(1) As used in this section, the term:

(a) “Complaint” means any dissatisfaction expressed by a policyholder concerning an insurer or its network providers.
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Terms Used In Florida Statutes 627.6472

  • Contract: A legal written agreement that becomes binding when signed.
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • insured: as used in this part , shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits, and rights provided therein. See Florida Statutes 627.631
  • minor: includes any person who has not attained the age of 18 years. See Florida Statutes 1.01
  • person: includes individuals, children, firms, associations, joint adventures, partnerships, estates, trusts, business trusts, syndicates, fiduciaries, corporations, and all other groups or combinations. See Florida Statutes 1.01
  • Recourse: An arrangement in which a bank retains, in form or in substance, any credit risk directly or indirectly associated with an asset it has sold (in accordance with generally accepted accounting principles) that exceeds a pro rata share of the bank's claim on the asset. If a bank has no claim on an asset it has sold, then the retention of any credit risk is recourse. Source: FDIC
  • Settlement: Parties to a lawsuit resolve their difference without having a trial. Settlements often involve the payment of compensation by one party in satisfaction of the other party's claims.
  • writing: includes handwriting, printing, typewriting, and all other methods and means of forming letters and characters upon paper, stone, wood, or other materials. See Florida Statutes 1.01
(b) “Emergency care” means medical services provided after the sudden or unexpected onset of a medical condition manifesting itself by acute symptoms, including injury caused by an accident, which are severe enough that the lack of immediate medical attention could reasonably be expected to result in any of the following:

1. The patient’s life or health would be placed in serious jeopardy.
2. Vital bodily functions would be seriously impaired.
3. There would be serious and permanent dysfunction of a bodily organ or part.
(c) “Exclusive provider” means a provider of health care, or a group of providers of health care, that has entered into a written agreement with the insurer to provide benefits under a health insurance policy issued under this section, which agreement shall include any health care provider listed in s. 627.419(3) and (4) and shall provide reasonable access to such health care providers.
(d) “Exclusive provider provision” means any provision that conditions the payment of benefits, in whole or in part, on the use of exclusive providers.
(e) “Agency” means the Agency for Health Care Administration.
(f) “Grievance” means dissatisfaction with the administration, claims practices, or provisions of services concerning an insurer or its network providers, expressed in writing by a policyholder under a health insurance policy or certificate.
(g) “Service area” means the geographic area approved by the agency within which an insurer is authorized to offer a health insurance policy.
(2) The agency may authorize a health insurer to offer a health insurance policy or certificate under this section if the agency finds that the insurer has satisfied all of the requirements of this section.
(3) An insurer may not issue a policy or certificate in this state that is subject to an exclusive provider provision until its plan of operation has been approved by the agency. If the insurer files a plan of operation which states that the insurer will be utilizing a health maintenance organization provider network, subscriber grievance procedure, and internal and external quality assurance program, all of which have been approved by the agency, the insurers plan of operation shall be deemed to have met the requirements of subsections (4), (5), (12), and (14).
(4) An insurer must file a proposed plan of operation with the agency in a format prescribed by the agency. The plan of operation must contain evidence that all covered services that are subject to exclusive provider provisions are available and accessible through exclusive providers, including a demonstration that:

(a) Such services can be provided by exclusive providers with reasonable promptness with respect to geographic location, hours of operation, and after-hour care. The hours of operation and availability of after-hour care must reflect usual practice in the local area. Geographic availability must reflect the usual travel times within the community.
(b) The number of exclusive providers in the service area is sufficient, with respect to current and expected policyholders, either:

1. To deliver adequately all services that are subject to an exclusive provider provision; or
2. To make appropriate referrals.
(c) There are written agreements with exclusive providers describing specific responsibilities.
(d) Emergency care is available 24 hours a day and 7 days a week.
(e) In the case of covered services that are subject to an exclusive provider provision, there are written agreements with exclusive providers prohibiting such providers from billing or otherwise seeking reimbursement from or recourse against any policyholders. This paragraph does not apply to supplemental charges or coinsurance amounts stated in the policy or certificate.
(5) The proposed plan of operation must include:

(a) A statement or map providing a clear description of the service area.
(b) A description of the grievance procedure to be used.
(c) A description of the quality assurance program, including all of the following:

1. The formal organizational structure.
2. The written criteria for selection, retention, and removal of exclusive providers.
3. The procedures for evaluating quality of care provided by exclusive providers, and the process to initiate corrective action when warranted.
(d) A list and description, by specialty, of the exclusive providers.
(e) The written information proposed to be used by the insurer to comply with subsection (10).
(f) Any other information requested by the agency.
(6) An insurer must file any proposed changes to the plan of operation, except for changes to the list of exclusive providers, with the agency prior to implementing the changes. The changes are considered approved by the agency after 30 days unless specifically disapproved.
(7) An updated list of exclusive providers must be filed with the agency at least semiannually.
(8) A health insurance policy or certificate may not restrict payment for covered services provided by nonexclusive providers if:

(a) The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury, or condition; and
(b) A network provider is not reasonably accessible.
(9) If any service or treatment is not within the scope of services provided by the network or exclusive providers, but is within the scope of services or treatment covered by the policy, the service or treatment shall be reimbursed at a rate not less than 10 percentage points lower than the percentage rate paid to network providers. The reimbursement rate must be applied to the usual and customary charges in the area.
(10) An insurer must make full and fair disclosure in writing of the provisions, restrictions, and limitations of the policy or certificate to each policyholder and certificateholder, including at least the following:

(a) A description (including address and phone number) of the exclusive providers, including primary care physicians, specialty physicians, hospitals, and other providers.
(b) A description of the exclusive provider provisions, including coinsurance and deductible levels if providers other than exclusive providers are used.
(c) A description of coverage for emergency and urgently needed care and other out-of-service area coverage.
(d) A description of limitations on referrals to restricted exclusive providers and to other providers.
(e) A description of the insurer’s quality assurance program and grievance procedure.
(11) Prior to or at the time of the sale of a policy or certificate that is subject to an exclusive provider organization, the insurer must obtain from the policyholder or certificateholder a signed and dated form stating that the policyholder or certificateholder has received the information provided pursuant to subsection (10) and that the policyholder or certificateholder understands the restrictions of the policy or certificate.
(12)(a) An insurer issuing policies or certificates that are subject to an exclusive provider organization must have and use procedures for hearing complaints and resolving written grievances from the policyholders. The procedures must be aimed at mutual agreement for settlement and may include arbitration procedures.
(b) The grievance procedure must be described in the policy and certificates.
(c) At the time the policy or certificate is issued, the insurer must provide detailed information to the policyholder describing how a grievance may be registered with the insurer.
(d) Grievances must be considered in a timely manner and must be transmitted to appropriate decisionmakers who have the authority to fully investigate the issue and take corrective action.
(e) If a grievance is found to be valid, corrective action must be taken promptly.
(f) All concerned parties must be notified about the results of a grievance.
(g) The insurer must report no later than each March 31 to the agency regarding its grievance procedure. The report must be in a format prescribed by the agency and must contain the number of grievances filed in the past year and a summary of the subject, nature, and resolution of such grievances.
(13) At the time of initial purchase, an insurer issuing policies or certificates that are subject to an exclusive provider organization must offer to each policyholder the opportunity to purchase a policy otherwise offered by the insurer that is not subject to an exclusive provider network.
(14)(a) There is imposed on every authorized insurer that offers exclusive provider policies under this section an annual assessment payable to the agency. The assessment must be determined and collected pursuant to the procedures specified in s. 641.58, and may not exceed 0.1 percent of the gross premium collected by the insurer in the prior year for exclusive provider policies issued in this state under this section. The assessment does not apply to policies issued pursuant to s. 627.6473.
(b) The agency must deposit the assessments in the Health Care Trust Fund. Assessments deposited under this subsection must be used to defray the expenses of the agency connected with implementation of this section. Prior to collection of assessments under this subsection, the agency may use moneys in the Health Care Trust Fund, as appropriated by the Legislature, to defray the expenses of the agency connected with implementation of this section.
(c) The failure of the insurer to pay the assessment within the time specified in s. 641.58 constitutes grounds for suspension or revocation of the insurer’s certificate of authority by the office.
(15) If psychotherapeutic services are covered by a policy issued by the insurer, the insurer shall provide eligibility criteria for all groups of health care providers licensed under chapter 458, chapter 459, chapter 490, or chapter 491, which include psychotherapy within the scope of their practice as provided by law, or for any person who is licensed as an advanced practice registered nurse in psychiatric mental health under s. 464.012. When psychotherapeutic services are covered, eligibility criteria shall be established by the insurer to be included in the insurer’s criteria for selection of network providers. The insurer may not discriminate against a health care provider by excluding such practitioner from its provider network solely on the basis of the practitioner’s license.
(16) Notwithstanding any provision of this section to the contrary, an exclusive provider organization which offers dermatological services shall provide direct patient access, for office visits and minor procedures and testing, to a dermatologist who is under contract with the exclusive provider organization. The term “direct patient access” means the ability of an insured to obtain such services without a referral or other authorization before receiving services. The exclusive provider organization shall, by July 1, 1997, develop criteria for compliance with the provisions of this subsection which do not impede or inhibit access to dermatological services for policyholders of the exclusive provider organization. The criteria may include a maximum of five office visits to a dermatologist without prior authorization for a dermatologic problem within a 12-month period.
(17) An exclusive provider organization shall not discriminate with respect to participation as to any advanced practice registered nurse licensed pursuant to s. 464.012, who is acting within the scope of such license, solely on the basis of such license. This subsection shall not be construed to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan’s enrollees or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan.
(18) Each organization shall allow, without prior authorization, a female subscriber to visit a contracted obstetrician/gynecologist for one annual visit and medically necessary followup care detected at that visit. Nothing in this subsection shall prevent an organization from requiring that an obstetrician/gynecologist treating a covered patient coordinate the medical care through the patient’s primary care physician, if applicable.
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