and minor procedures and testing, to a dermatologist who is under contract with the health maintenance organization. The term “direct patient access” means the ability of a subscriber to obtain such services without a referral or other authorization before receiving services.

The health maintenance organization shall, by July 1, 1997, develop criteria for compliance with the provisions of this subsection which do not impede or inhibit access to dermatological services for policyholders of the health maintenance organization. The criteria may include a maximum of five office visits to a dermatologist without prior authorization for a dermatologic problem within a 12-month period.

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

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

section is subject to terms and conditions applicable to other benefits.

(36) A health maintenance organization may increase the copayment for any benefit, or delete, amend, or limit any of the benefits to which a subscriber is entitled under the group contract only, upon written notice to the contract holder at least 45 days in advance of the time of coverage renewal. The health maintenance organization may amend the contract with the contract holder, with such amendment to be effective immediately at the time of coverage renewal.

The written notice to the contract holder shall specifically identify any deletions, amendments, or limitations to any of the benefits provided in the group contract during the current contract period which will be included in the group contract upon renewal. This subsection does not apply to any increases in benefits. The 45-day notice requirement shall not apply if benefits are amended, deleted, or limited at the request of the contract holder.

(37) All health maintenance contracts that provide coverage for massage must also cover the services of persons licensed to practice massage therapy pursuant to

chapter 480 if the massage is prescribed by a contracted physician licensed under

chapter 458,

chapter 459,

chapter 460, or

chapter 461 as medically necessary and the prescription specifies the number of treatments. Such massage services are subject to the same terms, conditions, and limitations as those of other covered services.

(38)(

a) Notwithstanding any other provision of this part, a health maintenance organization that meets the requirements of paragraph (

b) may, through a point-of-service rider to its contract providing comprehensive health care services, include a point-of-service benefit. Under such a rider, a subscriber or other covered person of the health maintenance organization may choose, at the time of covered service, a provider with whom the health maintenance organization does not have a health maintenance organization provider contract. The rider may not require a referral from the health maintenance organization for the point-of-service benefits.

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

(40)(

a) Any group rate, rating schedule, or rating manual for a health maintenance organization policy, which provides creditable coverage as defined in s. 627.6562(3), filed with the office shall provide for an appropriate rebate of premiums paid in the last policy year, contract year, or calendar year when the majority of members of a health plan are enrolled in and have maintained participation in any health wellness, maintenance, or improvement program offered by the group contract holder.

The group must provide evidence of demonstrative maintenance or improvement of his or her health status as determined by assessments of agreed-upon health status indicators between the group and the health insurer, including, but not limited to, reduction in weight, body mass index, and smoking cessation.

Any rebate provided by the health maintenance organization is presumed to be appropriate unless credible data demonstrates otherwise, or unless the rebate program requires the insured to incur costs to qualify for the rebate which equals or exceeds the value of the rebate but the rebate may not exceed 10 percent of paid premiums.

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

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

(43) Whenever, in any health maintenance organization claim form, a subscriber specifically authorizes payment of benefits directly to any contracted hospital, ambulance provider, physician, or dentist, the health maintenance organization shall make such payment to the designated provider of such services if any benefits are due to the subscriber under the terms of the agreement between the subscriber and the health maintenance organization.

The health maintenance organization contract may not prohibit, and claims forms must provide an option for, the payment of benefits directly to a licensed hospital, ambulance provider, physician, or dentist for covered services provided, for services provided pursuant to s. 395.1041, and for ambulance transport and treatment provided pursuant to

part III of

chapter 401. The attestation of assignment of benefits may be in written or electronic form. Payment to the provider from the health maintenance organization may not be more than the amount that the insurer would otherwise have paid without the assignment. This subsection does not affect the applicability of ss. 641.3154 and 641.513 with respect to services provided and payment for such services provided pursuant to the subsection.

(44)(

a) A health maintenance organization issuing or delivering in this state a health maintenance contract that provides prescription drug coverage shall offer medication synchronization to allow a subscriber to align at least once in a plan year the refill dates for prescription drugs covered by the health maintenance contract. The health maintenance organization shall implement a process for dispensing prescription drugs to a subscriber for the purpose of aligning the refill dates of such drugs, and such medication synchronization may be available only through a network pharmacy.

A controlled substance, a prescription drug dispensed in an unbreakable package, or a multidose unit of a prescription drug may not be partially filled for the purpose of aligning refill dates. The health maintenance organization shall pay a full dispensing fee to the network pharmacy for each partial refill of a covered prescription drug dispensed to align refill dates, unless otherwise agreed to by the plan and the network pharmacy at the time a subscriber requests medication synchronization.

The health maintenance organization shall prorate the cost-sharing obligations of the subscriber for each partial refill of a covered prescription drug dispensed to align refill dates. This subsection applies to contracts renewed or entered into on or after January 1, 2018.

(45) A contract between a health maintenance organization issuing major medical individual or group coverage and a telehealth provider, as defined in s. 456.47, must be voluntary between the health maintenance organization and the provider and must establish mutually acceptable payment rates or payment methodologies for services provided through telehealth. Any contract provision that distinguishes between payment rates or payment methodologies for services provided through telehealth and the same services provided without the use of telehealth must be initialed by the telehealth provider.

(46)(

a) As used in this subsection, the term:

(47)(

a) As used in this subsection, the terms “operative date” and “preexisting medical condition” have the same meanings as provided in s. 627.6046.

History. — s. 15, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 794, 804, 809(1st), ch. 82-243; s. 11, ch. 83-198; s. 9, ch. 84-313; s. 21, ch. 85-177; ss. 2, 11, ch. 87-236; s. 2, ch. 87-273; s. 3, ch. 88-269; s. 52, ch. 88-380; s. 14, ch. 88-388; s. 4, ch. 89-190; s. 1, ch. 89-357; s. 9, ch. 90-232; s. 38, ch. 90-295; ss. 121, 187, 188, ch. 91-108; s. 61, ch. 91-110; s. 3, ch. 91-185; s. 69, ch. 91-282; s. 4, ch. 91-429; s. 2, ch. 93-245; s. 27, ch. 95-418; s. 3, ch. 96-195; s. 25, ch. 96-199; ss. 3, 5, ch. 96-279; s. 4, ch. 96-282; s. 12, ch. 97-48; s. 1752, ch. 97-102; s. 4, ch. 97-166; s. 2, ch. 97-171; s. 23, ch. 97-179; s. 5, ch. 98-66; s. 23, ch. 98-159; s. 4, ch. 98-312; s. 5, ch. 99-264; s. 3, ch. 99-275; s. 4, ch. 99-393; s. 13, ch. 2000-252; s. 23, ch. 2000-256; s. 142, ch. 2000-318; s. 4, ch. 2003-139; s. 1578, ch. 2003-261; s. 135, ch. 2004-5; s. 34, ch. 2004-297; s. 10, ch. 2005-231; s. 98, ch. 2006-1; s. 1, ch. 2007-215; s. 10, ch. 2008-32; s. 4, ch. 2008-119; s. 7, ch. 2008-212; s. 16, ch. 2013-26; s. 24, ch. 2013-101; s. 21, ch. 2013-162; s. 14, ch. 2016-11; s. 21, ch. 2016-194; s. 2, ch. 2017-94; s. 111, ch. 2018-24; s. 9, ch. 2019-129; s. 3, ch. 2019-137; s. 13, ch. 2019-138; s. 154, ch. 2020-2; s. 20, ch. 2021-143; s. 2, ch. 2022-47; s. 18, ch. 2023-29.

641.3101 Additional contract contents.

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

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

History. — ss. 23, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.31015 Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.

History. — s. 8, ch. 96-223.

641.3102 Restrictions upon expulsion or refusal to issue or renew contract.

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

(2) A health maintenance organization shall not expel or refuse to renew the coverage of, or refuse to enroll, any individual member of a subscriber group on the basis of the race, color, creed, marital status, sex, or national origin of the subscriber or individual. A health maintenance organization shall not expel or refuse to renew the coverage of any individual member of a subscriber group on the basis of the age, health status, health care needs, or prospective costs of health care services of the subscriber or individual. Nothing in this

section shall prohibit a health maintenance organization from requiring that, as a condition of continued eligibility for membership, dependents of a subscriber, upon reaching a specified age, convert to a converted contract or that individuals entitled to have payments for health costs made under Title XVIII of the United States Social Security Act, as amended, be issued a health maintenance contract for Medicare beneficiaries so long as the health maintenance organization is authorized to issue health maintenance contracts for Medicare beneficiaries.

History. — ss. 24, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 24, ch. 97-179.

641.3103 Charter, bylaw provisions.

History. — ss. 25, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.3104 Execution of contracts.

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

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

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

History. — ss. 26, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.3105 Validity of noncomplying contracts.

(1) Any health maintenance contract, rider, endorsement, attachment, or addendum otherwise valid which contains any condition or provision not in compliance with the requirements of this part shall not be thereby rendered invalid, but shall be construed and applied in accordance with such conditions and provisions as would have applied had such contract, rider, endorsement, attachment, or addendum been in full compliance with this part.

In the event an organization issues or delivers any contract for an amount which exceeds any limitations otherwise provided in this part, such organization shall be liable to the subscriber or her or his beneficiary for the full amount stated in the contract in addition to any other penalties that may be imposed under this part.

(2) Any health maintenance contract delivered or issued for delivery in this state covering a subscriber, which subscriber, pursuant to the provisions of this part, the organization may not lawfully cover under the contract, shall be cancelable at any time by the organization, any provision of the contract to the contrary notwithstanding; and the organization shall promptly cancel the contract in accordance with the request of the office therefor.

No such illegality or cancellation shall be deemed to relieve the organization of any liability incurred by it under the contract while in force or to prohibit the organization from retaining the pro rata earned premium or rate thereon. This provision does not relieve the organization from any penalty otherwise incurred by the organization under this part on account of any such violation.

History. — ss. 27, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 489, ch. 97-102; s. 1579, ch. 2003-261.

641.3106 Construction of contracts.

History. — ss. 28, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.

641.3107 Delivery of contract;

definitions.

(1) A health maintenance contract, certificate of coverage, endorsements and riders, or member handbook shall be mailed, delivered, or otherwise provided to the subscriber or, in the case of a group health maintenance contract, to the employer or other person who will hold the contract on behalf of the subscriber group, as provided in s. 627.421.

(2) As used in s. 627.421, the term:

(3) If the health maintenance organization elects to post health maintenance contracts on its Internet website in lieu of mailing or delivery to subscribers or the person who will hold the contract on behalf of a subscriber group, the health maintenance organization must comply with the requirements of s. 627.421(4). This

section does not apply to the delivery of those contracts specified in s. 641.31(13).

History. — ss. 29, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 10, ch. 91-110; s. 4, ch. 91-429; s. 14, ch. 2018-131; s. 99, ch. 2019-3.

641.31071 Preexisting conditions.

(1) As used in this section, the term:

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

(3) Genetic information shall not be treated as a condition described in paragraph (2)(

a) in the absence of a diagnosis of the condition related to such information.

(4)(

a) Subject to paragraph (b), a health maintenance organization that offers group coverage may not impose any preexisting condition exclusion in the case of:

History. — s. 25, ch. 97-179; s. 55, ch. 99-3; s. 1580, ch. 2003-261; s. 22, ch. 2016-194.

641.31072 Special enrollment periods.

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

(2) For dependent beneficiaries, if:

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

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

History. — s. 26, ch. 97-179.

641.31073 Prohibiting discrimination against individual participants and beneficiaries based on health status.

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

(2) Subsection (1) does not:

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

(4)(

a) A health maintenance organization that offers health insurance coverage may not require any individual, as a condition of enrollment or continued enrollment under the contract, to pay a premium or contribution that is greater than such premium or contribution for a similarly situated individual enrolled under the contract on the basis of any health-status-related factor in relation to the individual or to an individual enrolled under the contract as a dependent of the individual.

History. — s. 27, ch. 97-179.

641.31074 Guaranteed renewability of coverage.

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

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

(3)(

a) A health maintenance organization may discontinue offering a particular contract form only if:

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

(5) In applying this

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

History. — s. 28, ch. 97-179; s. 24, ch. 98-159; s. 1581, ch. 2003-261; s. 8, ch. 2015-121; s. 23, ch. 2016-194.

641.31075 Advanced practice registered nurse services.

History. — s. 32, ch. 2020-9.

641.31076 Shared savings incentive program.

(1) This

section and ss. 627.6387 and 627.6648 may be cited as the “Patient Savings Act.”

(2) As used in this section, the term:

(3) A health maintenance organization may offer a shared savings incentive program to provide incentives to a subscriber when the subscriber obtains a shoppable health care service from the health maintenance organization’s shared savings list. A subscriber may not be required to participate in a shared savings incentive program. A health maintenance organization that offers a shared savings incentive program must:

(4) A shared savings incentive offered by a health maintenance organization in accordance with this section:

(5) The commission may adopt rules necessary to implement and enforce this section.

History. — s. 7, ch. 2019-100; s. 54, ch. 2020-156; s. 49, ch. 2021-51; s. 9, ch. 2024-183.

641.31077 Coverage for organ transplants.

History. — s. 4, ch. 2020-139.

641.3108 Notice of cancellation of contract.

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

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

(3) In the case of a health maintenance contract issued to an employer or person holding the contract on behalf of the subscriber group, the health maintenance organization may make the notification through the employer or group contract holder, and, if the health maintenance organization elects to take this action through the employer or group contract holder, the organization shall be deemed to have complied with the provisions of this

section upon notifying the employer or group contract holder of the requirements of this

section and requesting the employer or group contract holder to forward to all subscribers the notice required herein.

History. — ss. 30, 47, ch. 85-177; ss. 122, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 14, ch. 99-204; s. 8, ch. 99-275; s. 13, ch. 99-393.

641.31085 Disclosures to subscribers; coverage of behavioral health care services.

(1) A health maintenance organization shall make all of the following information available on its website:

(2) On an annual basis, a health maintenance organization shall provide a direct notice to subscribers which must include a description of the federal and state requirements for coverage of behavioral health care services. Such notice must also include the website address and statewide toll-free telephone number of the Division of Consumer Services of the department for receiving and logging complaints.

History. — s. 3, ch. 2021-146.

641.31094 Nondiscrimination of coverage for certain surgical procedures involving bones or joints.

History. — s. 5, ch. 96-361.

641.31095 Coverage for mammograms.

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

(2) The coverage required by this

section is subject to the deductible and copayment provisions applicable to outpatient visits, and is also subject to all other terms and conditions applicable to other benefits. A health maintenance organization shall make available to the subscriber as part of the application, for an appropriate additional premium, the coverage required in this

section without such coverage being subject to any deductible or copayment provisions in the contract.

History. — s. 9, ch. 95-188.

641.31096 Requirements with respect to breast cancer and routine followup care.

History. — s. 11, ch. 97-48.

641.31097 Decreasing inappropriate utilization of emergency care.

(1) The Legislature finds and declares it to be of vital importance that emergency services and care be provided by hospitals and physicians to every person in need of such care, but with the double-digit increases in health insurance premiums, health care providers and insurers should encourage patients and the insured to assume responsibility for their treatment, including emergency care.

The Legislature finds that inappropriate utilization of emergency department services increases the overall cost of providing health care and these costs are ultimately borne by the hospital, by the insured patients, and, many times, by the taxpayers of this state. Finally, the Legislature declares that the providers and insurers must share the responsibility of providing alternative treatment options to urgent care patients outside of the emergency department.

Therefore, it is the intent of the Legislature to place the obligation for educating consumers and creating mechanisms for delivery of care that will decrease the overutilization of emergency service on health maintenance organizations and providers.

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

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

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

History. — s. 26, ch. 2004-297.

641.31098 Coverage for individuals with developmental disabilities.

(1) This

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

(2) As used in this section, the term:

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

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

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

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

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

(8) The maximum benefit under paragraph (4)(

b) shall be adjusted annually on January 1 of each calendar year to reflect any change from the previous year in the medical component of the then current Consumer Price Index for All Urban Consumers, published by the Bureau of Labor Statistics of the United States Department of Labor.

History. — s. 4, ch. 2008-30; s. 14, ch. 2012-27; s. 161, ch. 2014-17; s. 2, ch. 2016-222.

641.31099 Restrictions on use of state and federal funds for state exchanges.

(1) A health maintenance contract under which coverage is purchased in whole or in part with any state or federal funds through an exchange created pursuant to the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, may not provide coverage for an abortion as defined in s. 390.011(1), except if the pregnancy is the result of

an act of rape or incest, or in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, which would, as certified by a physician, place the woman in danger of death unless an abortion is performed. Coverage is deemed to be purchased with state or federal funds if any tax credit or cost-sharing credit is applied toward the health maintenance contract.

(2) This

section does not prohibit a health maintenance contract from offering separate coverage for an abortion if such coverage is not purchased in whole or in part with state or federal funds.

(3) As used in this section, the term “state” means this state or any political subdivision of the state.

History. — s. 3, ch. 2011-111.

641.3111 Extension of benefits.

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

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

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

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

History. — ss. 16, 24, ch. 88-388; ss. 124, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 25, ch. 98-159.

641.312 Scope.

History. — s. 13, ch. 2012-44; s. 108, ch. 2013-15; s. 24, ch. 2016-194; s. 112, ch. 2018-24.

641.313 Health maintenance contracts; cancer treatment parity; orally administered cancer treatment medications.

(1) As used in this section, the term:

(2) A health maintenance contract delivered, issued for delivery, renewed, amended, or continued in this state that provides medical, major medical, or similar comprehensive coverage and includes coverage for cancer treatment medications must also cover prescribed, orally administered cancer treatment medications and may not apply cost-sharing requirements for orally administered cancer treatment medications that are less favorable to the covered person than cost-sharing requirements for intravenous or injected cancer treatment medications covered under the contract.

(3) A health maintenance organization providing a contract described in subsection (2) and any participating entity through which the health maintenance organization offers health services may not:

(4) This

section does not apply to grandfathered health plans or to Medicare supplement, dental, vision, long-term care, disability, accident only, specified disease policies, or other supplemental limited-benefit plans.

History. — s. 9, ch. 2013-153.

641.314 Pharmacy benefit manager contracts.

(1) As used in this section, the term:

(2) In addition to the requirements of

part VII of

chapter 626, a contract between a health maintenance organization and a pharmacy benefit manager must require that the pharmacy benefit manager:

(3) This

section applies to contracts entered into or renewed on or after July 1, 2018.

History. — s. 6, ch. 2018-91; s. 19, ch. 2023-29.

641.315 Provider contracts.

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

(2)(

a) For all provider contracts executed after October 1, 1991, and within 180 days after October 1, 1991, for contracts in existence as of October 1, 1991:

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

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

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

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

(7) A health maintenance organization or health care provider may not terminate a contract with a health care provider or health maintenance organization unless the party terminating the contract provides the terminated party with a written reason for the contract termination, which may include termination for business reasons of the terminating party. The reason provided in the notice required in this

section or any other information relating to the reason for termination does not create any new administrative or civil action and may not be used as substantive evidence in any such action, but may be used for impeachment purposes. As used in this subsection, the term “health care provider” means a physician licensed under

chapter 458,

chapter 459,

chapter 460, or

chapter 461, or a dentist licensed under

chapter 466.

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

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

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

Any contract provision that violates this

section is void. A violation of this

section is not subject to the criminal penalty specified in s. 624.15.

(11) A contract between a health maintenance organization and a dentist licensed under

chapter 466 for the provision of services to a subscriber of the health maintenance organization may not contain a provision that requires the dentist to provide services to the subscriber of the health maintenance organization at a fee set by the health maintenance organization unless such services are covered services under the applicable contract.

As used in this subsection, the term “covered services” means dental care services for which a reimbursement is available under the subscriber’s contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.

(12)(

a) A health maintenance organization may not require an ophthalmologist licensed pursuant to

chapter 458 or

chapter 459 or an optometrist licensed pursuant to

chapter 463 to join a network solely for the purpose of credentialing the licensee for another organization’s vision network. This paragraph does not prevent such organization from entering into a contract with another organization’s vision care plan to use the vision network.

(13)(

a) A contract between a health maintenance organization and a dentist licensed under

chapter 466 for the provision of services to a subscriber of the health maintenance organization may not specify credit card payment as the only acceptable method for payments from the health maintenance organization to the dentist.

(14)(

a) A health maintenance organization may not deny any claim subsequently submitted by a dentist licensed under

chapter 466 for procedures specifically included in a prior authorization unless at least one of the following circumstances applies for each procedure denied:

History. — ss. 795, 809(1st), ch. 82-243; s. 12, ch. 83-198; s. 17, ch. 88-388; ss. 125, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 5, ch. 96-223; s. 2, ch. 97-159; s. 2, ch. 99-264; s. 4, ch. 99-275; s. 1, ch. 2000-252; s. 24, ch. 2000-256; s. 3, ch. 2001-107; s. 1582, ch. 2003-261; s. 2, ch. 2004-321; s. 3, ch. 2009-41; s. 3, ch. 2014-64; s. 3, ch. 2016-69; s. 4, ch. 2024-196.

641.3154 Organization liability; provider billing prohibited.

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

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

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

(4) A provider or any representative of a provider, regardless of whether the provider is under contract with the health maintenance organization, may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency a subscriber of an organization for payment of services for which the organization is liable, if the provider in good faith knows or should know that the organization is liable.

This prohibition applies during the pendency of any claim for payment made by the provider to the organization for payment of the services and any legal proceedings or dispute resolution process to determine whether the organization is liable for the services if the provider is informed that such proceedings are taking place. It is presumed that a provider does not know and should not know that an organization is liable unless:

(5) An organization, the office, and the department shall report any suspected violation of this

section by a health care practitioner to the Department of Health and by a facility to the agency, which shall take such action as authorized by law.

History. — s. 2, ch. 2000-252; s. 11, ch. 2002-389; s. 1583, ch. 2003-261; s. 14, ch. 2004-297; s. 113, ch. 2018-24.

641.3155 Prompt payment of claims.

(1) As used in this section, the term “claim” for a noninstitutional provider means a paper or electronic billing instrument submitted to the health maintenance organization’s designated location that consists of the HCFA 1500 data set, or its successor, that has all mandatory entries for a physician licensed under

chapter 458,

chapter 459,

chapter 460,

chapter 461, or

chapter 463, or psychologists licensed under

chapter 490 or any appropriate billing instrument that has all mandatory entries for any other noninstitutional provider. For institutional providers, “claim” means a paper or electronic billing instrument submitted to the health maintenance organization’s designated location that consists of the UB-92 data set or its successor with entries stated as mandatory by the National Uniform Billing Committee.

(2) All claims for payment or overpayment, whether electronic or nonelectronic:

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

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

(5) If a health maintenance organization determines that it has made an overpayment to a provider for services rendered to a subscriber, the health maintenance organization must make a claim for such overpayment to the provider’s designated location. A health maintenance organization that makes a claim for overpayment to a provider under this

section shall give the provider a written or electronic statement specifying the basis for the retroactive denial or payment adjustment. The health maintenance organization must identify the claim or claims, or overpayment claim portion thereof, for which a claim for overpayment is submitted.

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

(7) For all contracts entered into or renewed on or after October 1, 2002, a health maintenance organization’s internal dispute resolution process related to a denied claim not under active review by a mediator, arbitrator, or third-party dispute entity must be finalized within 60 days after the receipt of the provider’s request for review or appeal.

(8) A provider or any representative of a provider, regardless of whether the provider is under contract with the health maintenance organization, may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency a subscriber for payment of covered services for which the health maintenance organization contested or denied the provider’s claim.

This prohibition applies during the pendency of any claim for payment made by the provider to the health maintenance organization for payment of the services or internal dispute resolution process to determine whether the health maintenance organization is liable for the services. For a claim, this pendency applies from the date the claim or a portion of the claim is denied to the date of the completion of the health maintenance organization’s internal dispute resolution process, not to exceed 60 days.

This subsection does not prohibit collection by the provider of copayments, coinsurance, or deductible amounts due the provider.

(9) The provisions of this

section may not be waived, voided, or nullified by contract.

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

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

(12) A permissible error ratio of 5 percent is established for health maintenance organizations’ claims payment violations of paragraphs (3)(a), (b), (c), and (

e) and (4)(a), (b), (c), and (e). If the error ratio of a particular insurer does not exceed the permissible error ratio of 5 percent for an audit period, no fine shall be assessed for the noted claims violations for the audit period. The error ratio shall be determined by dividing the number of claims with violations found on a statistically valid sample of claims for the audit period by the total number of claims in the sample. If the error ratio exceeds the permissible error ratio of 5 percent, a fine may be assessed according to s. 624.4211 for those claims payment violations which exceed the error ratio.

Notwithstanding the provisions of this section, the office may fine a health maintenance organization for claims payment violations of paragraphs (3)(

e) and (4)(

e) which create an uncontestable obligation to pay the claim. The office shall not fine organizations for violations which the office determines were due to circumstances beyond the organization’s control.

(13) This

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

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

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

(16) Notwithstanding the 30-month period provided in subsection (5), all claims for overpayment submitted to a provider licensed under

chapter 458,

chapter 459,

chapter 460,

chapter 461,

chapter 466, or

chapter 490 must be submitted to the provider within 12 months after the health maintenance organization’s payment of the claim. A claim for overpayment may not be permitted beyond 12 months after the health maintenance organization’s payment of a claim, except that claims for overpayment may be sought beyond that time from providers convicted of fraud pursuant to s. 817.234.

(17) Notwithstanding any other provision of this section, all claims for underpayment from a provider licensed under

chapter 458,

chapter 459,

chapter 460,

chapter 461, or

chapter 466 must be submitted to the health maintenance organization within 12 months after the health maintenance organization’s payment of the claim. A claim for underpayment may not be permitted beyond 12 months after the health maintenance organization’s payment of a claim.

History. — s. 1, ch. 98-79; s. 5, ch. 99-393; s. 3, ch. 2000-252; s. 25, ch. 2000-256; s. 12, ch. 2002-389; s. 1584, ch. 2003-261; s. 8, ch. 2008-212; s. 155, ch. 2020-2; s. 2, ch. 2025-45.

641.3156 Treatment authorization; payment of claims.

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

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

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

History. — s. 4, ch. 2000-252.

641.316 Fiscal intermediary services.

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

(2)(

a) The term “fiduciary” or “fiscal intermediary services” means reimbursements received or collected on behalf of health care professionals for services rendered, patient and provider accounting, financial reporting and auditing, receipts and collec