Current through Reg. 50, No. 187; September 24, 2024
(1)
Group and non-group subscriber contracts shall include all elements contained
in this section.
(a) Definitions;
(b) Effective date and term of contract. The
benefit and renewal periods shall be no less than twelve months for non-group
and group subscriber contracts, unless otherwise requested by the subscriber in
writing. HMOs shall not offer or initiate this request during initial
solicitation or prior to renewal;
(c) Space for rate to be charged;
(d) Mode of payment (monthly, quarterly,
etc., with provision for change of mode if applicable);
(e) Eligibility requirements for enrollment,
including waiting periods for receiving services and any other
restrictions;
(f) Grace period for
late payment;
(g) Co-payment
features, if any;
(h) Renewal,
re-enrollment, termination, cancellation, and disenrollment
conditions;
(i) Services to be
furnished and how physicians licensed under Chapters 458 or 459, 460 and 461,
F.S., will be made available, as detailed in Rule 69O-191.046,
F.A.C.;
(j) The contract,
certificate, or handbook shall state where and in what manner the comprehensive
health care services may be obtained;
(k) Factors pertaining to pre-existing
conditions, if applicable. Pre-existing conditions cannot be excluded longer
than two years;
(l) All
limitations, exclusions, and exceptions;
(m) Provisions covering in and out of area
emergencies, which includes a definition of emergency;
(n) Provisions for adding new family members,
including newborn and adopted children;
(o) Subscriber grievance procedures, formal
and informal;
(p) Any other factors
necessary for complete understanding of what is covered and what is excluded by
the contract;
(q) Provisions
relating to coordination of benefits if applicable;
(r) Provisions relating to the right of
subrogation shall be allowed, providing it is not in conflict with any
applicable Florida Statute or the decisions of courts of competent jurisdiction
which eliminate or restrict such rights;
(s) Provisions relating to the right of
reimbursement pursuant to Section
641.31(8),
F.S., shall be allowed, providing it is not in conflict with any applicable
Florida Statute or the decisions of courts of competent jurisdiction which
eliminate or restrict such rights;
(t) Arbitration provisions, if any, shall
include a statement that arbitration shall not preclude review pursuant to Rule
69O-191.081, F.A.C., and shall be conducted pursuant to Chapter 682,
F.S.;
(u) Conversion and extension
of benefit privileges;
(v) Optional
benefits pursuant to Sections
627.668 and
627.669, F.S., for group
contracts; and,
(w) Complications
of pregnancy which must be treated the same as any other
illness.
(2) Group master
contracts shall contain complete information as above, but a certificate or
member handbook may be issued to the individual members of the group in lieu of
the group master contract.
(3)
Non-group contracts shall contain the entire agreement between the HMO and the
subscriber.
(4) All contracts,
certificates, and member handbooks shall be clear and legible. All limitations,
exclusions, and exceptions shall be grouped together with captions in
bold-faced type and shall be printed with at least the same prominence as
provisions which describe the benefits.
(5) Contracts that contain limitations,
exclusions, and/or exceptions cannot restrict those health care services which
would create provisions which are unfair, inequitable, encourage
misrepresentation, or are contrary to the public policy of this
state.
(6) All health maintenance
policies or contracts which provide coverage, benefits, or services as
described in Section 463.002(5),
F.S., shall offer to the subscriber the services of optometrists licensed
pursuant to Chapter 463, F.S. "Coverage, benefits, or services as defined in
Section 463.002(5),
F.S." are not limited to refraction's for eyeglasses or contact lenses, but
include the full scope of services that fall within the definition of optometry
as provided in Section
463.002(5),
F.S. A health maintenance organization may not prohibit optometrists from
providing the full range of existing services offered by the health maintenance
organization that fall within the scope of optometric practice as defined in
Section 463.002(5),
F.S. This rule is not intended to expand contractual services required to be
offered by a health maintenance organization.
Rulemaking Authority 641.36 FS. Law Implemented 641.31(19)
FS.
New 2-22-88, Amended 10-25-89, Formerly 4-31.033, Amended
5-28-92, 10-10-00, Formerly 4-191.033.
