<P> HMOs in the USA are regulated at both the state and federal levels . They are licensed by the states, under a license that is known as a certificate of authority (COA) rather than under an insurance license . State and federal regulators also issue mandates, requirements for health maintenance organizations to provide particular products . In 1972 the National Association of Insurance Commissioners adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operation . </P> <P> HMOs often have a negative public image due to their restrictive appearance . HMOs have been the target of lawsuits claiming that the restrictions of the HMO prevented necessary care . Whether an HMO can be held responsible for a physician's negligence partially depends on the HMO's screening process . If an HMO only contracts with providers meeting certain quality criteria and advertises this to its members, a court may be more likely to find that the HMO is responsible, just as hospitals can be liable for negligence in selecting physicians . However, an HMO is often insulated from malpractice lawsuits . The Employee Retirement Income Security Act (ERISA) can be held to preempt negligence claims as well . In this case, the deciding factor is whether the harm results from the plan's administration or the provider's actions . ERISA does not preempt or insulate HMOs from breach of contract or state law claims asserted by an independent, third - party provider of medical services143 . </P>

Which of the following is not required in order to operate as an hmo in florida