Current through Reg. 50, No. 187; September 24, 2024
(1)
(a) Each health insurance issuer that offers
individual health insurance coverage shall make available to eligible
individuals the two policy forms with the largest and the next to largest
premium volume of all such policy forms offered by the issuer in the state or a
particular marketing or service area in the individual market.
(b) First year premium volume shall be
calculated by using first year premium for the calendar year. In compiling the
earned first year premium for the year, the company shall include earned
premium for individuals renewing into a replacement form where a previously
approved form has been discontinued.
(c) An insurer offering coverage in the
individual market is not prohibited from establishing premium
discounts.
(2)
(a) Both policy forms shall be designed for,
made generally available to, actively marketed to, and enroll both eligible and
other individuals.
(b) Issuers are
not required to reopen closed blocks to meet this requirement.
(c) Eligible individuals must be offered
these policy forms using the rate schedule and rating manual filed with and
approved by the Office. If in the application of the company's underwriting
standards, the eligible individual is determined to be uninsurable, the highest
approved rate class may be used. Rates in each approved rate class must be
generally applicable to all individuals and be based on sound actuarial
practices without regard to the individual being an eligible
individual.
(3) To enable
the Office to monitor this coverage, the issuer shall file, no later than April
1 of each year, Form OIR-B2-1386, (Rev. 8/03), Individual Health Coverage
Policy Forms Issued/Renewed in Florida, which is hereby adopted and
incorporated by reference. All filings shall be submitted electronically to
http://www.floir.com/iportal. Copies of the form may be printed from the
Office's website: http://www.floir.com/iportal.
(4)
(a) If
one or both of the largest first year earned premium volume policy forms are
closed blocks of business, the issuer shall so inform the Office.
(b) The issuer shall provide evidence that
the Office was notified of the intent to close these policy forms and shall
provide the information listed in subparagraph 4. for the replacement
forms.
(5)
(a) If the health insurance issuer offers
policy forms in the individual market that provide dependent coverage, the
issuer may apply a pre-existing condition exclusion to dependents who are not
eligible individuals.
(b) The
issuer may not apply a preexisting condition exclusion on certain children who
have less than 18 months creditable coverage but are dependents who were
enrolled as a dependent under a group health plan within 30 days of birth,
adoption, or placement for adoption and have not had a significant break in
coverage.
(6) Each issuer
offering health insurance coverage in the individual market must disclose, in
writing, to all applicants at the time of application the availability of
quarantee issue coverage for eligible individuals. Each issuer offering health
insurance coverage in the individual market is responsible for informing the
applicant at the time of application of the information necessary to determine
whether an applicant for coverage is an eligible individual as defined in
Section 627.6487(3),
F.S., as follows:
(a) The issuer shall
exercise reasonable diligence in making this determination.
(b) The issuer shall promptly determine
whether an applicant is an eligible individual.
(c) If an issuer determines that an
individual is an eligible individual, the issuer shall promptly issue a policy
to that individual.
(7)
If the information presented in or with an application is substantially
insufficient for the issuer to make a determination, the issuer may immediately
request additional information from the individual. Upon receipt of the
requested information, the issuer shall act promptly to make its
determination.
(8) If an entity
fails to provide the applicant with the certificate required under Section
627.64871, F.S., the issuer is
subject to the procedures set forth in Rule
69O-154.111, F.A.C., concerning
an individual's right to demonstrate creditable coverage.
Rulemaking Authority 624.308, 624.424(1)(c), 627.6487(4)(b)
FS. Law Implemented 624.307(1),
627.6487
FS.
New 9-19-00, Amended 9-30-01, 2-13-03, 9-22-03, Formerly
4-154.112, Amended 9-15-05.
