2023 Florida Statutes › Title XXXVII - Insurance › Chapter 641 - Health Care Service Programs › Part I - Health Maintenance Organizations (Ss. 641.17-641.3923) › 641.19 - Definitions.

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, through:
(a) Equity ownership of voting securities;
(b) Common managerial control; or
(c) Collusive participation by the management of the health maintenance organization and affiliate in the management of the health maintenance organization or the affiliate.
(2) “Agency” means the Agency for Health Care Administration.
(3) “Capitation” means the fixed amount paid by an HMO to a health care provider under contract with the health maintenance organization in exchange for the rendering of covered medical services.
(4) “Comprehensive health care services” means services, medical equipment, and supplies furnished by a provider, which may include, but which are not limited to, medical, surgical, and dental care; psychological, optometric, optic, chiropractic, podiatric, nursing, physical therapy, and pharmaceutical services; health education, preventive medical, rehabilitative, and home health services; inpatient and outpatient hospital services; extended care; nursing home care; convalescent institutional care; technical and professional clinical pathology laboratory services; laboratory and ambulance services; appliances, drugs, medicines, and supplies; and any other care, service, or treatment of disease, or correction of defects for human beings.
(5) “Copayment” means a specific dollar amount, except as otherwise provided for by statute, that the subscriber must pay upon receipt of covered health care services. Copayments may not be established in an amount that will prevent a person from receiving a covered service or benefit as specified in the subscriber contract approved by the office.
(6) “Emergency medical condition” means:
(a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
1. Serious jeopardy to the health of a patient, including a pregnant woman or a fetus.
2. Serious impairment to bodily functions.
3. Serious dysfunction of any bodily organ or part.
(b) With respect to a pregnant woman:
1. That there is inadequate time to effect safe transfer to another hospital prior to delivery;
2. That a transfer may pose a threat to the health and safety of the patient or fetus; or
3. That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes.
(7) “Emergency services and care” means medical screening, examination, and evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a physician, to determine if an emergency medical condition exists and, if it does, the care, treatment, or surgery for a covered service by a physician necessary to relieve or eliminate the emergency medical condition, within the service capability of a hospital.
(8) “Entity” means any legal entity with continuing existence, including, but not limited to, a corporation, association, trust, or partnership.
(9) “Geographic area” means the county or counties, or any portion of a county or counties, within which the health maintenance organization provides or arranges for comprehensive health care services to be available to its subscribers.
(10) “Guaranteeing organization” is an organization that is domiciled in the United States; that has authorized service of process against it; and that has appointed the Chief Financial Officer as its agent for service of process issuing upon any cause of action arising in this state, based upon any guarantee entered into under this part.
(11) “Health maintenance contract” means any contract entered into by a health maintenance organization with a subscriber or group of subscribers to provide coverage for comprehensive health care services in exchange for a prepaid per capita or prepaid aggregate fixed sum.
(12) “Health maintenance organization” means any organization authorized under this part which:
(a) Provides, through arrangements with other persons, emergency care, inpatient hospital services, physician care including care provided by physicians licensed under chapters 458, 459, 460, and 461, ambulatory diagnostic treatment, and preventive health care services.
(b) Provides, either directly or through arrangements with other persons, health care services to persons enrolled with such organization, on a prepaid per capita or prepaid aggregate fixed-sum basis.
(c) Provides, either directly or through arrangements with other persons, comprehensive health care services which subscribers are entitled to receive pursuant to a contract.
(d) Provides physician services, by physicians licensed under chapters 458, 459, 460, and 461, directly through physicians who are either employees or partners of such organization or under arrangements with a physician or any group of physicians.
(e) 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. Each female subscriber may select as her primary physician an obstetrician/gynecologist who has agreed to serve as a primary physician and is in the health maintenance organization’s provider network.
Except in cases in which the health care provider is an employee of the health maintenance organization, the fact that the health maintenance organization arranges for the provision of health care services under this chapter does not create an actual agency, apparent agency, or employer-employee relationship between the health care provider and the health maintenance organization for purposes of vicarious liability for the medical negligence of the health care provider.
(13) “Insolvent” or “insolvency” means that all the statutory assets of the health maintenance organization, if made immediately available, would not be sufficient to discharge all of its liabilities or that the health maintenance organization is unable to pay its debts as they become due in the usual course of business. In the event that all the assets of the health maintenance organization, if made immediately available, would not be sufficient to discharge all of its liabilities, but the organization has a written guarantee of the type and subject to the same provisions as outlined in s. 641.225, the organization shall not be considered insolvent unless it is unable to pay its debts as they become due in the usual course of business.
(14) “Provider” means any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state.
(15) “Reporting period” means the annual calendar year accounting period or any part thereof.
(16) “Schedule of reimbursements” means a schedule of fees to be paid by a health maintenance organization to a physician provider for reimbursement for specific services pursuant to the terms of a contract. The physician provider’s net reimbursement may vary after consideration of other factors, including, but not limited to, bundling codes together into another code and member cost-sharing responsibility, as long as these factors are disclosed and included in the terms of the contract between the health maintenance organization and provider. The reimbursement schedule may be stated as:
(a) A percentage of the Medicare fee schedule for specific relative-value services;
(b) A listing of the reimbursements to be paid by Current Procedural Terminology codes for physicians that pertain to each physician’s practice; or
(c) Any other method agreed upon by the parties.
Specific nonrelative-value services shall be stated separately from relative-value services, and reimbursement for unclassified services shall be on a reasonable basis.
(17) “Statutory accounting principles” means accounting principles as defined in the National Association of Insurance Commissioners Accounting Practices and Procedures Manual as of 2002.
(18) “Subscriber” means an entity or individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract.
(19) “Surplus” means total statutory assets in excess of total liabilities, except that assets pledged to secure debts not reflected on the books of the health maintenance organization shall not be included in surplus. Surplus includes capital stock, capital in excess of par, other contributed capital, retained earnings, and surplus notes.
(20) “Uncovered expenditures” means the cost of health care services that are covered by a health maintenance organization, for which a subscriber would also be liable in the event of the insolvency of the organization.
(21) “Health care risk contract” means a contract under which an individual or entity receives consideration or other compensation in an amount greater than 1 percent of the health maintenance organization’s annual gross written premium in exchange for providing to the health maintenance organization a provider network or other services, which may include administrative services. The 1-percent threshold shall be calculated on a contract-by-contract basis for each such individual or entity and not in the aggregate for all health care risk contracts.
(22) “Provider service network” means a network authorized under s. 409.912(1), reimbursed on a prepaid basis, operated by a health care provider or group of affiliated health care providers, and which directly provides health care services under a Medicare, Medicaid, or Healthy Kids contract.
History.—s. 3, ch. 72-264; s. 1, ch. 76-33; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 780, 804, 809(1st), ch. 82-243; s. 1, ch. 83-198; s. 137, ch. 83-216; s. 2, ch. 84-313; s. 6, ch. 85-177; s. 1, ch. 87-236; s. 1, ch. 87-273; s. 2, ch. 88-126; s. 2, ch. 88-388; s. 2, ch. 89-357; s. 74, ch. 89-360; ss. 111, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 2, ch. 95-281; s. 13, ch. 96-199; s. 3, ch. 96-223; s. 22, ch. 2001-213; s. 10, ch. 2002-247; s. 1555, ch. 2003-261; s. 46, ch. 2003-416; s. 1, ch. 2004-321; s. 33, ch. 2011-135; s. 30, ch. 2015-3; s. 18, ch. 2017-4; s. 14, ch. 2022-42.