Current through Reg. 50, No. 187; September 24, 2024
(1) All terms defined in the Prepaid Health
Clinic Act which are used in these rules shall have the same meaning as in the
Act.
(2) PHC. Prepaid health
clinics shall be abbreviated as PHC in these rules.
(3) Basic Services. Basic services include
any of the following services which if offered shall meet the definitions in
paragraphs (a) through (d) of this subsection:
(a) Emergency Care. Emergency outpatient
services shall be provided on a twenty-four hour basis, either by the PHC
through its own facilities or through guaranteed arrangements with other
providers. Life-saving measures must be furnished. A physician and sufficient
other licensed and ancillary personnel shall be readily available at all
times.
(b) Physician Care.
Physician care including licensed paramedical and other ancillary health care
personnel shall be of sufficient type and amount to provide adequately for the
contracted services.
(c) Ambulatory
Diagnostic Treatment. Ambulatory and/or outpatient diagnostic treatment
services shall be provided with emphasis directed toward primary
care.
(d) Preventive Health Care
Services. A program of health evaluation, education and immunizations shall be
provided which is designed to prevent illness and disease and to improve the
general health of PHC subscribers. This program shall include at least the
following:
1. Services for
infertility;
2. Well-child care
from birth;
3. Periodic health
evaluations for adults;
4. Eye and
ear examinations for children through age 17, to determine the need for vision
and hearing correction; and
5.
Pediatric and adult immunizations, in accord with accepted medical
practice.
(4)
Assets.
(a) Assets Defined. In any
determination of the financial condition of a PHC, there shall be allowed as
"assets" only those assets that are owned by the PHC and which assets consist
of:
1. Cash in the possession of the PHC, or
in transit under its control, including the true balance of any deposit in a
solvent bank, savings and loan association, or trust company which is domiciled
in the United States.
2.
Investments, securities, properties, and loans acquired or held in accordance
with Part III, Chapter 641, F.S., and in connection therewith the following
items:
a. Interest due or accrued on any bond
or evidence of indebtedness which is not in default and which is not valued on
a basis including accrued interest.
b. Declared and unpaid dividends on stock and
shares, unless the amount of the dividends has otherwise been allowed as an
asset.
c. Interest due or accrued
upon a collateral loan which is not in default in an amount not to exceed 1
year's interest thereon.
d.
Interest due or accrued on deposits or certificates of deposit in solvent
banks, savings and loan associations, and trust companies domiciled in the
United States, and interest due or accrued on other assets, if such interest is
in the judgment of the Office a collectible asset.
e. Interest due or accrued on current
mortgage loans, in an amount not exceeding in any event the amount, if any, of
the excess of the value of the property less delinquent taxes thereon over the
unpaid principal; but in no event shall interest accrued for a period in excess
of 90 days be allowed as an asset.
f. Rent due or accrued on real property if
such rent is not in arrears for more than 3 months, but in no event shall rent
accrued for a period in excess of 90 days be allowed as an asset.
g. The unaccrued portion of taxes paid prior
to the due date on real property.
3. Premiums in the course of collection, not
more than 3 months past due, less commissions payable thereon. This limitation
shall not apply to premiums payable directly or indirectly by any governmental
body in the United States or by any of their instrumentalities.
4. Furniture, fixtures, furnishings,
vehicles, medical libraries, and equipment, if the original cost of each item
is at least $200, which cost shall be amortized in full over a period not to
exceed 5 calendar years, unless otherwise approved by the Office.
5. Pharmaceutical and medical supply
inventories.
6. The liquidation
value of prepaid expenses.
7. Other
assets, not inconsistent with the provisions of this rule, deemed by the Office
to be available for the payment of benefits and claims, at values to be
determined by it.
(b)
Evaluation of Assets. The Office, upon determining that a PHC's asset has not
been evaluated according to applicable law or that it does not qualify as an
asset, shall require the PHC to reevaluate the asset properly or to replace the
asset with an asset acceptable to the Office within 90 days of this
determination, if the removal of the asset from the PHC's assets would impair
the PHC's solvency.
(c) Assets Not
Allowed. In addition to assets impliedly excluded by the provisions of
paragraph (a) of subsection (4), above, the following expressly shall not be
allowed as assets in any determination of the financial condition of a PHC:
1. Good will, trade names, and other like
intangible assets.
2. Advances to
officers, directors, and controlling stockholders, whether secured or not, and
advances to employees, agents, and other persons on personal security
only.
3. Stock of the PHC owned by
it directly or owned indirectly by it through any entity in which the PHC owns
or controls, directly or indirectly, more than 25 percent of the ownership
interest.
4. Leasehold
improvements, nonmedical libraries, stationery, literature, and nonmedical
supply inventories.
5. Furniture,
fixtures, furnishings, vehicles, medical libraries, and equipment, other than
those items authorized under subparagraph 5. of paragraph (a).
6. Notes or other evidences of indebtedness
which are secured by mortgages or deeds of trust which are in default and
beyond the express period specified in the instrument for curing the
default.
7. Bonds in default for
more than 60 days.
8. Deferred
costs other than prepaid expenses.
(5) Liabilities.
(a) In any determination of the financial
condition of a PHC, liabilities to be charged against its assets shall include:
1. The amount, estimated consistent with the
provisions of Part III, Chapter 641, F.S., necessary to pay all of its unpaid
losses and claims incurred for or on behalf of a subscriber on or prior to the
end of the reporting period, whether reported or unreported.
2. The amount equal to the unearned portions
of the gross premium charged on policies in force, computed in accordance with
Part III of Chapter 641, F.S.
3.
Taxes, expenses, and other obligations due or accrued at the date of the
statement.
(b) Evaluation
of liabilities. The Office, upon determining that a PHC has failed to report
liabilities that should have been reported, shall require a corrected report
which reflects the proper liabilities to be submitted by the PHC to the Office
within 10 working days of receipt of notification.
(6) Security. Security means any note, stock,
treasury stock, bond, debenture, evidence of indebtedness, certificate of
interest or participation, whiskey warehouse receipt or other commodity
warehouse receipt, or right to subscribe to any of the foregoing; certificate
of interest in a profit-sharing agreement or the right to participate therein;
certificate of interest in an oil, gas, petroleum, mineral, or mining title or
lease, or the right to participate therein; collateral trust certificate,
reorganization certificate, preorganization subscription, or any transferable
share, investment contract, or beneficial interest in title to property,
profits, or earnings; interests in or under a profit-sharing or participation
agreement or scheme, or any other instrument commonly known as a security,
including an interim or temporary bond, debenture, note, certificate, or
receipt for a security or for subscription to a security.
(7) Surplus Notes. Surplus notes must meet
the following requirements:
(a) They must be
subordinated to the Florida minimum surplus requirement as provided for in
Section 641.407, F.S.;
(b) They must be subordinated to all other
liabilities; and
(c) The PHC must
obtain written consent from the Office before any repayment of principal or
interest may be made.
(8)
Actuarially Sound. Means the ability of the proposed PHC to deliver all the
services to be furnished by the PHC at the rate structure established including
administrative costs, which shall be defined as general and administrative
expenses for the PHC. Actuarial soundness will be determined by the Office
based on a review of the actuarial study under which the rates and loss
reserves are established. Consideration will be given to the character and
amount of guaranteed services by the organizers, the method of marketing, and
the degree of market penetration that can reasonably be expected.
(9) Excessive, Inadequate or Unfairly
Discriminatory Rates. A rate shall be deemed to be excessive if the rate is
unreasonably high for the services provided when compared with the cost for
similar health care services in the community. A rate shall be deemed to be
inadequate if the continued use of the rate endangers the solvency of the PHC
using it, or if continued use by the PHC has or will have the effect of being
unfair competition or creating a monopoly. This provision is designed to
promote efficient and effective operation of PHC's. A rate shall be deemed to
be unfairly discriminatory if the PHC knowingly makes or permits any unfair
discrimination between individuals of the same actuarially supportable class
and essentially the same hazard, in the amount of premium, policy fees, rates
charged, or benefits payable under the terms or conditions of the contract, or
in any other manner whatever.
(10)
Premium. The fixed sum paid by or on behalf of a subscriber or group of
subscribers on a prepaid per capita or prepaid aggregate basis for the services
rendered by the PHC.
Rulemaking Authority 641.403 FS. Law Implemented
641.402(1), 641.405, 641.406, 641.418, 641.42, 641.441
FS.
New 5-9-85, Formerly 4-69.02, 4-69.002, 4-194.002, Amended
9-28-22.
