reglab/statecodes huggingface dataset:
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6402 - Insurance rebates for healthy lifestyles.

627.6402 Insurance rebates for healthy lifestyles.—
(1) Any rate, rating schedule, or rating manual for an individual health insurance policy filed with the office may provide for an appropriate rebate of premiums paid in the last year when the individual covered by such plan is enrolled in and maintains participation in any health wellness, maintenance, or improvement program approved by the health plan. The rebate may be based on premiums paid in the last calendar year or the last policy year. The individual must provide evidence of demonstrative maintenance or improvement of the individual’s health status as determined by assessments of agreed-upon health status indicators between the individual and the health insurer, including, but not limited to, reduction in weight, body mass index, and smoking cessation. Any rebate provided by the health insurer is presumed to be appropriate unless credible data demonstrates otherwise, or unless such rebate program requires the insured to incur costs to qualify for the rebate which equal or exceed the value of the rebate, but in no event shall the rebate exceed 10 percent of paid premiums.
(2) The premium rebate authorized by this section shall be effective for an insured on an annual basis, unless the individual fails to maintain or improve his or her health status while participating in an approved wellness program, or credible evidence demonstrates that the individual is not participating in the approved wellness program.
History.—s. 33, ch. 2004-297; s. 5, ch. 2005-231.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64025 - Advanced practice registered nurse services.

627.64025 Advanced practice registered nurse services.—A health insurance policy that provides major medical coverage and that is delivered, issued, or renewed in this state on or after January 1, 2021, may not require an insured to receive services from an advanced practice registered nurse registered under s. 464.0123 in place of a physician.
History.—s. 28, ch. 2020-9.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6403 - Payment of acupuncture benefits to certified acupuncturists.

627.6403 Payment of acupuncture benefits to certified acupuncturists.—Any policy of individual health insurance that provides coverage for acupuncture shall cover the services of an acupuncturist certified pursuant to chapter 457 under the same conditions that apply to services of a licensed physician.
History.—ss. 1, 3, ch. 87-176; s. 114, ch. 92-318.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6405 - Decreasing inappropriate utilization of emergency care.

627.6405 Decreasing inappropriate utilization of emergency care.—
(1) A health insurer shall post on its website, and update annually, information regarding appropriate utilization of emergency care services which shall include, but need not be limited to:
(a) A list of alternative urgent care contracted providers;
(b) The types of services offered by these providers;
(c) At least two examples illustrating the impact on insured and insurer paid amounts of inappropriate utilization of nonemergent services and care in a hospital emergency department setting compared to utilization of nonemergent services and care in an urgent care center;
(d) An interactive tool to locate local in-network and out-of-network urgent care centers; and
(e) What to do in the event of a true emergency.
(2) Health insurers shall develop community emergency department diversion programs. Such programs may include, at the discretion of the insurer, but not be limited to, enlisting providers to be on call to insurers after hours, coordinating care through local community resources, and providing incentives to providers for case management.
(3) As a disincentive for insureds to inappropriately use emergency department services for nonemergency care, health insurers may require higher copayments for urgent care or primary care provided in an emergency department and higher copayments for use of out-of-network emergency departments. Higher copayments may not be charged for the utilization of the emergency department for emergency care. For the purposes of this section, the term “emergency care” has the same meaning as the term “emergency services and care” as defined in s. 395.002(9) and includes services provided to rule out an emergency medical condition.
History.—s. 25, ch. 2004-297; s. 4, ch. 2021-112.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6407 - Massage.

627.6407 Massage.—Any policy of health insurance that provides coverage for massage shall also cover the services of persons licensed to practice massage therapy pursuant to chapter 480, where the massage therapy, as defined in chapter 480, has been prescribed by a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461, as being medically necessary and the prescription specifies the number of treatments.
History.—s. 57, ch. 92-318; s. 241, ch. 98-166; s. 17, ch. 2021-143.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6408 - Diabetes treatment services.

627.6408 Diabetes treatment services.—
(1) A health insurance policy or group health insurance policy sold in this state must provide coverage for all medically appropriate and necessary equipment, supplies, and diabetes outpatient self-management training and educational services used to treat diabetes, if the patient’s treating physician or a physician who specializes in the treatment of diabetes certifies that such services are necessary.
(2) The policy may require that diabetes outpatient self-management training and educational services be provided under the direct supervision of a certified diabetes educator or a board-certified endocrinologist. The policy may further require that nutrition counseling be provided by a licensed dietitian.
(3) The Agency for Health Care Administration shall adopt standards for diabetes outpatient self-management training and educational services, taking into consideration standards approved by the American Diabetes Association.
History.—s. 3, ch. 95-268; s. 1, ch. 96-279.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6409 - Coverage for osteoporosis screening, diagnosis, treatment, and management.

627.6409 Coverage for osteoporosis screening, diagnosis, treatment, and management.—Any health insurance policy that covers a resident of this state and that is issued, amended, delivered, or renewed in this state after October 1, 1996, must provide coverage for the medically necessary diagnosis and treatment of osteoporosis for high-risk individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis. This section does not apply to specified-accident, specified-disease, hospital-indemnity, Medicare supplement, or long-term-care health insurance policies or to the state employee health insurance program.
History.—s. 2, ch. 96-282.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.641 - Coverage for newborn children.

627.641 Coverage for newborn children.—
(1) A health insurance policy that provides coverage on an expense-incurred basis for a member of the family of the insured or subscriber shall, as to the family member’s coverage, also provide that the health insurance benefits applicable for children will be payable with respect to a newborn child of the insured or subscriber, or covered family member of the insured or subscriber, from the moment of birth. However, with respect to a newborn child of a covered family member other than the spouse of the insured or subscriber, the coverage for the newborn child terminates 18 months after the birth of the newborn child.
(2) The coverage for newborn children required by this section consists of coverage for injury or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and transportation costs of the newborn to and from the nearest available facility appropriately staffed and equipped to treat the newborn’s condition, when such transportation is certified by the attending physician as necessary to protect the health and safety of the newborn child. The coverage of such transportation costs may not exceed the usual and customary charges, up to $1,000.
(3) This section does not apply to disability income or hospital indemnity policies or to normal maternity policy provisions applicable to the mother.
(4) A policy may require the insured, subscriber, or covered family member to notify the insurer of the birth of a child within a time period, as specified in the policy, of not less than 30 days after the birth. If timely notice is given, the insurer may not charge an additional premium for coverage of the newborn child for the duration of the notice period. If timely notice is not given, the insurer may charge an additional premium from the date of birth. The insurer may not deny coverage for a child due to the failure of the insured to timely notify the insurer of the birth of the child.
(5) If the policy does not require the insured to notify the insurer of the birth of a child within a specified time period, the insurer may not deny coverage for such child or retroactively charge the insured an additional premium for such child. However, the insurer may prospectively charge the insured an additional premium for the child if the insurer provides at least 45 days’ notice of the additional premium required.
History.—s. 1, ch. 72-82; s. 1, ch. 74-8; s. 3, ch. 76-168; s. 1, ch. 77-174; s. 1, ch. 77-457; s. 1, ch. 80-177; ss. 2, 3, ch. 81-318; ss. 490, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 84-202; ss. 123, 149, ch. 92-33; s. 114, ch. 92-318.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6415 - Coverage for natural-born, adopted, and foster children; children in insured’s custodial care.

627.6415 Coverage for natural-born, adopted, and foster children; children in insured’s custodial care.—
(1) A health insurance policy that provides coverage for a member of the family of the insured shall, as to the family member’s coverage, provide that the health insurance benefits applicable to children of the insured also apply to an adopted child or a foster child of the insured placed in compliance with chapter 63, prior to the child’s 18th birthday, from the moment of placement in the residence of the insured. Except in the case of a foster child, the policy may not exclude coverage for any preexisting condition of the child. In the case of a newborn child, coverage begins at the moment of birth if a written agreement to adopt the child has been entered into by the insured prior to the birth of the child, whether or not the agreement is enforceable. This section does not require coverage for an adopted child who is not ultimately placed in the residence of the insured in compliance with chapter 63.
(2) A policy may require the insured to notify the insurer of the birth or placement of an adopted child within a specified time period of not less than 30 days after the birth or placement in the residence of a child adopted by the insured. If timely notice is given, the insurer may not charge an additional premium for coverage of the child for the notice period. If timely notice is not given, the insurer may charge an additional premium from the date of birth or placement. If notice is given within 60 days of the birth or placement of the child, the insurer may not deny coverage for the child due to the failure of the insured to timely notify the insurer of the birth or placement of the child.
(3) If the policy does not require the insured to notify the insurer of the birth or placement of an adopted child within a specified time period, the insurer may not deny coverage for such child or retroactively charge the insured an additional premium for such child. However, the insurer may prospectively charge the insured an additional premium for the child if the insurer provides at least 45 days’ notice of the additional premium required.
(4) In order to increase access to postnatal, infant, and pediatric health care for all children placed in court-ordered custody, including foster children, all health insurance policies that provide coverage for a member of the family of the insured shall, as to such family member’s coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a foster child or other child in court-ordered temporary or other custody of the insured, prior to the child’s 18th birthday.
History.—ss. 3, 5, ch. 85-189; s. 1, ch. 88-269; s. 1, ch. 91-185; ss. 124, 149, ch. 92-33; s. 5, ch. 92-278; s. 114, ch. 92-318; s. 9, ch. 98-159.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6416 - Coverage for child health supervision services.

627.6416 Coverage for child health supervision services.—
(1) All health insurance policies providing coverage on an expense-incurred basis which provide coverage for a member of a family of the insured or subscriber must, as to such family member’s coverage, also provide that the health insurance benefits applicable for children include coverage for child health supervision services from the moment of birth to age 16 years. Such services must be exempt from any deductible provisions that are in force in such policies or contracts.
(2) As used in this section, the term “child health supervision services” means physician-delivered or physician-supervised services that include, at a minimum, services delivered at the intervals and scope stated in this section.
(a) Child health supervision services must include periodic visits which shall include a history, a physical examination, a developmental assessment and anticipatory guidance, and appropriate immunizations and laboratory tests. Such services and periodic visits shall be provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics.
(b) Minimum benefits may be limited to one visit payable to one provider for all of the services provided at each visit cited in this section.
(3) This section does not apply to disability income, specified disease, Medicare supplement, or hospital indemnity policies.
History.—ss. 2, 6, ch. 86-122; s. 1, ch. 88-329; s. 114, ch. 92-318; s. 1, ch. 97-166.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6417 - Coverage for surgical procedures and devices incident to mastectomy.

627.6417 Coverage for surgical procedures and devices incident to mastectomy.—
(1) Any health insurance policy that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy. The insurer may charge an appropriate additional premium for the coverage required by this subsection. The coverage for prosthetic devices and breast reconstructive surgery shall be subject to any deductible and coinsurance conditions and all other terms and conditions applicable to other benefits. Breast reconstructive surgery must be in a manner chosen by the treating physician, consistent with prevailing medical standards, and in consultation with the patient.
(2) As used in this section, the term “mastectomy” means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician, and the term “breast reconstructive surgery” means surgery to reestablish symmetry between the two breasts.
(3) This section does not apply to disability income, specified disease other than cancer, or hospital indemnity policies.
History.—ss. 2, 4, ch. 87-262; s. 4, ch. 88-269; ss. 58, 114, ch. 92-318; s. 1, ch. 97-48.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64172 - Requirements with respect to breast cancer and routine followup care.

627.64172 Requirements with respect to breast cancer and routine followup care.—Routine followup care to determine whether a breast cancer has recurred in a person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment for purposes of determining preexisting conditions, unless evidence of breast cancer is found during or as a result of the followup care.
History.—s. 3, ch. 97-48.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6418 - Coverage for mammograms.

627.6418 Coverage for mammograms.—
(1) An accident or health insurance policy issued, amended, delivered, or renewed in this state must provide coverage for at least the following:
(a) A baseline mammogram for any woman who is 35 years of age or older, but younger than 40 years of age.
(b) A mammogram every 2 years for any woman who is 40 years of age or older, but younger than 50 years of age, or more frequently based on the patient’s physician’s recommendation.
(c) A mammogram every year for any woman who is 50 years of age or older.
(d) One or more mammograms a year, based upon a physician’s recommendation, for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has or has had breast cancer, or because a woman has not given birth before the age of 30.
(2) Except as provided in paragraph (1)(b), for mammograms done more frequently than every 2 years for women 40 years of age or older but younger than 50 years of age, the coverage required by subsection (1) applies, with or without a physician prescription, if the insured obtains a mammogram in an office, facility, or health testing service that uses radiological equipment registered with the Department of Health for breast cancer screening. The coverage is subject to the deductible and coinsurance provisions applicable to outpatient visits, and is also subject to all other terms and conditions applicable to other benefits. This section does not affect any requirements or prohibitions relating to who may perform, analyze, or interpret a mammogram or the persons to whom the results of a mammogram may be furnished or released.
(3) This section does not apply to disability income, specified disease, or hospital indemnity policies.
(4) Every insurer subject to the requirements of this section shall make available to the policyholder as part of the application, for an appropriate additional premium, the coverage required in this section without such coverage being subject to the deductible or coinsurance provisions of the policy.
History.—s. 4, ch. 88-269; s. 125, ch. 92-33; s. 6, ch. 95-188; s. 260, ch. 99-8; s. 89, ch. 2006-1.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6419 - Requirements with respect to breast cancer.

627.6419 Requirements with respect to breast cancer.—
(1) An insurer may not deny the issuance or renewal of, or cancel, a policy of accident insurance or health insurance, nor include any exception or exclusion of benefits in a policy solely because the insured has been diagnosed as having a fibrocystic condition or a nonmalignant lesion that demonstrates a predisposition, or solely due to the family history of the insured related to breast cancer, or solely due to any combination of these factors, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer.
(2) An insurer may not deny the issuance or renewal of, or cancel, a policy of accident insurance or health insurance, nor include any exception or exclusion of benefits in a policy solely due to breast cancer, if the insured has been free from breast cancer for more than 2 years before the applicant’s request for health insurance coverage.
(3) This section also applies to a policy of group, blanket, or franchise accident or health insurance and to a contract or evidence of coverage issued by a health maintenance organization.
History.—s. 59, ch. 92-318; s. 7, ch. 95-188; s. 4, ch. 97-48; s. 2, ch. 97-182.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64193 - Required coverage for cleft lip and cleft palate.

627.64193 Required coverage for cleft lip and cleft palate.—A health insurance policy that covers a child under the age of 18 must provide coverage for treatment of cleft lip and cleft palate for the child. The coverage must include medical, dental, speech therapy, audiology, and nutrition services only if such services are prescribed by the treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary and consequent to treatment of the cleft lip or cleft palate. The coverage required by this section is subject to terms and conditions applicable to other benefits. This section does not apply to specified-accident, specified-disease, hospital indemnity, limited benefit disability income, or long-term care insurance policies.
History.—s. 1, ch. 98-66.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64195 - Requirements for opioid coverage.

627.64195 Requirements for opioid coverage.—
(1) DEFINITIONS.—As used in this section, the term:
(a) “Abuse-deterrent opioid analgesic drug product” means a brand or generic opioid analgesic drug product approved by the United States Food and Drug Administration with an abuse-deterrence labeling claim that indicates the drug product is expected to deter abuse.
(b) “Opioid analgesic drug product” means a drug product in the opioid analgesic drug class prescribed to treat moderate to severe pain or other conditions in immediate-release, extended-release, or long-acting form regardless of whether or not combined with other drug substances to form a single drug product or dosage form.
(2) COVERAGE REQUIREMENTS.—A health insurance policy that provides coverage for abuse-deterrent opioid analgesic drug products:
(a) May impose a prior authorization requirement for an abuse-deterrent opioid analgesic drug product only if the policy imposes the same prior authorization requirement for each opioid analgesic drug product without an abuse-deterrence labeling claim.
(b) May not require use of an opioid analgesic drug product without an abuse-deterrence labeling claim before authorizing the use of an abuse-deterrent opioid analgesic drug product.
History.—s. 1, ch. 2016-112.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64196 - Medication synchronization.

627.64196 Medication synchronization.—
(1) A health insurer issuing or delivering in this state an individual or a group health insurance policy that provides prescription drug coverage shall offer medication synchronization to allow an insured to align at least once in a plan year the refill dates for prescription drugs covered by the policy. The insurer shall implement a process for dispensing prescription drugs to an insured for the purpose of aligning the refill dates of such drugs, and such medication synchronization may be available only through a network pharmacy. A controlled substance, a prescription drug dispensed in an unbreakable package, or a multidose unit of a prescription drug may not be partially filled for the purpose of aligning refill dates. The insurer shall pay a full dispensing fee to the network pharmacy for each partial refill of a covered prescription drug dispensed to align refill dates, unless otherwise agreed to by the plan and the network pharmacy at the time an insured requests medication synchronization. The insurer shall prorate the cost-sharing obligations of the insured for each partial refill of a covered prescription drug dispensed to align refill dates. This section applies to policies renewed or entered into on or after January 1, 2018.
(2) Notwithstanding subsection (1), an alternate process used by an insurer which includes early refill dates, refill overrides, and access on the insurer’s public website to the terms and conditions of such a process is deemed to comply with the requirements of this section.
History.—s. 1, ch. 2017-94.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64197 - Coverage for organ transplants.

627.64197 Coverage for organ transplants.—A health insurance policy issued, delivered, or renewed on or after July 1, 2020, in this state by an insurer which provides coverage for organ transplants on an expense-incurred basis may not deny coverage for an organ transplant solely on the basis of an insured’s disability. This section may not be construed to require such insurer to provide coverage for an organ transplant that is not medically necessary. For purposes of this section, the term “organ transplant” has the same meaning as in s. 765.523.
History.—s. 2, ch. 2020-139.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6426 - Short-term health insurance.

627.6426 Short-term health insurance.—
(1) For purposes of this part, the term “short-term health insurance” means health insurance coverage provided by an issuer with an expiration date specified in the contract that is less than 12 months after the original effective date of the contract and, taking into account renewals or extensions, has a duration not to exceed 36 months in total.
(2) All contracts for short-term health insurance entered into by an issuer and an individual seeking coverage shall include the following disclosure:
“This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Patient Protection and Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.”
History.—s. 5, ch. 2019-129.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.643 - Uniform minimum standards.

627.643 Uniform minimum standards.—
(1) The commission shall adopt rules which establish minimum standards for the general content of forms of individual and family health insurance policies. The rules must include terms of renewability, initial and subsequent conditions of eligibility, termination of insurance, probationary periods, exclusions, limitations, and reductions. The minimum standards are in addition to, and must comply with, the individual health insurance policy provisions provided in part II and in this part.
(2) The commission shall adopt rules which establish minimum standards of benefits and identification for each of the following categories of coverage in individual and family accident and health insurance policy forms, other than conversion policy forms:
(a) Basic hospital expense insurance.
(b) Basic medical expense insurance.
(c) Basic surgical expense insurance.
(d) Hospital confinement indemnity insurance.
(e) Major medical expense insurance.
(f) Disability income protection insurance.
(g) Accident-only insurance.
(h) Limited benefit insurance.
(i) Supplemental insurance.
(j) Home health care coverage.
(k) Nonconventional coverage.
This subsection does not preclude the issuance of a policy which combines two or more of the categories of coverage enumerated in paragraphs (a)-(e). This subsection does not preclude the issuance of a policy that does not meet the prescribed minimum standards for categories of coverage in paragraphs (a)-(g) if the office determines that the policy is either experimental in nature or is demonstrated to be a type of coverage that fulfills a reasonable need of the person or persons to be insured. Any policy not meeting the minimum standards that is approved by the office must be identified as to category only as prescribed by the office.
(3) The office may, within the time provided by law for the disapproval of an individual or family form of accident or health insurance, disapprove any form if it finds that the form does not comply with applicable law or it finds that the form is unjust, unfair, or inequitable to the policyholder, any insured, or any beneficiary. In acting upon any submission, the office shall consider whether the benefits afforded under the submitted policy or benefit form fulfill a reasonable need of a policyholder.
History.—s. 1, ch. 74-281; s. 3, ch. 76-168; s. 1, ch. 77-174; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 492, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 60, 114, ch. 92-318; s. 1152, ch. 2003-261.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.644 - Discrimination against handicapped prohibited.

627.644 Discrimination against handicapped prohibited.—No health insurer shall refuse to provide, or shall charge unfairly discriminatory rates for, health insurance coverage for a person solely because the person is mentally or physically handicapped. Nothing in this section should be construed as requiring an insurer to provide insurance coverage against a handicap which the applicant or policyholder has already sustained.
History.—s. 1, ch. 76-127; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 493, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.645 - Denial of health insurance claims restricted.

627.645 Denial of health insurance claims restricted.—
(1) A claim for payment under a health insurance policy or self-insured program of health benefits for treatment, care, or services in a licensed hospital that is accredited by an accrediting organization whose standards incorporate comparable regulations required by this state may not be denied because such hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for treatment of physical disability.
(2) No claim for payment under a health insurance policy for medical care or treatment of a child in a licensed hospital which is nonprofit; which primarily provides diagnosis, treatment, or care for patients whose physical functions or movements are impaired by accident, disease, or congenital deformity; and which accepts patients for treatment without regard to race, color, national origin, sex, religion, or affiliation shall be denied because the hospital does not have facilities for major surgery or because the treatment and care are primarily of a charitable nature.
History.—s. 1, ch. 77-32; s. 12, ch. 78-106; ss. 1, 3, ch. 80-33; s. 2, ch. 81-318; ss. 494, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 11, ch. 2013-93.
Note.—Former s. 391.11.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.646 - Conversion on termination of eligibility.

627.646 Conversion on termination of eligibility.—
(1) Every health insurance policy providing hospital or medical expense coverage hereafter delivered or issued for delivery in this state or under which benefits are altered, modified, or amended shall contain a provision that, if the insurance on a person covered under the policy ceases because of the termination of such person’s eligibility for coverage prior to his or her becoming eligible for Medicare or Medicaid benefits, then such person shall be entitled to have issued to him or her by the insurer, without evidence of insurability, a policy of health insurance, either individual or family, whichever is appropriate, provided application for the policy is made and the first premium is paid to the insurer within 31 days after such termination, and provided further that:
(a) The coverage under the policy shall be in an amount equal to or, at the option of the insured, less than the amount of health insurance which ceases because of such termination.
(b) The premium on the policy shall be at the insurer’s then customary rate applicable to such policies, to the class of risk to which such person then belongs, and to his or her age attained on the effective date of the policy.
(c) The policy of health insurance will not result in overinsurance on the basis of the company underwriting standards at the time of issue.
(d) The policy of health insurance may be reduced by the amount of any benefits paid for the same injury or same sickness under the prior policy.
(e) The policy of health insurance may exclude any condition excluded by the prior policy.
(2) An insurer shall offer maternity benefits and dental benefits if those benefits were provided in the policy.
(3) The provisions of this section shall be effectuated in such a way as to result in continuous coverage during the 31-day period for such insured.
(4) This section does not apply to disability income, Medicare supplement, accident only, hospital indemnity, specified disease, limited benefit, nonconventional, or excess policies.
History.—s. 1, ch. 78-385; s. 2, ch. 81-318; ss. 495, 497, 809(2nd), ch. 82-243; ss. 60, 79, ch. 82-386; s. 3, ch. 90-249; s. 114, ch. 92-318; s. 345, ch. 97-102.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.647 - Standard health claim form.

627.647 Standard health claim form.—
(1) The commission shall prescribe a standard health claim form to be used by all hospitals and a standard health claim form to be used by all physicians, dentists, and pharmacists. Such forms shall be in a format that allows for the use of generally accepted coding systems by providers in order to facilitate the processing of claims. Such forms shall provide for the disclosure by the claimant of the name, policy number, and address of every insurance policy which may cover the claimant with respect to the submitted claim except those policies specified in s. 627.4235(5). The required information on diagnosis, dental procedures, medical procedures, services, date of service, supplies, and fees may also be met by an attachment to the appropriate physician claim form. However, for the purpose of filing Medicaid claims, such attachments shall be prohibited. Such standard health claim forms shall be accepted by all insurers and all agencies, departments, and divisions of the state.
(2) This section does not apply to claims submitted by electronic or electromechanical means, except that such claims must include disclosure of every insurance policy which may cover the claimant with respect to the submitted claim.
History.—s. 1, ch. 77-46; s. 1, ch. 79-175; s. 2, ch. 81-318; ss. 496(1st), 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 88-30; s. 114, ch. 92-318; s. 1153, ch. 2003-261.
Note.—Former s. 627.6111.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64725 - Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.

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627.64725 Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.—Each health maintenance organization or exclusive provider organization shall provide prospective enrollees with written information about the terms and conditions of the plan in accordance with s. 641.31(4) so that the prospective enrollees can make informed decisions about accepting a managed-care system of health care delivery; however, information about where, in what manner, and from whom the comprehensive health care services or specific health care services can be obtained need be disclosed only upon request by the prospective enrollee. All marketing materials distributed by the health maintenance organization or exclusive provider organization must contain a notice in boldfaced type which states that the information required under this section is available to the prospective enrollee upon request.
History.—s. 8, ch. 96-223.
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Note.—Also published at s. 641.31015.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6473 - Combined preferred provider and exclusive provider policies.

627.6473 Combined preferred provider and exclusive provider policies.—An insurer may issue a policy that provides coverage for certain benefits through a preferred provider network and other benefits through an exclusive provider network. With regard to the coverage provided through a preferred provider network, the requirements of s. 627.6471 apply, and with regard to the coverage provided through an exclusive provider network, the requirements of s. 627.6472 apply.
History.—s. 128, ch. 92-33.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.6474 - Provider contracts.

627.6474 Provider contracts.—
(1) A health insurer may not require a contracted health care practitioner as defined in s. 456.001(4) to accept the terms of other health care practitioner contracts with the insurer or any other insurer, or health maintenance organization, under common management and control with the insurer, including Medicare and Medicaid practitioner contracts and those authorized by s. 627.6471, s. 627.6472, s. 636.035, or s. 641.315, except for a practitioner in a group practice as defined in s. 456.053 who must accept the terms of a contract negotiated for the practitioner by the group, as a condition of continuation or renewal of the contract. Any contract provision that violates this section is void. A violation of this subsection is not subject to the criminal penalty specified in s. 624.15.
(2) A contract between a health insurer and a dentist licensed under chapter 466 for the provision of services to an insured may not contain a provision that requires the dentist to provide services to the insured under such contract at a fee set by the health insurer unless such services are covered services under the applicable contract. As used in this subsection, the term “covered services” means dental care services for which a reimbursement is available under the insured’s contract, or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
(3)(a) A health insurer may not require an ophthalmologist licensed pursuant to chapter 458 or chapter 459 or an optometrist licensed pursuant to chapter 463 to join a network solely for the purpose of credentialing the licensee for another insurer’s vision network. This paragraph does not prevent a health insurer from entering into a contract with another insurer’s vision care plan to use the vision network.
(b) A health insurer may not restrict an ophthalmologist licensed pursuant to chapter 458 or chapter 459, an optometrist licensed pursuant to chapter 463, or an optician licensed pursuant to part I of chapter 484 to specific suppliers of materials or optical laboratories. This paragraph does not restrict a health insurer in determining specific amounts of coverage or reimbursement for the use of network or out-of-network suppliers or laboratories.
(c) A health insurer’s online vision care network provider directory must be updated monthly to reflect the vision care providers currently participating in the health insurer’s network.
(d) A knowing violation of paragraph (a) or paragraph (b) constitutes an unfair insurance trade practice under s. 626.9541(1)(d).
History.—s. 1, ch. 2001-107; s. 1, ch. 2014-64; s. 1, ch. 2016-69.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64741 - Pharmacy benefit manager contracts.

627.64741 Pharmacy benefit manager contracts.—
(1) As used in this section, the term:
(a) “Maximum allowable cost” means the per-unit amount that a pharmacy benefit manager reimburses a pharmacist for a prescription drug, excluding dispensing fees, prior to the application of copayments, coinsurance, and other cost-sharing charges, if any.
(b) “Pharmacy benefit manager” means a person or entity doing business in this state which contracts to administer or manage prescription drug benefits on behalf of a health insurer to residents of this state.
(2) In addition to the requirements of part VII of chapter 626, a contract between a health insurer and a pharmacy benefit manager must require that the pharmacy benefit manager:
(a) Update maximum allowable cost pricing information at least every 7 calendar days.
(b) Maintain a process that will, in a timely manner, eliminate drugs from maximum allowable cost lists or modify drug prices to remain consistent with changes in pricing data used in formulating maximum allowable cost prices and product availability.
(3) This section applies to contracts entered into or renewed on or after July 1, 2018.
History.—s. 4, ch. 2018-91; s. 16, ch. 2023-29.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VI - Health Insurance Policies (Ss. 627.601-627.64995) › 627.64995 - Restrictions on use of state and federal funds for state exchanges.

627.64995 Restrictions on use of state and federal funds for state exchanges.—
(1) A health insurance policy under which coverage is purchased in whole or in part with any state or federal funds through an exchange created pursuant to the federal Patient Protection and Affordable Care Act, Pub. L. No. 111-148, may not provide coverage for an abortion as defined in s. 390.011(1), except if the pregnancy is the result of an act of rape or incest, or in the case where a woman suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, which would, as certified by a physician, place the woman in danger of death unless an abortion is performed. Coverage is deemed to be purchased with state or federal funds if any tax credit or cost-sharing credit is applied toward the health insurance policy.
(2) This section does not prohibit a health insurance policy from offering separate coverage for an abortion if such coverage is not purchased in whole or in part with state or federal funds.
(3) As used in this section, the term “state” means this state or any political subdivision of the state.
History.—s. 1, ch. 2011-111.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VII - Group, Blanket, and Franchise Health Insurance Policies (Ss. 627.651-627.66997) › 627.651 - Group contracts and plans of self-insurance must meet group requirements.

627.651 Group contracts and plans of self-insurance must meet group requirements.—
(1) Except as otherwise provided by law, a group health insurance policy or certificate insuring more than one individual delivered or issued for delivery in this state must be delivered or issued for delivery to one of the groups provided for in ss. 627.653-627.656. A plan of self-insurance providing health coverage benefits to residents of this state must comply with s. 627.419 and the applicable provisions of this part relating to the rights of individuals to specified benefits and coverages.
(2) Subsection (1) does not apply to health insurance policies or plans of self-insurance:
(a) Insuring or providing benefits only to individuals related by blood, marriage, or legal adoption.
(b) Insuring or providing benefits only to individuals who have a common interest through ownership of a business enterprise, or a substantial legal interest or equity in the business enterprise, and who are actively engaged in the management of the business enterprise.
(c) Insuring or providing benefits only to individuals otherwise having an insurable interest in each other’s lives.
(d) Issued as blanket insurance pursuant to s. 627.659.
(3) A nongovernmental self-insurance plan for health benefits may not be contributory by participants.
(4) This section does not apply to any plan which is established or maintained by an individual employer in accordance with the Employee Retirement Income Security Act of 1974, Pub. L. No. 93-406, or to a multiple-employer welfare arrangement as defined in s. 624.437(1), except that a multiple-employer welfare arrangement shall comply with ss. 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(7). This subsection does not allow an authorized insurer to issue a group health insurance policy or certificate which does not comply with this part.
History.—s. 584, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 4, 10, ch. 80-341; ss. 2, 3, ch. 81-318; ss. 498, 500, 523, 809(2nd), ch. 82-243; ss. 62, 79, ch. 82-386; s. 6, ch. 83-203; s. 1, ch. 83-213; s. 17, ch. 83-288; s. 1, ch. 84-50; s. 4, ch. 86-122; s. 1, ch. 90-255; ss. 61, 114, ch. 92-318; s. 26, ch. 95-211; s. 5, ch. 97-48; s. 82, ch. 2000-154; s. 6, ch. 2002-389.
2023 Florida Statutes › Title XXXVII - Insurance › Chapter 627 - Insurance Rates and Contracts › Part VII - Group, Blanket, and Franchise Health Insurance Policies (Ss. 627.651-627.66997) › 627.6512 - Exemption of certain group health insurance policies.

627.6512 Exemption of certain group health insurance policies.—Sections 627.6561, 627.65615, 627.65625, and 627.6571 do not apply to any group insurance policy in relation to its provision of benefits described in s. 627.6513(1)-(14).
History.—s. 7, ch. 97-179; s. 14, ch. 2016-194.