Florida Statutes Part I - Health Maintenance Organizations (Ss. 641.17-641.3923)

• 641.17 - Short Title.
  This part shall be known and may be cited as the “Health Maintenance Organization Act.”History.—s. 1, ch. 72-264; s. 3, ch. 76-168; s. 1, ch....
• 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...
• 641.183 - Statutory Accounting Procedures; Transition Provisions.
  All health maintenance organizations, authorized to do business under this chapter on January 1, 2001, shall elect a transition method for compliance with statutory accounting...
• 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 shall serve as standards to be followed...
• 641.19 - Definitions.
  As used in this part, the term:(1) “Affiliate” means any entity that exercises control over or is controlled by the health maintenance organization, directly or indirectly,...
• 641.201 - Applicability Of Other Laws.
  Except as provided in this part, health maintenance organizations shall be governed by the provisions of this part and part III of this chapter and...
• 641.2011 - Insurance Holding Companies.
  Part IV of chapter 628 applies to health maintenance organizations licensed under this part.History.—s. 76, ch. 2000-318.
• 641.2015 - Incorporation Required.
  On or after October 1, 1985, any entity that has not yet obtained a certificate of authority to operate a health maintenance organization in this...
• 641.2017 - Insurance Business Not Authorized.
  Nothing in the Florida Insurance Code or this part shall be deemed to authorize any health maintenance organization to transact any insurance business other than...
• 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...
• 641.20185 - High-deductible Contracts For Medical Savings Accounts.
  Notwithstanding the provisions of this part and part III related to the requirement for providing comprehensive coverage, a health maintenance organization may offer a high-deductible...
• 641.2019 - Provider Service Network Certificate Of Authority.
  A prepaid provider service network that applies for and obtains a health care provider certificate pursuant to part III of this chapter, meets the surplus...
• 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...
• 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...
• 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...
• 641.22 - Issuance Of Certificate Of Authority.
  The office shall issue a certificate of authority to any entity filing a completed application in conformity with s. 641.21, upon payment of the prescribed...
• 641.221 - Continued Eligibility For Certificate Of Authority.
  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...
• 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...
• 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...
• 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...
• 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...
• 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...
• 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...
• 641.2342 - Contract Providers.
  Each health maintenance organization shall file, upon the request of the office, financial statements for all contract providers of comprehensive health care services who have...
• 641.25 - Administrative Penalty In Lieu Of Suspension Or Revocation.
  If the office finds that one or more grounds exist for the revocation or suspension of a certificate issued under this part, the office may,...
• 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...
• 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...
• 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...
• 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...
• 641.28 - Civil Remedy.
  In any civil action brought to enforce the terms and conditions of a health maintenance organization contract, the prevailing party is entitled to recover reasonable...
• 641.281 - Injunction.
  In addition to the penalties and other enforcement provisions of this part, the office and department, within the scope of their regulatory jurisdictions, are vested...
• 641.282 - Payment Of Judgment By Health Maintenance Organization.
  Except as otherwise ordered by the court or mutually agreed upon by the parties, every judgment or decree entered in any of the courts of...
• 641.284 - Liquidation, Rehabilitation, Reorganization, And Conservation; Exclusive Methods Of Remedy.
  A delinquency proceeding under part I of chapter 631, or supervision by the office under ss. 624.80-624.87, constitute the sole and exclusive means of liquidating,...
• 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...
• 641.286 - Levy Upon Deposit Limited.
  No judgment creditor or other claimant of a health maintenance organization shall have the right to levy upon any of the assets or securities held...
• 641.29 - Fees.
  Every health maintenance organization shall pay to the office the following fees:(1) For filing a copy of its application for a certificate of authority or amendment...
• 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...
• 641.3005 - Application Of Ch. 85-177.
  This act shall take effect October 1, 1985, and shall apply to all health maintenance organizations that have obtained certificates of authority before, on, or...
• 641.3007 - Hiv Infection And Aids For Contract Purposes.
  (1) PURPOSE.—The purpose of this section is to prohibit unfair practices in a health maintenance organization contract with respect to exposure to the human immunodeficiency virus...
• 641.305 - Language Used In Contracts And Advertisements; Translations.
  (1)(a) All health maintenance contracts or forms shall be printed in English.(b) If the negotiations by a health maintenance organization with a member leading up to the...
• 641.309 - Standards For Marketing To Persons Eligible For Medicare.
  (1) Every health maintenance organization marketing coverage to Medicare participants or persons eligible for Medicare in this state, directly or through its agents, shall:(a) Establish marketing procedures...
• 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...
• 641.3101 - Additional Contract Contents.
  A health maintenance contract may contain additional provisions not inconsistent with this part which are:(1) Necessary, on account of the manner in which the organization is...
• 641.31015 - Health Maintenance Organization Or Exclusive Provider Organization; Disclosure Of Terms And Conditions Of Plan.
  Each health maintenance organization or exclusive provider organization shall provide prospective enrollees with written information about the terms and conditions of the plan in accordance...
• 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...
• 641.3103 - Charter, Bylaw Provisions.
  No health maintenance contract shall contain any provision purporting to make any portion of the articles of incorporation, charter, bylaws, or other organizational document of...
• 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,...
• 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...
• 641.3106 - Construction Of Contracts.
  Every health maintenance contract shall be construed according to the entirety of its terms and conditions as set forth in the contract and as amplified,...
• 641.3107 - Delivery Of Contract.
  Unless delivered upon execution or issuance, a health maintenance contract, certificate of coverage, or member handbook shall be mailed or delivered to the subscriber or,...
• 641.31071 - Preexisting Conditions.
  (1) As used in this section, the term:(a) “Enrollment date” means, with respect to an individual covered under a group health maintenance organization contract, the date of...
• 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...
• 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...
• 641.31074 - Guaranteed Renewability Of Coverage.
  (1) Except as otherwise provided in this section, a health maintenance organization that issues a group health insurance contract must renew or continue in force such...
• 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...
• 641.31094 - Nondiscrimination Of Coverage For Certain Surgical Procedures Involving Bones Or Joints.
  No health maintenance contract or policy which provides coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton shall discriminate against...
• 641.31095 - Coverage For Mammograms.
  (1) Every health maintenance contract issued or renewed on or after January 1, 1996, shall provide coverage for at least the following:(a) A baseline mammogram for any...
• 641.31096 - Requirements With Respect To Breast Cancer And Routine Followup Care.
  Routine followup care to determine whether a breast cancer has recurred in a person who has been previously determined to be free of breast cancer...
• 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...
• 641.31098 - Coverage For Individuals With Developmental Disabilities.
  (1) This section and s. 627.6686 may be cited as the “Steven A. Geller Autism Coverage Act.”(2) As used in this section, the term:(a) “Applied behavior analysis” means...
• 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...
• 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...
• 641.312 - Scope.
  The Office of Insurance Regulation may adopt rules to administer the provisions of the National Association of Insurance Commissioners’ Uniform Health Carrier External Review Model...
• 641.313 - Health Maintenance Contracts; Cancer Treatment Parity; Orally Administered Cancer Treatment Medications.
  (1) As used in this section, the term:(a) “Cancer treatment medication” means medication prescribed by a treating physician who determines that the medication is medically necessary to...
• 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...
• 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...
• 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...
• 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...
• 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...
• 641.32 - Acceptable Payments.
  Each health maintenance organization may accept from governmental agencies, corporations, associations, groups, or individuals payments covering all or part of the cost of contracts entered...
• 641.33 - Certain Words Prohibited In Name Of Organization.
  (1) No entity certificated as a health maintenance organization, other than a licensed insurer insofar as its name is concerned, shall use in its name, contracts,...
• 641.35 - Assets, Liabilities, And Investments.
  (1) ASSETS.—In any determination of the financial condition of a health maintenance organization, there shall be allowed as “assets” only those assets that are owned by...
• 641.36 - Adoption Of Rules; Penalty For Violation.
  The commission shall adopt rules necessary to carry out the provisions of this part. The office shall collect and make available all health maintenance organization...
• 641.365 - Dividends.
  (1)(a) A health maintenance organization shall not pay any dividend or distribute cash or other property to stockholders except out of that part of its available...
• 641.37 - Prohibited Activities; Penalties.
  (1) Any person or entity which knowingly renews, issues, or delivers any health maintenance contract without first obtaining and thereafter maintaining a certificate of authority is...
• 641.38 - Operational Health Maintenance Organizations; Issuance Of Certificate.
  The provisions of this part do not apply to those organizations providing the services defined in ss. 641.17-641.38 which have been continuously engaged in providing...
• 641.385 - Order To Discontinue Certain Advertising.
  If in the opinion of the office any advertisement by a health maintenance organization violates any of the provisions of this part, the department may...
• 641.386 - Agent Licensing And Appointment Required; Exceptions.
  (1) With respect to a health maintenance contract, no person shall, unless licensed and appointed as a health insurance agent in accordance with the applicable provisions...
• 641.39001 - Soliciting Or Accepting New Or Renewal Health Maintenance Contracts By Insolvent Or Impaired Health Maintenance Organization Prohibited; Penalty.
  (1) Whether or not delinquency proceedings as to a health maintenance organization have been or are to be initiated, a director or officer of a health...
• 641.3901 - Unfair Methods Of Competition And Unfair Or Deceptive Acts Or Practices Prohibited.
  No person, entity, or health maintenance organization shall engage in this state in any trade practice which is defined in this part as, or determined...
• 641.3903 - Unfair Methods Of Competition And Unfair Or Deceptive Acts Or Practices Defined.
  The following are defined as unfair methods of competition and unfair or deceptive acts or practices:(1) MISREPRESENTATION AND FALSE ADVERTISING OF HEALTH MAINTENANCE CONTRACTS.—Knowingly making, issuing,...
• 641.3905 - General Powers And Duties Of The Department And Office.
  In addition to the powers and duties set forth in s. 624.307, the department and office shall each have the power within its respective regulatory...
• 641.3907 - Defined Unfair Practices; Hearings, Witnesses, Appearances, Production Of Books, And Service Of Process.
  (1) Whenever the department or office has reason to believe that any person, entity, or health maintenance organization has engaged, or is engaging, in this state...
• 641.3909 - Cease And Desist And Penalty Orders.
  After the hearing provided in s. 641.3907, the department or office shall enter a final order in accordance with s. 120.569. If it is determined...
• 641.3911 - Appeals From The Department Or Office.
  Any person, entity, or health maintenance organization subject to an order of the department or office under s. 641.3909 or s. 641.3913 may obtain a...
• 641.3913 - Penalty For Violation Of Cease And Desist Orders.
  Any person, entity, or health maintenance organization which violates a cease and desist order of the department or office under s. 641.3909 while such order...
• 641.3915 - Health Maintenance Organization Anti-fraud Plans And Investigative Units.
  Each authorized health maintenance organization and applicant for a certificate of authority shall comply with the provisions of ss. 626.989 and 626.9891 as though such...
• 641.3917 - Civil Liability.
  The provisions of this part are cumulative to rights under the general civil and common law, and no action of the department or office shall...
• 641.3921 - Conversion On Termination Of Eligibility.
  A group health maintenance contract delivered or issued for delivery in this state by a health maintenance organization shall provide that a subscriber or covered...
• 641.3922 - Conversion Contracts; Conditions.
  Issuance of a converted contract shall be subject to the following conditions:(1) TIME LIMIT.—Written application for the converted contract shall be made and the first premium...
• 641.3923 - Discrimination Against Providers Prohibited.
  A health maintenance organization shall not discriminate with respect to participation as to any advanced registered nurse practitioner licensed and certified pursuant to s. 464.012,...

Last modified: September 23, 2016