(1) In the event that an HMO is insolvent, the plan shall:

(a) Guarantee, reinsure, assume, or provide coverage for or cause to be guaranteed, reinsured, assumed, or covered all of the subscriber contracts of the insolvent HMO subject to the terms and limitations provided in this part.

Terms Used In Florida Statutes 631.818

  • Assets: (1) The property comprising the estate of a deceased person, or (2) the property in a trust account.
  • Board: means the board of directors of the plan. See Florida Statutes 631.814
  • Continuance: Putting off of a hearing ot trial until a later time.
  • Contract: A legal written agreement that becomes binding when signed.
  • Contractual obligations: means any obligation under covered health care policies. See Florida Statutes 631.814
  • Date of insolvency: means the effective date of an order of liquidation entered by a court of competent jurisdiction. See Florida Statutes 631.814
  • 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.
  • Germane: On the subject of the pending bill or other business; a strict standard of relevance.
  • Health care services: means comprehensive health care services as defined in…. See Florida Statutes 631.814
  • HMO: means a health maintenance organization possessing a valid certificate of authority issued by the office pursuant to part I of chapter 641. See Florida Statutes 631.814
  • Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
  • Person: means any individual, corporation, partnership, association, or voluntary organization. See Florida Statutes 631.814
  • Plan: means the Florida Health Maintenance Organization Consumer Assistance Plan created by this part. See Florida Statutes 631.814
  • Subscriber: means any resident of this state who is enrolled for benefits provided by an HMO and who makes premium payments or for whom premium payments are made. See Florida Statutes 631.814
(b) Cover all services that would have been covered by the subscribers’ contracts with the insolvent HMO during any period from the date of insolvency until the effective date of the replacement coverage with another HMO or other entity that provides health care services or reimbursement or with a product determined by the plan and approved by the office.
(c) Defend any claim filed contrary to the provisions of s. 641.315 or s. 641.3154 against a subscriber of an insolvent HMO asserted by a health care provider for services covered by the HMO contract. In the event that a provider obtains a judgment despite the provisions of s. 641.315 or s. 641.3154, the plan shall pay the judgment. If a provider fails to obtain a judgment as to such claim, the plan shall be entitled to recover its reasonable costs and attorney’s fees incurred in defending the claim.
(d) Levy and collect assessments from HMOs pursuant to s. 631.819.
1(2) In the event of a long-term care insurer impairment or insolvency, pursuant to s. 631.819(2)(c), the plan shall:

(a) Collect and transmit all information requested by the Florida Life and Health Insurance Guaranty Association for the association to determine the appropriate assessment base of the health insurance account pursuant to ss. 631.715(2)(a)1. and 631.718(3)(b).
(b) Levy and collect assessments from HMOs.
(c) Coordinate the administration and collection of member HMO assessments for long-term care insurer impairments and insolvencies with the Florida Life and Health Insurance Guaranty Association.
(3) The plan may appoint one or more HMOs in the same geographical area as defined in s. 641.19 to provide health care services, subject to all of the following conditions:

(a) The plan must pay for the cost of all medical services provided by an HMO involuntarily appointed to provide services that exceed the amount of premium or contribution paid by the subscribers. Medical services cost may include a reasonable amount for administrative and other services as determined by the board.
(b) Once enrolled, an eligible subscriber may not be terminated from coverage by the HMO for a period of 6 months following the date of insolvency except for one of the following reasons:

1. Nonpayment of premiums.
2. Attainment of Medicare or Medicaid eligibility.
3. Nonresidency in the service area.
4. Abusive and disruptive behavior.
5. Fraud.
6. Termination of eligibility.
(c) The plan shall consider the premium, services, benefits, and exclusions to be provided to each eligible person in designating the contract of the appointed HMO to be used to provide services.
(d) Such coverage shall not exclude a preexisting condition not excluded by the policy of the insolvent HMO.
(4) If the plan fails to act within a reasonable period of time as provided in this section, the department shall have the powers and duties of the plan under this part.
1(5) The plan may render assistance and advice to the department, at the department’s request, concerning rehabilitation, payment of claims, continuance of coverage, or the performance of other contractual obligations of any HMO subject to a delinquency proceeding.
(6) The plan shall have standing to appear before any court in this state which has jurisdiction over an insolvent HMO to which the plan is or may become obligated under this part. Such standing shall extend to all matters germane to the powers and duties of the plan, including, but not limited to, proposals for reinsuring or guaranteeing the covered policies of the insolvent HMO and the determination of the covered policies and contractual obligations.
(7) The plan may:

(a) Enter into such contracts or perform such other actions as are necessary or proper to carry out the provisions and purposes of this part.
(b) Sue or be sued, including the taking of any legal actions necessary or proper for the recovery of any unpaid assessments under this part.
(c) Borrow money to effect the purposes of this part. Any notes or other evidence of indebtedness of the plan not in default shall be legal investments for domestic insurers or HMOs and may be carried as admitted assets.
(d) Employ or retain such persons as are necessary to handle the financial transactions of the plan and to perform such other functions as become necessary or proper under this part.
(e) Negotiate and contract with any liquidator, rehabilitator, conservator, or ancillary receiver to carry out the powers and duties of the plan.
1(f) In the event of a long-term care insurer impairment or insolvency, coordinate with the Florida Life and Health Insurance Guaranty Association to carry out the responsibilities of the association for the limited purpose of the long-term care insurer impairment or insolvency, including the development of any plan for handling the administration of the impairment or insolvency.
(g) Take such legal action as may be necessary to avoid payment of improper claims.
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