641.37 – Prohibited activities; penalties.
641.37 Prohibited activities; penalties.— (1) Any person or entity which knowingly renews, issues, or delivers any health maintenance contract without first obtaining and thereafter maintaining a certificate of authority is guilty of a felony of the third degree, punishable as provided in s. 775.082 or s. 775.083. (2) Except as provided in subsection (1), any person, entity, or […]
641.31099 – Restrictions on use of state and federal funds for state exchanges.
641.31099 Restrictions on use of state and federal funds for state exchanges.— (1) A health maintenance contract under which coverage is purchased in whole or in part with any state or federal funds through an exchange created pursuant to the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, may not provide coverage for an […]
641.3111 – Extension of benefits.
641.3111 Extension of benefits.— (1) Every group health maintenance contract shall provide that termination of the contract shall be without prejudice to any continuous loss which commenced while the contract was in force, but any extension of benefits beyond the period the contract was in force may be predicated upon the continuous total disability of the subscriber […]
641.312 – Scope.
641.312 Scope.—The Office of Insurance Regulation may adopt rules to administer the National Association of Insurance Commissioners’ Uniform Health Carrier External Review Model Act, issued by the National Association of Insurance Commissioners and dated April 2010. This section does not apply to the types of benefits or coverages provided under s. 627.6513(1)-(14) issued in any market. […]
641.313 – Health maintenance contracts; cancer treatment parity; orally administered cancer treatment medications.
641.313 Health maintenance contracts; cancer treatment parity; orally administered cancer treatment medications.— (1) As used in this section, the term: (a) “Cancer treatment medication” means medication prescribed by a treating physician who determines that the medication is medically necessary to kill or slow the growth of cancerous cells in a manner consistent with nationally accepted standards of practice. […]
641.314 – Pharmacy benefit manager contracts.
641.314 Pharmacy benefit manager contracts.— (1) As used in this section, the term: (a) “Maximum allowable cost” means the per-unit amount that a pharmacy benefit manager reimburses a pharmacist for a prescription drug, excluding dispensing fees, prior to the application of copayments, coinsurance, and other cost-sharing charges, if any. (b) “Pharmacy benefit manager” means a person or entity doing […]
641.315 – Provider contracts.
641.315 Provider contracts.— (1) Each contract between a health maintenance organization and a provider of health care services must be in writing and must contain a provision that the subscriber is not liable to the provider for any services for which the health maintenance organization is liable as specified in s. 641.3154. (2)(a) For all provider contracts executed […]
641.3154 – Organization liability; provider billing prohibited.
641.3154 Organization liability; provider billing prohibited.— (1) If a health maintenance organization is liable for services rendered to a subscriber by a provider, regardless of whether a contract exists between the organization and the provider, the organization is liable for payment of fees to the provider and the subscriber is not liable for payment of fees to […]
641.3155 – Prompt payment of claims.
641.3155 Prompt payment of claims.— (1) As used in this section, the term “claim” for a noninstitutional provider means a paper or electronic billing instrument submitted to the health maintenance organization’s designated location that consists of the HCFA 1500 data set, or its successor, that has all mandatory entries for a physician licensed under chapter 458, chapter […]
641.3156 – Treatment authorization; payment of claims.
641.3156 Treatment authorization; payment of claims.— (1) A health maintenance organization must pay any hospital-service or referral-service claim for treatment for an eligible subscriber which was authorized by a provider empowered by contract with the health maintenance organization to authorize or direct the patient’s utilization of health care services and which was also authorized in accordance with […]