Marisol Fitch, AHCA Administrator
Commercial Managed Care Unit
Bureau of Health Facility Regulation
2727 Mahan Drive MS #45
Tallahassee, FL 32308
Phone: (850) 412-4502
Florida Relay Service (TDD):(800)955-8771
Fax: (850) 413-0900
The Commercial Managed Care Unit (CMCU) conducts regulatory oversight and issues Health Care Provider Certificates for commercial health maintenance organizations (HMOs), prepaid health clinics (PHCs), and approves operational plans of exclusive provider organizations (EPOs), and Worker’s Compensation managed care arrangements (WCMCAs) as required by statute. Manages the Subscriber Assistance Program (SAP) and other programs/contracts; Health Flex Plan Program, and Statewide Provider and Health Plan Claim Dispute Resolution Program (Maximus).
Florida's CHMOs are dually regulated by the Agency for Health Care Administration (Agency), and the Department of Financial Services Office of Insurance Regulation (DFS), Florida Office of Insurance Regulation (OIR). The Agency monitors quality of care-related issues and the OIR monitors financial and contractual issues. To become a commercially licensed HMO, an organization must receive a certificate of authority from OIR and a health care provider certificate from the Agency. Additionally, an HMO must be accredited.
Exclusive Provider Organizations (EPOs) are individual providers or groups of providers who have entered into written agreements with an insurer to provide health care services to subscribers.
An insurer may not issue a policy or certificate that is subject to an exclusive provider provision until the EPO's plan of operation has been approved by the Agency. An EPO is required to maintain a quality assurance program and procedures for hearing complaints and resolving written grievances from the subscribers.
The Health Flex Plan, established in Section 408.909, Florida Statutes, became effective July 1, 2002. The Legislature found that a significant proportion of the residents of this state are unable to obtain affordable health insurance coverage. Therefore, it is the intent of the Legislature to expand the availability of health options for low-income uninsured state residents by encouraging health insurers, health maintenance organizations, health care provider sponsored organizations, local governments, health care districts or other public or private community-sponsored organizations to develop alternative approaches to traditional health insurance that emphasize coverage for basic and preventive health care services.
The Subscriber Assistance Program, established in section 408.7056, Florida Statutes, provides an unbiased forum for the review and analysis of unresolved grievances.
Prepaid Health Clinics (PHCs) are health plans that provide health care services to groups and individual subscribers who have made regular premium payments to the plan. These plans emphasize effective cost and quality controls. PHCs meet similar quality of care requirements as HMOs and must also be accredited.
Florida's PHCs are dually regulated by the Agency for Health Care Administration (Agency) and the Department of Financial Services (DFS), Florida Office of Insurance Regulation (OIR). To become a commercially licensed PHC, an organization must receive a health care provider certificate from the Agency and a certificate of authority from OIR. Quality of care issues, such as timely access to appropriate health care professionals or services, are monitored and enforced by the Agency. Financial and contractual issues, such as the financial stability of a PHC, are monitored and regulated by OIR.
Request for Workers' Compensation Managed Care Information should be sent to:
Agency for Health Care Administration
Public Records Coordinator
2727 Mahan Drive, Ft. Knox #3, MS #3
Tallahassee, Florida 32308
Phone: (850) 412-3688
Note: there will be a charge for all requests.
The Department of Financial Services regulates employers, insurers, health care providers, and provides assistance to injured employees. Please contact DFS at (800)342-1791 or (850)413-1601 or visit the website at www.myfloridacfo.com/division/wc/ for information.
The 2008 Florida Legislature established the Cover Florida Health Care Access Program, recognizing that a significant number of Florida residents are unable to obtain affordable health insurance coverage. The Cover Florida Health Care Access Program was established to expand the availability of health care options for uninsured residents. Affordable health care products were developed that emphasized coverage for basic and preventive health care services, as well as inpatient hospital, urgent and emergency care services. (Section 408.9091, Florida Statutes.)