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 Health Maintenance Organization (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.
The Office's information and requirements for health plans can be accessed at the following links:
The Commercial Managed Care Unit conducts the following reviews as applicable to 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 network 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).
For information on purchasing insurance coverage and to verify the license of agents and companies, please reference the Office's Consumer Resources/How Do I internet link: http://www.floir.com/Office/SearchableTools.aspx.