Current through Reg. 50, No. 187; September 24, 2024
An individual policy of accident and health insurance or
nonprofit, medical, surgical, or hospital service corporation contract shall
not be delivered or issued for delivery in this state unless the outline of
coverage required by Section
627.642, F.S., labels and
describes the policy or contract in accordance with the specified categories of
coverage contained in this rule. Nothing in this rule shall preclude the
issuance of any policy or contract combining two or more categories of coverage
set forth in Section 627.643(2),
F.S. This rule does not apply to policies issued pursuant to a conversion
privilege. Types of policies controlled by this rule are as follows:
(1) Basic Hospital Expense Insurance - "Basic
Hospital Expense Insurance" is a policy of accident and health insurance which
provides coverage for a period of not less than 31 days during any one period
of confinement for each person insured under the policy for the expense
incurred for necessary treatment and services rendered as a result of an injury
or sickness for at least the following:
(a)
Daily hospital room and board in an amount not less than the lesser of the
average semi-private room rate in the community in which the insured resides or
$30.00 per day; and,
(b)
Miscellaneous hospital service in an amount not less than ten times the daily
hospital room and board benefit for the expense incurred for the charges made
by the hospital for services and supplies rendered by the hospital and provided
for use only during the period of confinement; and,
(c) Hospital outpatient services up to an
amount of $50.00 for hospital-rendered services as an outpatient incurred
within 72 hours of any one accident. Benefits provided under paragraphs (a) and
(b) above may be provided subject to a combined deductible amount in excess of
$100.00. This section does not prohibit a policy or rider especially designed
to provide benefits for an insured person to supplement existing in force
coverage.
(2) Basic
Medical Expense Insurance - "Basic Medical Expense Insurance" is a policy of
accident and health insurance which provides coverage for each person insured
under the policy for the expense incurred for the necessary services and
treatment of an injury or sickness for at least the following: In-hospital
medical services, consisting of physician services rendered to a person who is
a bed patient in a hospital for treatment of sickness or injury other than that
for which surgical care is required, in an amount not less than $5.00 per call,
one call per day, for at least 21 such calls during "one period of confinement"
or similar benefit acceptable to the Office.
(3) Basic Surgical Expense Insurance - "Basic
Surgical Expense Insurance" is a policy of accident and health insurance which
provides coverage for each insured under the policy for the expense incurred
for the necessary services rendered by a physician for treatment of an injury
or sickness for at least the following:
(a)
Surgical procedures for the treatment of a sickness, or injury, and endoscopic
procedures including any preoperative and postoperative care usually rendered
in connection with such operation or procedure, in an amount (a) not less than
75% of the reasonable charges or (b) if specified in dollar amounts, a fee
schedule providing amounts for any procedure at least equal to those provided
in a fee schedule with a maximum of $400.00 based on a relative value schedule
acceptable to the Commissioner of Insurance.
(b) Anesthetic services, consisting of
administration of necessary general anesthetics and related procedures in
connection with covered surgical service rendered by a physician other than the
physician (or his assistant) performing the surgical services, of at least 15
percent of the surgical service benefit provided. Surgical schedules contained
in the policy shall include a provision providing coverage for procedures not
specifically listed in the schedules and not otherwise excluded by the policy,
and benefits therefore shall be consistent with the benefits for comparable
procedures. Whenever a policy is written that provides at least the coverages
required for both basic hospital expense coverage and basic medical and/or
basic surgical expense coverages, the allowable deductible may be applied to
the combined coverage.
(4) Hospital Confinement Indemnity Insurance
- "Hospital Confinement Indemnity Insurance" is a policy of accident and health
insurance which provides daily benefits for hospital confinement on an
indemnity basis in an amount not less than $10.00 per day and not less than 31
days during any one period of confinement for each person insured under the
policy and with no elimination period unless benefit period is 365 days or
more, in which case, a three day elimination period will be
acceptable.
(5) Major Medical
Expense Insurance:
(a) "Major Medical Expense
Insurance" is a policy of accident and health insurance which provides
hospital, medical and surgical coverage as follows:
1. The aggregate maximum is not less than
$10,000 per covered person.
2. The
co-payment by a covered person is not more than 25 percent of covered charges
except that the co-payment percentage applicable to subparagraph (5)(b)7. of
this section may not be more than 50 percent.
3. The deductible is stated on a per person,
per family, per illness, per benefit period or per year basis, or a combination
of such basis, and, other than as specified in the next sentence, is not more
than 10 percent of the maximum limit under the coverage. In lieu of a fixed
dollar amount, the deductible amount may be expressed as (a) the higher of a
fixed dollar amount of basic deductible and the policy's covered charges paid
by other medical expense coverage; or (b) not more than $500 plus the policy's
covered charges paid by other medical expense coverage.
4. The maximum benefit period of an "each
cause" type of policy (where a separate deductible is required for different
sicknesses and accidents) is not less than 18 months and the maximum benefit
period for an "all cause" type of policy (where separate deductibles are not
required for different sicknesses or accidents) is not less than the number of
days remaining in the calendar or policy year after the deductible has been
met.
5. The period allowed to
satisfy the deductible is not less than 90 days.
(b) Major Medical Expense Insurance must
provide for each covered person coverage of:
1. Hospital room and board expenses, prior to
application of the co-payment percentage, for not less than $40.00 daily (or in
lieu thereof the average daily cost of semiprivate room rate in the area where
the insured resides) for a period of not less than 30 days for any period of
continuous hospital confinement;
2.
Miscellaneous hospital services, prior to application of the co-payment
percentage, for an aggregate maximum of not less than $1,500 or 15 times the
daily room and board rate if specified in dollar amounts;
3. Surgical fees, prior to application of the
co-payment percentage, to a maximum of not less than $600.00 for the most
severe operation with the amounts provided for other operations reasonably
related to such maximum amount;
4.
Anesthetic services, prior to application of the co-payment percentage of at
least 15 percent of the covered surgical fees or, alternatively, if the
surgical schedule is based on relative values, not less than the amount
provided therein for anesthetic services at the same unit value as used for the
surgical schedule;
5. Doctor
visits, in or out of the hospital, with minimum dollar amounts per visit, prior
to application of the co-payment percentage, equal to not less than $8.00 per
visit, covering not less than one visit per day and for an aggregate maximum of
such covered charges of not less than $600.00;
6. Out-of-hospital diagnostic x-rays and
tests, prior to application of the co-payment percentage, for an aggregate
maximum of such covered charges of not less than $600.00;
7. No fewer than three of the following
additional benefits, prior to application of the co-payment percentage, for an
aggregate maximum of such covered charges of not less than $1,000:
a. Private duty registered or if not
available, licensed practical nurse services performed by other than a family
member while insured is hospital confined;
b. Convalescent nursing home care;
c. Diagnosis and treatment by a radiologist
or physiotherapist;
d. Rental of
special medical equipment, as defined by the insurer in the policy;
e. Artificial limbs or eyes, casts, splints,
trusses or braces;
f. Treatment for
functional nervous disorders, and mental and emotional disorders;
g. Out-of-hospital prescription drugs and
medications.
(6) Disability Income Protection Insurance:
(a) "Disability Income Protection Insurance"
is a policy of health insurance identified in the outline of coverage, as to
scope of coverage, if limited (e.g., accident only or sickness only), which
provides for periodic payments, weekly or monthly, for a specified period
during the continuance of disability resulting from sickness or injury or a
combination thereof.
(b) Such
coverage shall not require a loss from accidental injury to commence within
less than 30 days after the date of an accident.
(c) No reduction in benefits shall be put
into effect because of an increase in Social Security disability benefits
during a benefit period.
(7) Accident Only Insurance:
(a) "Accident Only Insurance" is a policy of
accident insurance which provides coverage, singly or in combination, for
death, dismemberment, disability or hospital and medical care caused by
accident.
(b) Accidental death and
dismemberment benefits shall be payable if the loss occurs within a period of
time of not less than 90 days from the date of the accident, irrespective of
total disability. Disability income benefits, if provided, shall not require
the loss to commence less than 30 days after the date of the
accident.
(c) The amount of the
accidental death benefit shall not be less than $1,000.00.
(d) The amount of the dismemberment benefit
shall not be less than:
1. $500.00 in the case
of a single dismemberment; and,
2.
$1,000.00 in the case of a double dismemberment.
(e) Specified dismemberment benefits shall
not be in lieu of other benefits unless the specific benefit exceeds the other
benefit.
(8) Limited
Benefit Insurance - "Limited Benefit Insurance" is that form of policy which
provides coverage for each person insured under the policy for a specifically
named disease (or diseases), specifically named accident, or specifically named
limited market fulfilling an experimental or reasonable need.
(a) "Specified Disease Insurance" is a policy
which provides coverage for each person insured under the policy for a
specifically named disease (or diseases) with a deductible amount not in excess
of $250.00 and an overall aggregate benefit limit of not less than $2,500.00
and a benefit period of not less than 2 years.
(b) "Specified Accident Coverage" is a policy
which provides coverage for specifically identified kind of accident (or
accidents) for each person insured under the policy for accidental death or
accidental death and dismemberment combined, with a benefit amount of not less
than $1,000 for accidental death; $1,000 for double dismemberment and $500 for
single dismemberment.
(9)
Supplemental Insurance - Any policy or contract which provides benefits that
are less than the minimum standards for benefits required under subsections (1)
through (3) of Rule 69O-154.106, F.A.C., may be
delivered or issued for delivery if the outline of coverage describes such
policy or contract as "supplemental hospital expense insurance", "supplemental
medical expense insurance" or "supplemental surgical expense insurance" and
prominently states that it does not meet the requirements of minimum standards
for the category involved.
(10)
Non-Conventional Coverage - Nothing contained in this section shall prohibit
the issuance of a policy or contract that does not fall within subsections (1)
through (9) of Rule 69O-154.106, F.A.C., if such
policy or contract is either experimental in nature or is demonstrated to be a
type coverage that will fulfill a reasonable need of a person or persons to be
insured and is appropriately and prominently described in the outline of
coverage.
(11) Home Service Health
Coverage (Exemption):
(a) "Home Service Health
Coverage" is a policy sold by a combination debit company and shall be exempt
from the minimum benefit requirements contained in Rule
69O-154.106, F.A.C.
(b) In order for a company to qualify as a
combination debit company under this Rule, it must certify that at least 90
percent of its Florida premium income for individual health insurance arises
from business produced by home service debit agents. If a combination company
does not meet this requirement on an overall basis, but does meet it relative
to a combination department, it may qualify under this rule relative only to
that combination department; in this case, however, the applicable policy forms
may be approved for use only by such combination department.
(c) Such certification as mentioned above
must be included in the letter of transmittal of each policy
submitted.
Rulemaking Authority 627.643, 624.308, 627.9407(1) FS. Law
Implemented 624.307(1), 627.642, 627.643, 627.9404(1)
FS.
New 1-1-75, Formerly 4-37.06, Amended 5-17-89, 9-18-89,
Formerly 4-37.006, Amended 3-24-99, Formerly
4-154.106.
