reglab/statecodes huggingface dataset:
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.30 - Construction and relationship to other laws.

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 Investigative and Forensic Services 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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3005 - Application of ch. 85-177.

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 after this date, unless otherwise provided in this act. Any provision of this act necessitating a change in a health maintenance contract shall apply to contracts issued or renewed after October 1, 1985.
History.—s. 48, ch. 85-177; s. 1, ch. 86-286; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.305 - Language used in contracts and advertisements; translations.

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 effectuation of a health maintenance contract are conducted in a language other than English, the health maintenance organization shall supply to the member a written translation of the contract, which translation accurately reflects the substance of the contract and is in the language used to negotiate the contract. The written translation shall be affixed to and shall become a part of the contract or form. Any such translation shall be furnished to the office as part of the filing of the health maintenance contract form. No translation of a health maintenance contract form shall be approved by the department unless the translation accurately reflects the substance of the health maintenance contract form in translation.
(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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.309 - Standards for marketing to persons eligible for Medicare.

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 to assure that any comparison of benefits between Medicare or any other health maintenance organization offering such coverage by its agents will be fair and accurate.
(b) Establish marketing procedures to assure proper notification to the Medicare participant of enrollment or disenrollment from the health maintenance organization. Such notification shall be made in a timely manner.
(c) Display prominently by type, stamp, or other appropriate means, on the first page of the application and contract, the following:
“Notice to buyer: When you enroll in this health maintenance organization, you will be disenrolled from Medicare. The buyer should be aware that in order to receive payment or coverage for services such services must be rendered by physicians, hospitals, and other health care providers designated by the health maintenance organization. If the services are rendered by a nonparticipating physician, hospital, or other health care provider, the purchaser may be liable for payment for such services except in very limited circumstances.”
(d) Inquire and otherwise make every reasonable effort to identify whether a prospective Medicare participant has previously been enrolled in either the same health maintenance organization as a Medicare participant or in another health maintenance organization as a Medicare participant.
(2) In addition to the practices prohibited in s. 641.3903:
(a) No health maintenance organization or person representing such health maintenance organization shall employ any method of marketing having the effect of or tending to induce the purchase of health care plans through fraud, deceit, force, fright, threat whether explicit or implied, intimidation, harassment, or undue pressure to purchase or recommend the purchase of a health maintenance organization contract.
(b) No participating provider, employee, or agent of such participating provider shall be an agent for or conduct any sales activities for a health maintenance organization with whom they have a provider contract.
History.—ss. 120, 188, ch. 91-108; s. 4, ch. 91-429.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3101 - Additional contract contents.

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 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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31015 - Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.

1
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 with s. 641.31(4) so that the prospective enrollees can make informed decisions about accepting a managed-care system of health care delivery; however, information about where, in what manner, and from whom the comprehensive health care services or specific health care services can be obtained need be disclosed only upon request by the prospective enrollee. All marketing materials distributed by the health maintenance organization or exclusive provider organization must contain a notice in boldfaced type which states that the information required under this section is available to the prospective enrollee upon request.
History.—s. 8, ch. 96-223.
1
Note.—Also published at s. 627.64725.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3102 - Restrictions upon expulsion or refusal to issue or renew contract.

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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3103 - Charter, bylaw provisions.

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 the health maintenance organization a part of the contract unless the provision is set forth in full in the contract. Any contract provision in violation of this section is invalid, unless the provision operates to the benefit of the subscriber.
History.—ss. 25, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3104 - Execution of contracts.

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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3105 - Validity of noncomplying contracts.

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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3106 - Construction of contracts.

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, extended, or modified by any application therefor or any rider, endorsement, attachment, or addendum thereto.
History.—ss. 28, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3107 - Delivery of contract; definitions.

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:
(a) “Insurance policies and endorsements,” “policy and endorsements,” “policy,” and “policy form and endorsement form” includes the health maintenance contract, endorsement and riders, certificate of coverage, or member handbook.
(b) “Insured” includes a subscriber or, in the case of a group health maintenance contract, the employer or other person who will hold the contract on behalf of the subscriber group.
(c) “Insurer” includes a health maintenance organization.
(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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31071 - Preexisting conditions.

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 enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period of such enrollment.
(b) “Late enrollee” means, with respect to coverage under a group health maintenance organization contract, a participant or beneficiary who enrolls under the contract other than during:
1. The first period in which the individual is eligible to enroll under the plan.
2. A special enrollment period, as provided under s. 641.31072.
(c) “Waiting period” means, with respect to a group health maintenance organization contract and an individual who is a potential participant or beneficiary under the contract, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the contract.
(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:
(a) Such exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;
(b) Such exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date; and
(c) The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, as defined in s. 627.6562(3), applicable to the participant or beneficiary as of the enrollment date.
(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:
1. An individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage.
2. A child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This provision shall not apply to coverage before the date of such adoption or placement for adoption.
3. Pregnancy.
(b) Subparagraphs (a)1. and 2. do not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.
History.—s. 25, ch. 97-179; s. 55, ch. 99-3; s. 1580, ch. 2003-261; s. 22, ch. 2016-194.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31073 - Prohibiting discrimination against individual participants and beneficiaries based on health status.

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:
(a) Health status.
(b) Medical condition, including physical and mental illnesses.
(c) Claims experience.
(d) Receipt of health care.
(e) Medical history.
(f) Genetic information.
(g) Evidence of insurability, including conditions arising out of acts of domestic violence.
(h) Disability.
(2) Subsection (1) does not:
(a) Require a health maintenance organization to provide particular benefits other than those provided under the terms of such plan or coverage.
(b) Prevent such a plan or coverage from establishing limitations or restrictions on the amount, level, extent, or nature of the benefits or coverage for similarly situated individuals enrolled in the plan or coverage.
(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.
(b) This subsection does not:
1. Restrict the amount that an employer may be charged for coverage under a group health insurance contract.
2. Prevent a health maintenance organization offering group health insurance coverage from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.
History.—s. 27, ch. 97-179.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31075 - Advanced practice registered nurse services.

641.31075 Advanced practice registered nurse services.—A health maintenance contract that is delivered, issued, or renewed in this state on or after January 1, 2021, may not require a subscriber to receive services from an advanced practice registered nurse registered under s. 464.0123 in place of a physician.
History.—s. 32, ch. 2020-9.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31077 - Coverage for organ transplants.

641.31077 Coverage for organ transplants.—A health maintenance contract issued or renewed on or after July 1, 2020, in this state by a health maintenance organization which provides coverage for organ transplants may not deny coverage for an organ transplant solely on the basis of a subscriber’s disability. This section may not be construed to require such health maintenance organization to provide coverage for an organ transplant that is not medically necessary. For purposes of this section, the term “organ transplant” has the same meaning as in s. 765.523.
History.—s. 4, ch. 2020-139.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3108 - Notice of cancellation of contract.

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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31085 - Disclosures to subscribers; coverage of behavioral health care services.

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:
(a) The federal and state requirements for coverage of behavioral health care services.
(b) Contact information for the Division of Consumer Services of the department, including a hyperlink, for consumers to submit inquiries or complaints relating to health maintenance organization products or services regulated by the department or the office.
(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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31094 - Nondiscrimination of coverage for certain surgical procedures involving bones or joints.

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 coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if, under accepted medical standards, such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. This section shall not be construed to affect any other coverage under this part or to restrict the scope of coverage under any policy, plan, or contract. Nothing in this section shall be construed to discourage appropriate nonsurgical procedures or to prohibit the continued coverage of nonsurgical procedures in the treatment of a bone or joint of the jaw and facial region. Furthermore, nothing in this subsection requires coverage for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes.
History.—s. 5, ch. 96-361.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31095 - Coverage for mammograms.

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 woman who is 35 years of age or older, but younger than 40 years of age.
(b) A mammogram every 2 years for any woman who is 40 years of age or older, but younger than 50 years of age, or more frequently based on the patient’s physician’s recommendations.
(c) A mammogram every year for any woman who is 50 years of age or older.
(d) One or more mammograms a year, based upon a physician’s recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30.
(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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31096 - Requirements with respect to breast cancer and routine followup care.

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 does not constitute medical advice, diagnosis, care, or treatment for purposes of determining preexisting conditions unless evidence of breast cancer is found during or as a result of the followup care.
History.—s. 11, ch. 97-48.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31097 - Decreasing inappropriate utilization of emergency care.

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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.31099 - Restrictions on use of state and federal funds for state exchanges.

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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3111 - Extension of benefits.

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:
(a) The expiration of 12 months.
(b) Such time as the member is no longer totally disabled.
(c) A succeeding carrier elects to provide replacement coverage without limitation as to the disability condition.
(d) The maximum benefits payable under the contract have been paid.
(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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.312 - Scope.

641.312 Scope.—The Office of Insurance Regulation may adopt rules to administer the National Association of Insurance Commissioners’ Uniform Health Carrier External Review Model Act, issued by the National Association of Insurance Commissioners and dated April 2010. This section does not apply to the types of benefits or coverages provided under s. 627.6513(1)-(14) issued in any market.
History.—s. 13, ch. 2012-44; s. 108, ch. 2013-15; s. 24, ch. 2016-194; s. 112, ch. 2018-24.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.314 - Pharmacy benefit manager contracts.

641.314 Pharmacy benefit manager contracts.—
(1) As used in this section, the term:
(a) “Maximum allowable cost” means the per-unit amount that a pharmacy benefit manager reimburses a pharmacist for a prescription drug, excluding dispensing fees, prior to the application of copayments, coinsurance, and other cost-sharing charges, if any.
(b) “Pharmacy benefit manager” means a person or entity doing business in this state which contracts to administer or manage prescription drug benefits on behalf of a health maintenance organization to residents of this state.
(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:
(a) Update maximum allowable cost pricing information at least every 7 calendar days.
(b) Maintain a process that will, in a timely manner, eliminate drugs from maximum allowable cost lists or modify drug prices to remain consistent with changes in pricing data used in formulating maximum allowable cost prices and product availability.
(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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3154 - Organization liability; provider billing prohibited.

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:
(a) The provider is informed by the organization that it accepts liability;
(b) A court of competent jurisdiction determines that the organization is liable; or
(c) The agency issues a final order that the organization is required to pay for such services subsequent to a recommendation made by a resolution organization pursuant to s. 408.7057.
(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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.3156 - Treatment authorization; payment of claims.

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.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.32 - Acceptable payments.

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 into between the health maintenance organization and its subscribers.
History.—s. 16, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 796, 804, 809(1st), ch. 82-243; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.33 - Certain words prohibited in name of organization.

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, 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, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 797, 804, 809(1st), ch. 82-243; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.36 - Adoption of rules; penalty for violation.

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 rules adopted by the commission. Any violation of a rule adopted under this section shall subject the violating entity to the provisions of s. 641.23.
History.—s. 20, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 800, 804, 809(1st), ch. 82-243; s. 12, ch. 87-236; ss. 127, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 1587, ch. 2003-261.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.37 - Prohibited activities; penalties.

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 guilty of a felony of the third degree, punishable as provided in s. 775.082 or s. 775.083.
(2) Except as provided in subsection (1), any person, entity, or health maintenance organization which knowingly violates the provisions of this part is guilty of a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.
(3) Any agent or representative, examining physician, applicant, or other person who knowingly makes any false and fraudulent statements or representation in, or with reference to, any application or negotiation for health maintenance organization coverage is, in addition to any other penalty provided by law, guilty of a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.
(4) Any agent, representative, collector, or other person who, while acting on behalf of a health maintenance organization, receives or collects its funds or premium payments and fails to satisfactorily account for or turn over, when required, all such funds or payments is, in addition to the other penalties provided for by law, guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.
(5) Any person who, without authority granted by a health maintenance organization, collects or secures cash advances, premium payments, or other funds owing to the health maintenance organization or otherwise conducts the business of a health maintenance organization without its authority is, in addition to the other penalties provided for by law, guilty of a misdemeanor of the second degree, punishable as provided in s. 775.082 or s. 775.083.
History.—s. 21, ch. 72-264; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 801, 804, 809(1st), ch. 82-243; s. 34, ch. 85-177; s. 52, ch. 87-226; ss. 187, 188, ch. 91-108; s. 164, ch. 91-224; s. 4, ch. 91-429; s. 26, ch. 96-199; s. 70, ch. 2002-206.