Florida Statutes 641.234 – Administrative, provider, and management contracts
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(1) The office may require a health maintenance organization to submit any contract for administrative services, contract with a provider other than an individual physician, contract for management services, and contract with an affiliated entity to the office.
(2) After review of a contract the office may order the health maintenance organization to cancel the contract in accordance with the terms of the contract and applicable law if it determines:
(a) That the fees to be paid by the health maintenance organization under the contract are so unreasonably high as compared with similar contracts entered into by the health maintenance organization or as compared with similar contracts entered into by other health maintenance organizations in similar circumstances that the contract is detrimental to the subscribers, stockholders, investors, or creditors of the health maintenance organization; or
Terms Used In Florida Statutes 641.234
- Agency: means the Agency for Health Care Administration. See Florida Statutes 641.19
- Contract: A legal written agreement that becomes binding when signed.
- Entity: means any legal entity with continuing existence, including, but not limited to, a corporation, association, trust, or partnership. See Florida Statutes 641.19
- Health care risk contract: means a contract under which an individual or entity receives consideration or other compensation in an amount greater than 1 percent of the health maintenance organization's annual gross written premium in exchange for providing to the health maintenance organization a provider network or other services, which may include administrative services. See Florida Statutes 641.19
- Health maintenance organization: means any organization authorized under this part which:(a) Provides, through arrangements with other persons, emergency care, inpatient hospital services, physician care including care provided by physicians licensed under chapters 458, 459, 460, and 461, ambulatory diagnostic treatment, and preventive health care services. See Florida Statutes 641.19
- 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
- Provider: means any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state. See Florida Statutes 641.19
- Subscriber: means an entity or individual who has contracted, or on whose behalf a contract has been entered into, with a health maintenance organization for health care coverage or other persons who also receive health care coverage as a result of the contract. See Florida Statutes 641.19
(b) That the contract is with an entity that is not licensed under state statutes, if such license is required, or is not in good standing with the applicable regulatory agency.
(3) All contracts for administrative services, management services, provider services other than individual physician contracts, and with affiliated entities entered into or renewed by a health maintenance organization on or after October 1, 1988, shall contain a provision that the contract shall be canceled upon issuance of an order by the office pursuant to this section.
(4)(a) If a health maintenance organization, through a health care risk contract, transfers to any entity the obligations to pay any provider for any claims arising from services provided to or for the benefit of any subscriber of the organization, the health maintenance organization shall remain responsible for any violations of ss. 641.3155, 641.3156, and 641.51(4). The provisions of ss. 624.418–624.4211 and 641.52 shall apply to any such violations.
(b) As used in this subsection:
1. The term “health care risk contract” means a contract under which an entity receives compensation in exchange for providing to the health maintenance organization a provider network or other services, which may include administrative services.
2. The term “entity” means a person licensed as an administrator under s. 626.88 and does not include any provider or group practice, as defined in s. 456.053, providing services under the scope of the license of the provider or the members of the group practice. The term does not include a hospital providing billing, claims, and collection services solely on its own and its physicians’ behalf and providing services under the scope of its license.