For the purposes of this part, the term:(1) “Administrator” means any person who directly or indirectly solicits or effects coverage of, collects charges or premiums from, or adjusts or settles claims on residents of this state in connection with authorized commercial self-insurance funds or with insured or self-insured programs which provide life or health insurance coverage or coverage of any other expenses described in s. 624.33(1); any person who, through a health care risk contract as defined in s. 641.234 with an insurer or health maintenance organization, provides billing and collection services to health insurers and health maintenance organizations on behalf of health care providers; or a pharmacy benefit manager. The term does not include any of the following:(a) An employer or wholly owned direct or indirect subsidiary of an employer, on behalf of such employer’s employees or the employees of one or more subsidiary or affiliated corporations of such employer.
(b) A union on behalf of its members.
(c) An insurance company which is either authorized to transact insurance in this state or is acting as an insurer with respect to a policy lawfully issued and delivered by such company in and pursuant to the laws of a state in which the insurer was authorized to transact an insurance business.
(d) A health care services plan, health maintenance organization, professional service plan corporation, or person in the business of providing continuing care, possessing a valid certificate of authority issued by the office, and the sales representatives thereof, if the activities of such entity are limited to the activities permitted under the certificate of authority.
(e) An entity that is affiliated with an insurer and that only performs the contractual duties, between the administrator and the insurer, of an administrator for the direct and assumed insurance business of the affiliated insurer. The insurer is responsible for the acts of the administrator and is responsible for providing all of the administrator’s books and records to the insurance commissioner, upon a request from the insurance commissioner. For purposes of this paragraph, the term “insurer” means a licensed insurance company, health maintenance organization, prepaid limited health service organization, or prepaid health clinic.
(f) A nonresident entity licensed in its state of domicile as an administrator if its duties in this state are limited to the administration of a group policy or plan of insurance and no more than a total of 100 lives for all plans reside in this state.
(g) An insurance agent licensed in this state whose activities are limited exclusively to the sale of insurance.
(h) A person appointed as a managing general agent in this state, whose activities are limited exclusively to the scope of activities conveyed under such appointment.
(i) An adjuster licensed in this state whose activities are limited to the adjustment of claims.
(j) A creditor on behalf of such creditor’s debtors with respect to insurance covering a debt between the creditor and its debtors.
(k) A trust and its trustees, agents, and employees acting pursuant to such trust established in conformity with 29 U.S.C. s. 186.
(l) A trust exempt from taxation under s. 501(a) of the Internal Revenue Code, a trust satisfying the requirements of ss. 624.438 and 624.439, or any governmental trust as defined in s. 624.33(3), and the trustees and employees acting pursuant to such trust, or a custodian and its agents and employees, including individuals representing the trustees in overseeing the activities of a service company or administrator, acting pursuant to a custodial account which meets the requirements of s. 401(f) of the Internal Revenue Code. (m) A financial institution which is subject to supervision or examination by federal or state authorities or a mortgage lender licensed under chapter 494 who collects and remits premiums to licensed insurance agents or authorized insurers concurrently or in connection with mortgage loan payments.
(n) A credit card issuing company which advances for and collects premiums or charges from its credit card holders who have authorized such collection if such company does not adjust or settle claims.
(o) A person who adjusts or settles claims in the normal course of such person’s practice or employment as an attorney at law and who does not collect charges or premiums in connection with life or health insurance coverage.
(p) A person approved by the department who administers only self-insured workers’ compensation plans.
(q) A service company or service agent and its employees, authorized in accordance with ss. 626.895-626.899, serving only a single employer plan, multiple-employer welfare arrangements, or a combination thereof. (r) Any provider or group practice, as defined in s. 456.053, providing services under the scope of the license of the provider or the member of the group practice. (s) Any hospital providing billing, claims, and collection services solely on its own and its physicians’ behalf and providing services under the scope of its license.
(t) A corporation not for profit whose membership consists entirely of local governmental units authorized to enter into risk management consortiums under s. 112.08. A person who provides billing and collection services to health insurers and health maintenance organizations on behalf of health care providers shall comply with the provisions of ss. 627.6131, 641.3155, and 641.51(4).
(2) “Affiliate” or “affiliated” means an entity or person who directly or indirectly through one or more intermediaries controls, is controlled by, or is under common control with a specified entity or person.
(3) “Control,” including the terms “controlling,” “controlled by,” and “under common control with,” means the possession, direct or indirect, of the power to direct or cause the direction of the management and policies of a person, whether through the ownership or voting securities, by contract other than a commercial contract for goods or nonmanagement services, or otherwise, unless the power is the result of an official position with or corporate office held by the person. Control shall be presumed to exist if any person directly or indirectly owns, controls, holds with the power to vote, or holds proxies representing 10 percent or more of the voting securities of any other person.
(4) “GAAP” means United States generally accepted accounting principles consistently applied.
(5) “Insurer” includes an authorized commercial self-insurance fund and includes any person undertaking to provide life or health insurance coverage or coverage of any of the other expenses described in s. 624.33(1). (6) “Pharmacy benefit manager” means a person or an entity doing business in this state which contracts to administer prescription drug benefits on behalf of a pharmacy benefits plan or program as defined in s. 626.8825. The term includes, but is not limited to, a person or an entity that performs one or more of the following services on behalf of such plan or program:(a) Pharmacy claims processing.
(b) Administration or management of a pharmacy discount card program and performance of any other service listed in this subsection.
(c) Managing pharmacy networks or pharmacy reimbursement.
(d) Paying or managing claims for pharmacist services provided to covered persons.
(e) Developing or managing a clinical formulary, including utilization management or quality assurance programs.
(f) Pharmacy rebate administration.
(g) Managing patient compliance, therapeutic intervention, or generic substitution programs.
(h) Administration or management of a mail-order pharmacy program.
