Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.024 - Definitions for the Purposes of These Rules

Current through Reg. 50, No. 138; July 16, 2024
(1) All terms defined in the Health
				Maintenance Organization Act, Part I, Chapter 641, F.S., which are used in
				these rules shall have the same meaning as in the Act.
(2) Advertising. Advertising includes but is
				not limited to printed and published material, descriptive literature and sales
				aids, sales talks and sales materials, booklets, forms and pamphlets,
				illustrations, depictions and form letters, newspaper, radio, television or
				direct mail advertising, and any materials used by agents.
(3) Audited Financial Statements. A
				statement, prepared by an independent CPA, which shall include an opinion from
				the CPA concerning the financial statements, a balance sheet, a statement of
				operations, a statement of cash flow (direct method), and notes to the
				financial statement, which shall be prepared on the basis of statutory
				accounting principles (see subsection
				69O-191.075(1),
				F.A.C.), on an accrual basis, covering the HMO's latest annual reporting
				period.
(4) Combination Model -
				HMO. A Health Maintenance Organization model that has a combination of the
				staff and IPA models to provide health care services to its
				membership.
(5) Community Rate. The
				per member per month revenue requirement for a set of benefits or services for
				a specific class of subscribers. Such class may encompass the community as a
				whole.
(6) Emergency Services.
				Services which are needed immediately because of an injury or unforeseen
				medical condition which could reasonably be expected to result in disability or
				death. These must be provided, or arranged to be provided, on a twenty-four
				hour basis by the HMO, but also may be covered inpatient services or outpatient
				services that are furnished by an appropriate source other than the HMO when
				the time required to reach the HMO providers (or alternatives authorized by the
				HMO) could mean the risk of permanent damage to the subscriber's health.
				Notwithstanding the above, these services are considered to be emergency
				services, in or out of the service area, only as long as transfer of the
				subscriber to the HMO's source of health care or designated alternative is
				precluded because of risk to the subscriber's health or because transfer would
				be unreasonable, given the distance involved in the transfer and nature of the
				medical condition.
(7) Fraud. A
				false statement concerning a material fact with knowledge by the person making
				the false statement and intent that the representation will induce action which
				results in detrimental reliance.
(8) Health Care Provider Certificate. A
				certificate issued by the Office of Health and Rehabilitative Services in
				accordance with Part III, Chapter 641, F.S.
(9) Health Maintenance Organization Type
				Insurance. The provision of health care services in exchange for a
				contractually set premium on a prepaid per capita or prepaid aggregate
				fixed-sum basis. The indemnity insurance type of arrangement which consists of
				a deductible amount and a percentage of fees due is permitted only where
				specifically authorized by Florida Statutes.
(10) HMO. Health Maintenance Organization may
				be abbreviated as HMO in these rules.
(11) Individual Physician. As used in Section
				641.2342, F.S., a physician who
				is a sole practitioner with no other physicians employed by the contracting
				physician or under contract with the physician to provide primary care
				services.
(12) Individual Practice
				Association (IPA) Model - HMO. A Health Maintenance Organization health care
				delivery model in which the HMO contracts with individual physician(s), a
				medical group, or physician organization which in turn may contract with other
				individual physicians or groups. The IPA physicians may practice in their own
				offices and continue to see their fee-for-service patients.
(13) Medical Emergency. An unexpected and
				unforeseen disease, illness or injury which will result in disability or death
				if not treated immediately.
(14)
				Medical Staff. A formal organization of physicians and other health care
				practitioners in an HMO with the delegated responsibility to maintain
				acceptable standards in delivery of health care and to plan for continued
				betterment of that care.
(15)
				Minimum Services. Minimum Services include the following services:
(a) Emergency Care. Emergency inpatient,
				outpatient and physician services shall be available on a twenty-four hour,
				seven day a week basis, either by the HMO through its own facilities or through
				arrangements with other providers. Emergency resuscitation supplies shall be
				available. Physicians and other health care practitioners shall be readily
				available at all times. In addition, emergency services, as defined in these
				rules, shall be covered by the HMO.
(b) Inpatient Hospital Services. Inpatient
				hospital services shall be available on a twenty-four hour, seven day a week
				basis either through the HMO's own facility or through arrangements with
				hospitals. Inpatient hospital services shall include, but are not limited to,
				room and board, general nursing care, meals and special diets when medically
				necessary, use of operating room and related facilities, use of intensive care
				unit and services, x-ray services, laboratory and other diagnostic tests,
				drugs, medications, biologicals, anesthesia and oxygen services, radiation
				therapy, inhalation therapy, and the providing and administration of whole
				blood and blood plasma, unless replacement blood is arranged or provided, in
				accordance with community replacement standards.
(c) Physician Care. Physician care, provided
				or supervised by physicians licensed under Chapter 458, 459, 460 or 461, F.S.,
				of sufficient type and number to adequately provide for the contracted
				services. Physician care shall include consultant and referral services by a
				physician.
(d) Ambulatory
				Diagnostic Treatment. Outpatient diagnostic treatment service with an emphasis
				directed toward primary care including but not limited to diagnostic laboratory
				and diagnostic radiological services.
(e) Preventive Health Care Services. A
				program of health evaluation, education and immunizations which is designed to
				prevent illness and disease and to improve the general health of HMO
				subscribers. This program shall include at least the following:
1. Well-child care from birth;
2. Periodic health evaluations for
				adults;
3. Eye screenings by a
				physician or optometrist licensed pursuant to Chapter 463, F.S., and ear
				screenings by a physician for children through age 17, to determine the need
				for vision and hearing correction; and,
4. Pediatric and adult immunizations which
				are medically necessary in accordance with accepted medical
				practice.