Section 69O-194.002 - Definitions(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; and5. 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.Fla. Admin. Code Ann. R. 69O-194.002
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 by Florida Register Volume 48, Number 178, September 13, 2022 effective 9/28/2022.New 5-9-85, Formerly 4-69.02, 4-69.002, 4-194.002, Amended 9-28-22.