Florida Statutes
Part I - Health Maintenance Organizations (Ss. 641.17-641.3923)
641.3903 - Unfair methods of competition and unfair or deceptive acts or practices defined.

(1) MISREPRESENTATION AND FALSE ADVERTISING OF HEALTH MAINTENANCE CONTRACTS.—Knowingly making, issuing, or circulating, or causing to be made, issued, or circulated, any estimate, illustration, circular, statement, sales presentation, omission, or comparison which:
(a) Misrepresents the benefits, advantages, conditions, or terms of any health maintenance contract.
(b) Is misleading, or is a misrepresentation as to the financial condition of any person.
(c) Uses any name or title of any contract misrepresenting the true nature thereof.
(d) Is a misrepresentation for the purpose of inducing, or tending to induce, the lapse, forfeiture, exchange, conversion, or surrender of any health maintenance contract or health insurance policy, or contract providing health insurance as defined in s. 624.603.
(e) Misrepresents the benefits, nature, characteristics, uses, standard, quantity, quality, cost, rate, scope, source, or geographic origin or location of any goods or services available from or provided by, directly or indirectly, any health maintenance organization.
(f) Misrepresents the affiliation, connection, or association of any goods, services, or business establishment.
(g) Advertises goods or services with intent not to sell them as advertised.
(h) Disparages the goods, services, or business of another person by any false or misleading representation.
(i) Misrepresents the sponsorship, endorsement, approval, or certification of goods or services.
(j) Uses an advertising format which, by virtue of the design, location, or size of printed matter, is deceptive or misleading or which would be deceptive or misleading to any reasonable person.
(k) Offers to provide a service which the health maintenance organization is unable to provide.
(l) Misrepresents the availability of a service provided by the health maintenance organization, either directly or indirectly, including the availability of the service as to location.

(2) FALSE INFORMATION AND ADVERTISING GENERALLY.—Knowingly making, publishing, disseminating, circulating, or placing before the public, or causing, directly or indirectly, to be made, published, disseminated, circulated, or placed before the public:
(a) In a newspaper, magazine, or other publication;
(b) In the form of a notice, circular, pamphlet, letter, or poster;
(c) Over any radio or television station; or
(d) In any other way,
an advertisement, announcement, or statement containing any assertion, representation, or statement with respect to the business of the health maintenance organization which is untrue, deceptive, or misleading.

(3) DEFAMATION.—Knowingly making, publishing, disseminating, or circulating, directly or indirectly, or aiding, abetting, or encouraging the making, publishing, disseminating, or circulating of, any oral or written statement, or any pamphlet, circular, article, or literature, which is false or maliciously critical of any person and which is calculated to injure such person.
(4) FALSE STATEMENTS AND ENTRIES.—
(a) Knowingly:
1. Filing with any supervisory or other public official,
2. Making, publishing, disseminating, or circulating,
3. Delivering to any person,
4. Placing before the public, or
5. Causing, directly or indirectly, to be made, published, disseminated, circulated, or delivered to any person, or place before the public,
any material false statement.

(b) Knowingly making any false entry of a material fact in any book, report, or statement of any person.

(5) UNFAIR CLAIM SETTLEMENT PRACTICES.—
(a) Attempting to settle claims on the basis of an application or any other material document which was altered without notice to, or knowledge or consent of, the subscriber or group of subscribers to a health maintenance organization;
(b) Making a material misrepresentation to the subscriber for the purpose and with the intent of effecting settlement of claims, loss, or damage under a health maintenance contract on less favorable terms than those provided in, and contemplated by, the contract; or
(c) Committing or performing with such frequency as to indicate a general business practice any of the following:
1. Failing to adopt and implement standards for the proper investigation of claims;
2. Misrepresenting pertinent facts or contract provisions relating to coverage at issue;
3. Failing to acknowledge and act promptly upon communications with respect to claims;
4. Denying of claims without conducting reasonable investigations based upon available information;
5. Failing to affirm or deny coverage of claims upon written request of the subscriber within a reasonable time not to exceed 30 days after a claim or proof-of-loss statements have been completed and documents pertinent to the claim have been requested in a timely manner and received by the health maintenance organization;
6. Failing to promptly provide a reasonable explanation in writing to the subscriber of the basis in the health maintenance contract in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement;
7. Failing to provide, upon written request of a subscriber, itemized statements verifying that services and supplies were furnished, where such statement is necessary for the submission of other insurance claims covered by individual specified disease or limited benefit policies, provided that the organization may receive from the subscriber a reasonable administrative charge for the cost of preparing such statement;
8. Failing to provide any subscriber with services, care, or treatment contracted for pursuant to any health maintenance contract without a reasonable basis to believe that a legitimate defense exists for not providing such services, care, or treatment. To the extent that a national disaster, war, riot, civil insurrection, epidemic, or any other emergency or similar event not within the control of the health maintenance organization results in the inability of the facilities, personnel, or financial resources of the health maintenance organization to provide or arrange for provision of a health service in accordance with requirements of this part, the health maintenance organization is required only to make a good faith effort to provide or arrange for provision of the service, taking into account the impact of the event. For the purposes of this paragraph, an event is not within the control of the health maintenance organization if the health maintenance organization cannot exercise influence or dominion over its occurrence; or
9. Systematic downcoding with the intent to deny reimbursement otherwise due.


(6) FAILURE TO MAINTAIN COMPLAINT-HANDLING PROCEDURES.—Failure of any person to maintain a complete record of all the complaints received since the date of the most recent examination of the health maintenance organization by the office. For the purposes of this subsection, the term “complaint” means any written communication primarily expressing a grievance and requesting a remedy to the grievance.
(7) OPERATION WITHOUT A SUBSISTING CERTIFICATE OF AUTHORITY.—Operation of a health maintenance organization by any person or entity without a subsisting certificate of authority therefor or renewal, issuance, or delivery of any health maintenance contract by a health maintenance organization, person, or entity without a subsisting certificate of authority.
(8) MISREPRESENTATION IN HEALTH MAINTENANCE ORGANIZATION APPLICATIONS.—Knowingly making false or fraudulent statements or representations on, or relative to, an application for a health maintenance contract for the purpose of obtaining a fee, commission, money, or other benefits from any health maintenance organization; agent; or representative, broker, or individual.
(9) TWISTING.—Knowingly making any misleading representations or incomplete or fraudulent comparisons of any health maintenance contracts or health maintenance organizations or of any insurance policies or insurers for the purpose of inducing, or intending to induce, any person to lapse, forfeit, surrender, terminate, retain, pledge, assign, borrow on, or convert any insurance policy or health maintenance contract or to take out a health maintenance contract or policy of insurance in another health maintenance organization or insurer.
(10) ILLEGAL DEALINGS IN PREMIUMS; EXCESS OR REDUCED CHARGES FOR HEALTH MAINTENANCE COVERAGE.—
(a) Knowingly collecting any sum as a premium or charge for health maintenance coverage which is not then provided or is not in due course to be provided, subject to acceptance of the risk by the health maintenance organization, by a health maintenance contract issued by a health maintenance organization as permitted by this part.
(b) Knowingly collecting as a premium or charge for health maintenance coverage any sum in excess of or less than the premium or charge applicable to health maintenance coverage, in accordance with the applicable classifications and rates as filed with the office, and as specified in the health maintenance contract.

(11) FALSE CLAIMS; OBTAINING OR RETAINING MONEY DISHONESTLY.—Any agent or representative, physician, claimant, or other person who causes to be presented to any health maintenance organization a false claim for payment knowing the same to be false.
(12) PROHIBITED DISCRIMINATORY PRACTICES.—A health maintenance organization may not:
(a) Engage or attempt to engage in discriminatory practices that discourage participation on the basis of actual or perceived health status of Medicaid recipients.
(b) Refuse to provide services or care to a subscriber solely because medical services may be or have been sought for injuries resulting from an assault, battery, sexual assault, sexual battery, or any other offense by a family or household member, as defined in s. 741.28, or by another who is or was residing in the same dwelling unit.

(13) MISREPRESENTATION IN HEALTH MAINTENANCE ORGANIZATION; AVAILABILITY OF PROVIDERS.—Knowingly misleading potential enrollees as to the availability of providers.
(14) ADVERSE ACTION AGAINST A PROVIDER.—Any retaliatory action by a health maintenance organization against a contracted provider, including, but not limited to, termination of a contract with the provider, on the basis that the provider communicated information to the provider’s patient regarding medical care or treatment options for the patient when the provider deems knowledge of such information by the patient to be in the best interest of the patient.
(15) PARTICIPATION IN A WELLNESS OR HEALTH IMPROVEMENT PROGRAM.—
(a) Authorization to offer rewards or incentives for participation.—A health maintenance organization issuing a group or individual health benefit plan may offer a voluntary wellness or health improvement program and may encourage or reward participation in the program by authorizing rewards or incentives, including, but not limited to, merchandise, gift cards, debit cards, premium discounts, contributions to a member’s health savings account, or modifications to copayment, deductible, or coinsurance amounts.
(b) Verification of medical condition by nonparticipants due to medical condition.—A health maintenance organization may require a member of a health benefit plan to provide verification, such as an affirming statement from the member’s physician, that the member’s medical condition makes it unreasonably difficult or inadvisable to participate in the wellness or health improvement program in order for that nonparticipant to receive the reward or incentive.
(c) Disclosure requirement.—A reward or incentive offered under this subsection shall be disclosed in the policy or certificate.
(d) Other incentives.—This subsection does not prohibit health maintenance organizations from offering other incentives or rewards for adherence to a wellness or health improvement program if otherwise authorized by state or federal law.

History.—ss. 36, 47, ch. 85-177; ss. 187, 188, ch. 91-108; s. 4, ch. 91-429; s. 28, ch. 96-199; s. 6, ch. 96-223; s. 1, ch. 99-264; s. 5, ch. 2000-252; s. 8, ch. 2002-55; s. 1591, ch. 2003-261; s. 2, ch. 2011-167.

Structure Florida Statutes