69O-191.024. Definitions for the Purposes of These Rules

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

(2) Advertising. Advertising includes but is not limited to printed and published material, descriptive literature and sales aids, sales talks and sales materials, booklets, forms and pamphlets, illustrations, depictions and form letters, newspaper, radio, television or direct mail advertising, and any materials used by agents.

(3) Audited Financial Statements. A statement, prepared by an independent CPA, which shall include an opinion from the CPA concerning the financial statements, a balance sheet, a statement of operations, a statement of cash flow (direct method), and notes to the financial statement, which shall be prepared on the basis of statutory accounting principles (see subsection 69O-191.075(1), F.A.C.), on an accrual basis, covering the HMO’s latest annual reporting period.

(4) Combination Model – HMO. A Health Maintenance Organization model that has a combination of the staff and IPA models to provide health care services to its membership.

(5) Community Rate. The per member per month revenue requirement for a set of benefits or services for a specific class of subscribers. Such class may encompass the community as a whole.

(6) Emergency Services. Services which are needed immediately because of an injury or unforeseen medical condition which could reasonably be expected to result in disability or death. These must be provided, or arranged to be provided, on a twenty-four hour basis by the HMO, but also may be covered inpatient services or outpatient services that are furnished by an appropriate source other than the HMO when the time required to reach the HMO providers (or alternatives authorized by the HMO) could mean the risk of permanent damage to the subscriber’s health. Notwithstanding the above, these services are considered to be emergency services, in or out of the service area, only as long as transfer of the subscriber to the HMO’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 nature of the medical condition.

(7) Fraud. A false statement concerning a material fact with knowledge by the person making the false statement and intent that the representation will induce action which results in detrimental reliance.

(8) Health Care Provider Certificate. A certificate issued by the Office of Health and Rehabilitative Services in accordance with Part III, Chapter 641, F.S.

(9) Health Maintenance Organization Type Insurance. The provision of health care services in exchange for a contractually set premium on a prepaid per capita or prepaid aggregate fixed-sum basis. The indemnity insurance type of arrangement which consists of a deductible amount and a percentage of fees due is permitted only where specifically authorized by Florida Statutes.

(10) HMO. Health Maintenance Organization may be abbreviated as HMO in these rules.

(11) Individual Physician. As used in Section 641.2342, F.S., a physician who is a sole practitioner with no other physicians employed by the contracting physician or under contract with the physician to provide primary care services.

(12) Individual Practice Association (IPA) Model – HMO. A Health Maintenance Organization health care delivery model in which the HMO contracts with individual physician(s), a medical group, or physician organization which in turn may contract with other individual physicians or groups. The IPA physicians may practice in their own offices and continue to see their fee-for-service patients.

(13) Medical Emergency. An unexpected and unforeseen disease, illness or injury which will result in disability or death if not treated immediately.

(14) Medical Staff. A formal organization of physicians and other health care practitioners in an HMO with the delegated responsibility to maintain acceptable standards in delivery of health care and to plan for continued betterment of that care.

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

(a) Emergency Care. Emergency inpatient, outpatient and physician services shall be available on a twenty-four hour, seven day a week basis, either by the HMO through its own facilities or through arrangements with other providers. Emergency resuscitation supplies shall be available. Physicians and other health care practitioners shall be readily available at all times. In addition, emergency services, as defined in these rules, shall be covered by the HMO.

(b) Inpatient Hospital Services. Inpatient hospital services shall be available on a twenty-four hour, seven day a week basis either through the HMO’s own facility or through arrangements with hospitals. Inpatient hospital services shall include, but are not limited to, 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 the providing and administration of whole blood and blood plasma, unless replacement blood is arranged or provided, in accordance with community replacement standards.

(c) Physician Care. Physician care, provided or supervised by physicians licensed under Chapter 458, 459, 460 or 461, F.S., of sufficient type and number 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 service with an emphasis directed toward primary care including but not limited to diagnostic laboratory and diagnostic radiological services.

(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 subscribers. This program shall include at least the following:

1. Well-child care from birth;

2. Periodic health evaluations for adults;

3. Eye screenings by a physician or optometrist licensed pursuant to Chapter 463, F.S., and ear screenings by a physician for children through age 17, to determine the need for vision and hearing correction; and

4. Pediatric and adult immunizations which are medically necessary in accordance with accepted medical practice.

(16) Optionally Renewable Contract. A contract for which renewal can be declined at the option of the HMO.

(17) Pre-Existing Condition or Illness. A condition, or symptoms thereof, which was diagnosed, and for which the individual received medical advice or treatment from a physician within a twenty-four month period preceding the effective date of coverage.

(18) Premium. The contracted sum paid by or on behalf of a subscriber or group of subscribers on a prepaid per capita or a prepaid aggregate basis for the services rendered by the HMO. The HMO may charge co-payments specified in the subscriber contract and in accordance with Rule 69O-191.035, F.A.C.

(19) Properly Completed Application. An application for a Certificate of Authority that contains all of the items specified in the Application for Certificate of Authority, obtained from the Applications Coordination Section, Insurer Services Support, Office of Insurance Regulation, Tallahassee, Florida 32399-0300, which is incorporated herein by reference. The application must be completed in accordance with Part II, Chapter 641, F.S., this rule chapter and in the manner specified within the application in order for each individual item to be considered complete for the purposes of determining that a properly completed application has been filed.

(20) Related Party. A related party means:

(a) Any director, officer, partner, or employee responsible for management of an HMO, or any person who is directly or indirectly beneficial owner of more than 5 percent of the equity of the HMO, any person who is the beneficial owner of a mortgage, deed of trust, note, evidence of indebtedness, or other interest secured by, and having a value of more than 5 percent of the assets of the HMO, and said debt is in default and may be subject to foreclosure and, in the case of an HMO organized as a nonprofit corporation, an incorporator or member of the corporation under applicable State corporation law;

(b) Any entity which has a director, officer, partner, or employee responsible for management or administration of an HMO, any person who is directly or indirectly beneficial owner of more than 5 percent of the equity of the HMO, any person who is the beneficial owner of a mortgage, deed of trust, note, evidence of indebtedness, or other interest, secured by assets of the HMO, and having a value of more than 5 percent of the assets of the HMO, and said debt is in default and may be subject to foreclosure and, in the case of an HMO organized as a nonprofit corporation, an incorporator or member of the corporation under applicable State corporation law or any of the persons identified in paragraph (a) above.

(21) Staff Model – HMO. A Health Maintenance Organization model in which the HMO employs and compensates its physicians. Generally, most ambulatory health services are provided at one or more healthcare delivery locations.

(22) Waiting Period. Waiting period shall relate to that period of time which may be specified in the policy and which must follow the date a person is initially insured under the policy before the coverage or coverages of the policy shall become effective as to such person.

Specific Authority 641.36 FS. Law Implemented 641.19, 641.21, 641.22, 641.31 FS. History–New 2-22-88, Amended 10-25-89, Formerly 4-31.024, Amended 5-28-92, 10-10-00, Formerly 4-191.024.