Contract Issues

• The office may require an HMO 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. 641.234(1)
• After review of a contract, the office may order the HMO 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 HMO under the contract are so unreasonably high as compared with similar contracts entered into by the HMO or as compared with similar contracts entered into by other HMOs in similar circumstances that the contract is detrimental to the subscribers, stockholders, investors, or creditors of the HMO; or (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. 641.234(2)
• Each HMO shall file, upon the request of the office, financial statements for all contract providers of comprehensive health care services who have assumed, through capitation or other means, more than 10 percent of the health care risks of the HMO. However, this provision shall not apply to any individual physician. 641.2342
• If an HMO, through a healthcare 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 HMO 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. 641.234(4)(a)
• Each contract between an HMO and a provider of healthcare 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 HMO is liable as specified in s. 641.3154. (641.315(1))
• All provider contracts must provide that the HMO will provide 60 days advance written notice to the provider and the office before canceling, without cause, the contract with the provider, except in a case in which a patient’s health is subject to imminent danger or a physician’s ability to practice medicine is effectively impaired by an action by the Board of Medicine or other governmental agency. 641.315(2)(b)
• A contract between a health plan and a provider of healthcare services must not contain any provision restricting the provider’s ability to communicate information to the provider’s patient regarding medical care or treatment options for the patient when the provider deems knowledge of such information by the patient to be in the best interest of the health of the patient. 641.315(5)
• A contract between a health plan and a provider of healthcare services may not contain any provision that in any way prohibits or restricts the healthcare provider from entering into a commercial contract with any other HMO or which restricts the health plan from entering into a commercial contract with any other healthcare provider. 641.315(6)
• A health insurer must not require a contracted healthcare practitioner to accept the terms of other healthcare practitioner contracts with the insurer or any other insured, or health plan, under common management and control with the insurer, except for a practitioner in a group practice who must accept the terms of a contract negotiated for the practitioner by the group, as a condition of continuation or renewal of the contract.
• Effective January 1, 2005, a health plan is required to disclose to the provider the complete schedule of reimbursements for all services that the HMO and provider have contracted, as well as any changes in or deviations from the contracted schedule of reimbursements. The HMO can satisfy this requirement by providing either an electronic or written copy of the reimbursement schedule and any applicable changes or deviations. The schedule of reimbursements is subject to the nondisclosure provisions of the contract and the provider must maintain the confidentiality of the schedule. 641.315(4)(d)