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Marisol Fitch, AHCA Administrator
Commercial Managed Care Unit

Bureau of Health Facility Regulation
2727 Mahan Drive MS #45


Tallahassee, FL 32308
Phone: (850) 412-4401
Florida Relay Service (TDD):(800) 955-8771
Fax: (850) 922-6059

 

The Commercial Managed Care Unit conducts the following reviews as applicable to Health Maintenance Organizations (HMOs), Prepaid Health Clinics (PHCs), Exclusive Provider Organizations (EPOs), and Workers' Compensation Managed Care Arrangements (WCMCAs). The HMOs and PHCs reviews consist of initial and biennial renewal Health Care Provider Certificates, expansion affidavits, annual risk management and triennial accreditation organizations. The EPOs reviews consist of initial Plan of Operations, expansion affidavits, semi-annual provider networks and annual grievance reporting. WCMCAs main function is to conduct annual and semi-annual provider network reviews to ensure network adequacy for the injured employee and determine the ability of provider networks to provide an adequate supply of medical services that are reasonably accessible within a geographic area. The unit also manages other programs/contracts, Health Flex Plan Program, and Statewide Provider and Health Plan Claim Dispute Resolution Program (MAXIMUS).

Notices/Updates

Effective July 1, 2018, the Subscriber Assistance Program is repealed pursuant Senate Bill 622

Commercial Health Maintenance Organizations (CHMOs)

Florida's CHMOs are dually regulated by the Agency for Health Care Administration (Agency), and the Department of Financial Services (DFS), Florida Office of Insurance Regulation (Office). The Agency monitors quality of care-related issues and the Office monitors financial and contractual issues. To become a commercially licensed HMO, an organization must receive a certificate of authority from the Office and a health care provider certificate from the Agency. Additionally, an HMO must be accredited.

Exclusive Provider Organizations (EPOs)

Florida's EPOs are dually regulated by the Agency for Health Care Administration (Agency), and the Department of Financial Services (DFS), Florida Office of Insurance Regulation (Office). The Agency monitors quality of care-related issues and the Office monitors financial and contractual issues. To become a licensed EPO, an organization must receive a certificate of authority from the Office and an approved plan of operation from the Agency.

Health Flex Plan Program

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.

Consumer Assistance Program

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) 

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 (Office). The Agency monitors quality of care-related issues and the Office monitors financial and contractual issues. To become a commercially licensed PHC, an organization must receive a certifcate of authority from the Office and a health care provider certificate from the Agency. Additionally, a PHC must be accredited.

Workers' Compensation Managed Care Arrangements 

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
Email: PublicRecordsReq@ahca.myflorida.com

Note: there will be a charge for all requests.

  • Section 440.134, Florida Statute: Workers' Compensation Managed Care Arrangements
  • Regulation and oversight of Florida's Workers' Compensation Managed Care Arrangements
  • Authorization, examination and compliance monitoring of an insured's workers' compensation managed care arrangement including approval of a workers' compensation managed care arrangement's plan of operation.
  • Drug-Free Workplace:
  • Section 440.101 and 440.102, Florida Statute: Drug- Free Workplace Standards & Requirements

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.

More information...

Cover Florida Health Care Access Program

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.)