59A-12.002. Definitions

(1) All terms defined in the Health Maintenance Organization Act, Chapter 641, F.S., which are used in these rules shall have the same meaning as in the act.

(2) HMO. Health Maintenance Organization shall be abbreviated as HMO in these rules.

(a) Individual Practice Assocation (IPA) Model HMO. A type of health care provider organization composed of a group of independent practicing physicians who maintain their own offices and band together for the purpose of contracting their services to HMOs.

(b) Staff Model HMO. Physicians and medical professionals are employees of the HMO and have offices in HMO owned or leased buldings. The physicians and medical professionals only see members of the HMO employer.

(c) Mixed Model HMO. A Staff Model HMO that also contracts with providers organized as IPAs.

(3) PHC. Prepaid Health Clinic shall be abbreviated as PHC in these rules.

(4) PCP. Primary Care Provider shall be abbreviated as PCP in these rules.

(5) Emergency Services. Services which are needed immediately because of an injury or unforeseen medical condition as provided for in the subscriber’s contract. These must be provided or arranged to be provided on a 24-hour basis by the HMO or PHC, but also may cover inpatient services or outpatient services that are furnished by an appropriate source other than the HMO or PHC when the time required to reach HMO or PHC providers, or alternatives authorized by the HMO or PHC, would mean the risk of permanent damage to the subscriber’s health. Notwithstanding the above, these services are considered to be emergency services only as long as transfer of the subscriber to the HMO’s or PHC’s source of health care or designated alternative is precluded because of risk to the subscriber’s health or because transfer would be unreasonable given the distance involved in the transfer and the nature of the medical condition.

(6) Medical Staff of the HMO or PHC. A formal organization of physicians in an HMO or PHC with responsibility to maintain acceptable standards concerning the delivery of health care and to plan for continued betterment of that care.

(7) Minimum Services. Minimum services include the following:

(a) Emergency Care. Emergency inpatient, outpatient and physician services shall be available on a 24-hour, 7-day a week basis, either by the HMO or PHC through its own facilities or through arrangements with providers. Emergency resuscitation supplies shall be available. In addition, emergency services, as defined in these rules, shall be covered by the HMO or PHC;

(b) Inpatient Hospital Services. Inpatient hospital services shall be available on a 24-hour, 7-day a week basis either through the HMO’s own facility or through arrangements with hospitals. Inpatient hospital services shall include, for example: room and board, general nursing care, meals and special diets when medically necessary, use of operating room and related facilities, use of intensive care unit and services, x-ray services, laboratory and other diagnostic tests, drugs, medications, biologicals, anesthesia and oxygen services, radiation therapy, inhalation therapy, and administration of whole blood and blood plasma;

(c) Physician Care. Physician care, provided or supervised by physicians licensed under Chapter 458, 459, 460 or 461, F.S., to include PCPs and specialists to adequately provide for the contracted services. Physician care shall include consultant and referral services by a physician;

(d) Ambulatory Diagnostic Treatment. Outpatient diagnostic treatment services with an emphasis directed toward primary care. Ambulatory diagnostic treatment shall include diagnostic laboratory and diagnostic radiological services; and,

(e) Preventive Health Care Services. A program of health evaluation, education and immunizations which is designed to prevent illness and disease and to improve the general health of HMO or PHC subscribers. This program shall include at least the following:

1. Well-child care from birth;

2. Periodic health evaluations for adults;

3. Eye and ear screenings by a physician for children through age 21 to determine the need for vision or hearing correction; and,

4. Pediatric and adult immunizations, in accord with accepted medical practice.

(8) Peer Review. Ongoing evaluation of services by Florida licensed health care professionals to achieve and maintain high standards of professional practice within the discipline.

(9) Quality of Care. The prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which, in light of all relevant surrounding circumstances, is recognized as acceptable and appropriate by reasonably prudent similar health care providers in the community.

(10) Health Care Personnel Engaged to Provide Health Care Services. A health care professional obligated in advance by written contract to provide health care services to an HMO or PHC subscriber. Said contract must include specific hold harmless language relieving the subscriber of any obligation to the provider for unpaid health care costs for covered benefits.

(11) ICD-10-CM. The International Classification of Diseases, 10th Revision, Clinical Modifications shall be abbreviated as ICD-10-CM in these rules.

(12) Second medical opinion. A consultation by a physician other than the member’s primary care physician, whose specialty is appropriate to the need, and whose services are obtained when the member disputes the appropriateness or necessity of a surgical procedure, is subject to a serious injury or illness, including failure to respond to the current treatment plan.

(13) Serious Injury or Illness. An injury or illness, the natural history of which, if untreated, is likely to result in death, to progress to a more severe form, or to develop complications.

Rulemaking Authority 641.56 FS. Law Implemented 641.47, 641.49, 641.495, 641.51, 641.513, 641.515, 641.51, 641.55 FS. History–New 1-28-88, Amended 3-11-92, Formerly 10D-100.002, Amended 4-10-03, 11-13-17.