Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.069 - Insurance - General Liability and Medical Malpractice/Professional Liability

Current through Reg. 50, No. 138; July 16, 2024
(1) Each HMO, in
				order to obtain its Certificate of Authority, shall furnish evidence of
				adequate insurance coverage or an adequate plan for self-insurance to respond
				to claims for injuries arising out of the furnishing of comprehensive health
				care. Once the HMO obtains its Certificate of Authority, it shall maintain on
				file with the Office continued evidence of adequate insurance coverage or
				evidence of the continuation of the self-insurance plan. Any reduction in the
				insurance coverage for the HMO shall be submitted to and approved by the Office
				prior to the time at which the reduction takes place. Evidence of the existence
				of the approved insurance plan shall also be submitted with each annual report.
				If the HMO is a staff model, the medical malpractice insurance shall insure
				coverage for the HMO as well as any physicians employed by the HMO. If the HMO
				is an IPA model, professional liability insurance coverage shall be obtained
				and the HMO shall require in its contract with providers that the providers
				certify and maintain appropriate levels of medical malpractice insurance or its
				equivalent in compliance with Florida Statutes.
(2) The Office of Insurance Regulation shall
				be listed on the General Liability and Medical Malpractice/Professional
				Liability insurance policies for HMOs such that the Office shall receive
				written notification of any reduction of coverage, cancellation, non-renewal or
				termination of any insurance policy referenced in Florida Statutes or these
				rules. Except for non-payment of premium, each agreement shall remain in full
				force and effect until replaced or for at least 30 days following written
				notification to the Office by registered mail of cancellation or termination of
				the policy by either party. If coverage is cancelled or terminated due to
				non-payment of premium, coverage shall remain in full force and effect for at
				least ten days following written notification to the Office by registered mail.
				Any substantial change to the policy shall be immediately reported, in writing,
				to the Office.
(3) Medical
				Malpractice/Professional Liability for HMOs. Acceptable insurance coverage is
				defined as follows:
Insurance - Minimum Limits
Members
Single Occurrence
Aggregate
0-19,999
$1,000,000
$ 1,000,000
20,000-39,999
$1,000,000
$ 2,000,000
40,000-49,999
$1,000,000
$ 3,000,000
50,000-59,999
$1,000,000
$ 5,000,000
60,000-79,999
$1,000,000
$ 6,000,000
80,000-89,999
$1,000,000
$ 7,000,000
90,000-99,999
$1,000,000
$ 8,000,000
100,000-109,999
$1,000,000
$ 9,000,000
110,000 or more
$1,000,000
$10,000,000
If the level of insurance calculated above exceeds what is
				  available in the insurance market (including the Florida Medical Malpractice
				  Joint Underwriting Association - FMMJUA) the level of coverage will be the
				  maximum available by market conditions. Maximum coverage available by market
				  conditions is subject to Office verification and approval.
(4) General Liability. Acceptable insurance
				coverage is defined as follows:
Members
Single Occurrence
Aggregate
0-19,999
$500,000
$ 500,000
20,000-39,999
$500,000
$1,000,000
40,000-64,999
$1,000,000
$2,000,000
65,000-79,999
$1,000,000
$3,000,000
80,000-94,999
$1,000,000
$4,000,000
95,000-109,999
$1,000,000
$5,000,000
110,000-124,999
$1,000,000
$6,000,000
125,000-139,999
$1,000,000
$7,000,000
140,000-154,999
$1,000,000
$8,000,000
155,000 or more
$1,000,000
$9,000,000
If the level of insurance calculated above exceeds what is
				  available in the insurance market, the level of coverage will be the maximum
				  available by market conditions. Maximum coverage available by market conditions
				  is subject to Office verification and approval. Limits can be achieved
				  separately or in concert with a following form umbrella
				  policy.
(5) Self-Insurance.
(a) Any HMO choosing to implement a
				self-insurance plan shall support its proposed plan for self-insurance by
				filing with the Office an actuarial study prepared by an actuarial firm
				acceptable to the Office or supervised by an actuary who is a member of the
				Casualty Actuarial Society.
1. The study shall
				establish a funding level based on the following factors:
a. Past and prospective loss and expense
				experience of other HMOs and other health care providers with similar
				exposure;
b. The prior claims
				experience of the HMO;
c. A risk
				loading sufficient to reduce the probability of the need for additional funding
				of the self-insurance plan for any policy year to 10% or less;
d. Administrative expenses necessary to
				administer the self-insured plan.