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A health maintenance organization subscriber should be eligible for coverage without discrimination against individual participants and beneficiaries of group plans based on health status pursuant to s. A health maintenance organization that issues a group health contract must: provide coverage for preexisting conditions pursuant to s. 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.641.31071; guarantee renewability of coverage pursuant to s. All claims to a health maintenance organization begun after October 1, 2000, not under active review by a mediator, arbitrator, or third-party dispute entity, shall result in a final decision on the claim by the health maintenance organization by January 2, 2003, for the purpose of the statewide provider and health plan claim dispute resolution program pursuant to s. 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.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.s. 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. 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 the health maintenance organization and that consist of: Cash or cash equivalents in the possession of the health maintenance organization, or in transit under its control, including the true balance of any deposit in a solvent bank, savings and loan association, or trust company which is domiciled in the United States. The provisions of this part do not apply to those organizations providing the services defined in ss. For the purposes of this subsection, the term “complaint” means any written communication primarily expressing a grievance and requesting a remedy to the grievance. Further, if the act or practice constitutes a violation of s. Any person, entity, or health maintenance organization subject to an order of the department or office under s. 641.3913 may obtain a review of the order by filing an appeal therefrom in accordance with the provisions and procedures for appeal under s. Any person, entity, or health maintenance organization which violates a cease and desist order of the department or office under s. Such persons shall fully disclose to the office and the directors of the health maintenance organization the extent and nature of any contracts or arrangements between them and the health maintenance organization, including any possible conflicts of interest; A complete biographical statement on forms prescribed by the commission, and an independent investigation report and fingerprints obtained pursuant to chapter 624, of all of the individuals referred to in paragraph (c); Forms of all health maintenance contracts, certificates, and member handbooks the applicant proposes to offer the subscribers, showing the benefits to which they are entitled, together with a table of the rates charged, or proposed to be charged, for each form of such contract. 395.1041, and for ambulance transport and treatment provided pursuant to part III of chapter 401. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim.Through these organizations, structured in various forms, health care services are provided directly to a group of people who make regular premium payments. An audited financial statement prepared on the basis of statutory accounting principles and certified by an independent certified public accountant, except that surplus notes acceptable to the office and meeting the requirements of this act shall be included in the calculation of surplus; and Such additional reasonable data, financial statements, and other pertinent information as the commission or office requires with respect to the determination that the applicant can provide the services to be offered. This subsection does not affect the applicability of ss. The notice that the claim for overpayment is denied or contested must identify the contested portion of the claim and the specific reason for contesting or denying the claim and, if contested, must include a request for additional information.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. 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. 641.3154 and 641.513 with respect to services provided and payment for such services provided pursuant to the subsection. If the organization submits additional information, the organization must, within 35 days after receipt of the request, mail or electronically transfer the information to the provider.
If offering services through a managed care system, has a system in which a primary physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461 is designated for each subscriber upon request of a subscriber requesting service by a physician licensed under any of those chapters, and is responsible for coordinating the health care of the subscriber of the respectively requested service and for referring the subscriber to other providers of the same discipline when necessary. 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. 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 maintenance organization, except with the written permission of the office, may not authorize or permit the health maintenance organization to solicit or accept new or renewal health maintenance contracts or provider contracts in this state after the director or officer knew, or reasonably should have known, that the health maintenance organization was insolvent or impaired.
641.31(12) and 641.513, and second opinions pursuant to s. A health maintenance organization subscriber should receive assurance that the health maintenance organization has been independently accredited by a national review organization pursuant to s. Notwithstanding paragraph (a), an alternate process used by a health maintenance organization which includes early refill dates, refill overrides, and access on the health maintenance organization’s public website to the terms and conditions of such a process is deemed to comply with the requirements of this subsection.s. A claim for overpayment shall not be permitted beyond 30 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. Payment of a claim is considered made on the date the payment was mailed or electronically transferred.
641.512, and is financially secure as determined by the state pursuant to ss. A health maintenance organization subscriber should receive timely, concise information regarding the health maintenance organization’s reimbursement to providers and services pursuant to ss. An overdue payment of a claim bears simple interest of 12 percent per year.
641.35, Florida Statutes (2000), through December 31, 2005. 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. 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 may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health maintenance organization’s overpayment claim as required by this paragraph.
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. 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. 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. Payment of an overpayment claim is considered made on the date the payment was mailed or electronically transferred.
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A health maintenance organization electing to report assets pursuant to this subsection shall maintain complete and detailed records reflecting such accounting treatment; or 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: A health maintenance organization shall ensure that the health care services provided to its subscribers shall be rendered under reasonable standards of quality of care which are at a minimum consistent with the prevailing standards of medical practice in the community pursuant to ss. A health maintenance organization subscriber should receive quality health care from a broad panel of providers, including referrals, preventive care pursuant to s. 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. An overdue payment of a claim bears simple interest at the rate of 12 percent per year.