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The Florida Statutes

The 2019 Florida Statutes

Title XXXVII
INSURANCE
Chapter 641
HEALTH CARE SERVICE PROGRAMS
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F.S. 641.54
641.54 Information disclosure.
(1) Every health maintenance organization shall maintain a current list, by geographic area, of all hospitals which are routinely and regularly used by the organization, indicating to which hospitals the organization may refer particular subscribers for nonemergency services. The list shall also include all physicians under the organization’s direct employ or who are under contract or other arrangement with the organization to provide health care services to subscribers. The list shall contain the following information for each physician:
(a) Name.
(b) Office location.
(c) Medical area or areas of specialty.
(d) Board certification or eligibility in any area.
(e) License number.
(2) The list shall be made available, upon request, to the office. The list shall also be made available, upon request:
(a) With respect to negotiation, application, or effectuation of a group health maintenance contract, to the employer or other person who will hold the contract on behalf of the subscriber group. The list may be restricted to include only physicians and hospitals in the group’s geographic area.
(b) With respect to an individual health maintenance contract or any contract offered to a person who is entitled to have payments for health care costs made under Medicare, to the person considering or making application to, or under contract with, the health maintenance organization. The list may be restricted to include only physicians and hospitals in the person’s geographic area.
(3) The organization shall make available to subscribers, upon request, a detailed description of the authorization and referral process for health care services. Any changes in the organization’s authorization and referral process shall be reported to the agency immediately.
(4) The organization shall make available to subscribers, upon request, a detailed description of the process used to determine whether health care services are “medically necessary.” Any change in the organization’s definition of “medically necessary” or the process used to determine medical necessity shall be reported to the agency immediately.
(5) Each organization shall provide to subscribers, upon request, the following:
(a) A description of the organization’s quality assurance program.
(b) Policies and procedures relating to the organization’s prescription drug benefits, including the disclosure, upon request of a subscriber or potential subscriber, of whether the organization uses a formulary. A subscriber or potential subscriber may also request information as to whether a specific drug is covered by the organization.
(c) Policies and procedures relating to the confidentiality and disclosure of the subscriber’s medical records.
(d) The decisionmaking process used for approving or denying experimental or investigational medical treatments.
(e) Policies and procedures for addressing the needs of non-English-speaking subscribers.
(f) A detailed description of the process used to examine qualifications of and the credentialing of all providers under contract with or employed by the organization.
(6) Each health maintenance organization shall make available to its subscribers on its website or by request the estimated copayment, coinsurance percentage, or deductible, whichever is applicable, for any covered services as described by the searchable bundles established on a consumer-friendly, Internet-based platform pursuant to s. 408.05(3)(c) or as described by a personalized estimate received from a facility pursuant to s. 395.301 or a practitioner pursuant to s. 456.0575, the status of the subscriber’s maximum annual out-of-pocket payments for a covered individual or family, and the status of the subscriber’s maximum lifetime benefit. Such estimate does not preclude the actual copayment, coinsurance percentage, or deductible, whichever is applicable, from exceeding the estimate.
(7) Each health maintenance organization that participates in the state group health insurance plan created under s. 110.123 or Medicaid managed care pursuant to part IV of chapter 409 shall contribute all claims data from Florida subscribers held by the organization and its affiliates to the contracted vendor selected by the Agency for Health Care Administration under s. 408.05(3)(c). Health maintenance organizations shall submit Medicaid managed care claims data to the vendor beginning July 1, 2017, and may submit data before that date. However, each health maintenance organization and its affiliates may not contribute claims data to the contracted vendor which reflect the following types of coverage:
(a) Coverage only for accident, or disability income insurance, or any combination thereof.
(b) Coverage issued as a supplement to liability insurance.
(c) Liability insurance, including general liability insurance and automobile liability insurance.
(d) Workers’ compensation or similar insurance.
(e) Automobile medical payment insurance.
(f) Credit-only insurance.
(g) Coverage for onsite medical clinics, including prepaid health clinics under part II of chapter 641.
(h) Limited scope dental or vision benefits.
(i) Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
(j) Coverage only for a specified disease or illness.
(k) Hospital indemnity or other fixed indemnity insurance.
(l) Medicare supplemental health insurance as defined under s. 1882(g)(1) of the Social Security Act, coverage supplemental to the coverage provided under chapter 55 of Title 10, U.S.C., and similar supplemental coverage provided to supplement coverage under a group health plan.
(8) Each health maintenance organization shall make available on its website a hyperlink to the health information that is disseminated by the Agency for Health Care Administration pursuant to s. 408.05(3) and shall include in every policy delivered or issued for delivery to any person in the state or in materials provided as required by s. 627.64725 notice that such information is available electronically and the address of its website.
History.ss. 31, 47, ch. 85-177; s. 22, ch. 87-236; ss. 187, 188, ch. 91-108; s. 91, ch. 91-282; s. 4, ch. 91-429; s. 9, ch. 97-159; s. 1631, ch. 2003-261; s. 41, ch. 2004-297; s. 16, ch. 2006-261; s. 7, ch. 2016-234.
Note.Former s. 641.3109.