631.818 Powers and duties of the plan.
631.818 Powers and duties of the plan.
(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.
(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.
(2) 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.
(3) 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.
(4) 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 or a proceeding under 1s. 624.90.
(5) 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.
(6) 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.
(f) Take such legal action as may be necessary to avoid payment of improper claims.
History. ss. 1, 23, ch. 88-388; ss. 106, 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 10, ch. 2000-252; s. 1366, ch. 2003-261.
1
Note. The referenced section does not exist.