Florida Statutes 1983, Volume 3 - Florida State University College of ...

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Ch.641 HEALTH CARE SERVICE PROGRAMS F.S.1983 On or before January 1 of each succeeding year, unless inapplicable, the organization shall deposit with the department cash, securities, or any combination of these or other measures acceptable to the department in an amount equal to 4 percent of the preceding 12 months' uncovered expenditures or 4 percent of its estimated annual uncovered expenditures for the succeeding year, whichever is greater. (b) Unless inapplicable, an organization that is in operation on the effective date of this section shall make a deposit equal to 1 percent of the preceding 12 months' uncovered expenditures or $100,000, whichever is greater, on the first day of the first calendar year beginning 6 months or more after the effective date of this section. In the second calendar year, if applicable, the amount of the additional deposit shall be equal to 2 percent of its estimated annual uncovered expenditures. In the third calendar year, if applicable, the additional deposit shall be equal to 3 percent of its estimated annual uncovered expenditures for that year, and in the fourth and subsequent years, if applicable, the additional deposit shall be equal to 4 percent of its estimated annual uncovered expenditures for each year. Each year's estimate, after the first year of operation, shall reasonably reflect the prior year's operating experience and delivery arrangements. (2) The department may waive any of the deposit requirements set forth in subsection (1) whenever the department is satisfied that: (a) The organization has sufficient surplus and an adequate history of generating net income to assure its financial viability for the next year; (b) The performance and obligations of the organization are guaranteed by an organization which has sufficient surplus and an adequate history of generating net income; or (c) The assets of the organization or its contracts with insurers (hospital or medical service corporations), governments, or other organizations are reasonably sufficient to assure the performance of the obligations of the organization. (3) When an organization has achieved a surplus, not including land, buildings, and equipment, of at least $1 million or has achieved a surplus, including organization-related land, buildings, and equipment, of at least $5 million, the annual deposit requirement does not apply. The annual deposit requirement does not apply to an organization if the total amount of the accumulated deposit is equal to 25 percent of its estimated annual uncovered expenditures for the next calendar year, or $1,500,000, whichever is less. If the organization has a guaranteeing organization which has been in operation for 5 years or more and has a surplus, not including land, buildings, and equipment, of at least $1 million, or which has been in operation for 10 years or more and has a surplus, including organization-related land, buildings, and equipment, of at least $5 million, the annual deposit requirement does not apply; however, if the guaranteeing organization is sponsoring more than one organization, the surplus requirement shall be increased by a multiple equal to the number of such organizations. This requirement to maintain a deposit in excess of $1 million does not apply during any time that the guaranteeing organization maintains for each or- 770 ganization it sponsors a surplus at least equal to $1,500,000. (4) All income from deposits shall belong to the depositing 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, securities, or any combination of these or other measures of equal amount and value. Any securities shall be approved by the department. (5) In any year in which an annual deposit is not required of an organization, at the request of the organization the department shall reduce the required, previously accumulated deposit to $100,000 for each $250,000 of surplus in excess of the amount that allows the organization not to make the annual deposit. If the amount of surplus no longer supports a reduction of its required deposit, the organization shall immediately redeposit $100,000 for each $250,000 of reduction in surplus, provided that its total deposit does not exceed the maximum required under this section. (6) The requirements of this section do not apply to an applying or licensed health maintenance organization which has on file with the department contracts of insurance or reinsurance to protect subscribers in the event the organization is unable to meet its obligations. Each such agreement between the organization and an insurer shall be subject to the laws of this state regarding reinsurance. Each such agreement and any modifications thereto must be filed with and approved by the department. Each such agreement shall remain in full force and effect until replaced or for at least 90 days following written notification to the department by registered mail of cancellation by either party. History.-S8. 791, 809(18t), ch. 82-243; 8. 10, ch. 83-198. 'Note.-Expires October 1, 1991, pursuant to s. 809(18t), ch. 82-243, and is scbeduled for review pursuant to s. 11.61 in advance of that date. 1641.29 Fees.-Every health maintenance organization shall pay to the department the following fees: (1) For filing a copy of its application for a certificate of authority or amendment thereto, a nonrefundable fee in the amount of $150. (2) For filing each annual report, $150. Fees charged under this section shall be distributed as follows: one-third to the Department of Health and Rehabilitative Services and two-thirds to the Department of Insurance. History.-8. 13, ch. 72-264; 8. 3, cb. 76-168; s. 1, ch. 77-457; S8. 2, 3, cb. 81-318; ... 792, 804, 809(18t), cb. 82-243. 'Note.-Expires October 1, 1991, pursuant to s. 809(18t), cb. 82-243, and is scheduled for review pursuant to s. 11.61 in advance of that date. 1641.30 Construction and relationship to other laws.- (1) Every health maintenance organization and its agents and employees shall be subject to the provisions of part VIII of chapter 626. (2) Except as provided in this part, the Florida Insurance Code does not apply to health maintenance organizations, and health maintenance organi-
F.S.1983 HEALTH CARE SERVICE PROGRAMS Ch.641 zations certificated under this part are not subject to part I of this chapter. (3) 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. History.-s. 14, ch. 72-264; s. 3, ch. 76-168; s. I, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 793, 804, 809(1st), ch. 82-243. 'Note.-Expires October I, 1991, pursuant to s. 809(lst), ch. 82-243, and is scheduled for review pursuant to s. 11.61 in advance of tbat date. 1641.31 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. (2) The rates charged by any health maintenance organization to its subscribers shall not be excessive, inadequate, or unfairly discriminatory. The department 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) If a health maintenance organization desires to amend any contract with its subscribers or desires to change any rate charged therefor, it may do so, upon filing with the department any proposed amendments or change in rates. Any proposed change shall be effective immediately, subject to disapproval by the department. However, it is not the intent of this subsection to restrict unduly the right to modify rates in the exercise of reasonable business judgment. (4) Every health maintenance contract must 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 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 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. (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) For an appropriate additional premium, the health maintenance organization shall make available, according to the standards and procedures of such organization, physician care provided by physicians licensed under chapter 459, chapter 460, or chapter 461. (8) A health maintenance organization is entitled to coordinate benefits on the same basis as an insurer under s. 627.4235. (9) A health maintenance organization providing medical benefits or payments to a subscriber who suffers injury, disease, or illness by virtue of the neg- 771 ligent act or omission of a third party is entitled to reimbursement from the subscriber, on a fee-for-service basis, for the reasonable value of the benefits or payments provided. However, the health maintenance organization is not entitled to reimbursement for medical expenses rendered in excess of the subscriber's monetary recovery from the third party. History.-s. 15, ch. 72-264; s. 3, ch. 76-168; s. I, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 794, 804, 809(lst), ch. 82-243; s. 11, ch. 83-198. 'Note.-Expires October I, 1991, pursuant to s. 809(1st), ch. 82-243, and is scheduled for review pursuant to s. 11.61 in advance of that date. 1641.315 Provider contracts.-Whenever a contract exists between a health maintenance organization and a provider and the organization fails to meet its obligations to pay fees for services already rendered to a subscriber, the health maintenance organization shall be liable for such fee or fees rather than the subscriber; and the contract shall so state. History.-ss. 795, 809(lst), ch. 82-243; s. 12, ch. 83-198. 'Note.-Expires October I, 1991, pursuant to s. 809(lst), ch. 82-243, and is scheduled for review pursuant to s. 11.61 in advance of that date. 1641.32 Acceptable payments.-Each health maintenance organization may accept from governmental agencies, corporations, associations, groups, or individuals payments covering all or part of the cost of contracts entered into between the health maintenance organization and its subscribers. History.-s. 16, ch. 72-264; s. 3, ch. 76-168; s. I, ch. 77-457; ss. 2, 3, cb. 81-318; ss. 796, 804, 809(1st), ch. 82-243. 'Note.-Expires October I , 1991, pursuant to s. 809(lst), cb. 82-243, and is scheduled for review pursuant to s. 11.61 in advance of that date. 1641.33 Certain words prohibited in name of organization.- (1) No entity certificated as a health maintenance organization, other than a licensed insurer insofar as its name is concerned, shall use in its name, contracts, or literature any of the words "insurance," "casualty," "surety," "mutual," or any other words descriptive of the insurance, casualty, or surety business or deceptively similar to the name or description of any insurance or surety corporation doing business in the state. (2) No person, entity, or health care plan not certificated under the provisions of this part shall use in its name, logo, contracts, or literature the phrase "health maintenance organization" or the initials "HMO"; imply, directly or indirectly, that it is a health maintenance organization; or hold itself out to be a health maintenance organization. History.-s. 17, cb. 72-264; s. 3, ch. 76-168; s. I, ch. 77-457; ss. 2, 3, cb. 81-318; ss. 797, 804, 809(lst), ch. 82-243. 'Note.-Expires October I, 1991, pursuant to s. 809(lst), ch. 82-243, and is scheduled for review pursuant to s. 11.61 in advance of that date. 1641.35 Investment of funds.-The funds of any health maintenance organization shall be invested only in securities permitted by the laws of this state for the investment of assets of life insurance companies. History.-s. 19, ch. 72-264; s. 3, ch. 76-168; s. I, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 799, 804, 809(lst), ch. 82-243. 'Note.- Expires October I, 1991, pursuant to s. 809(lst), ch. 82-243, and is scheduled for review pursuant to s. 11.61 in advance of that date. 1641.36 Promulgation of rules.-The depart-
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Page 6 and 7: Ch.638 AMBULANCE SERVICE CONTRACTS
Page 8: Ch.639 PRENEED FUNERAL MERCHANDISE
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