reglab/statecodes huggingface dataset:
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.010 - Approved Forms

Current through Reg. 50, No. 138; July 16, 2024
(1) Form
				OIR-B2-312, "Notice to Applicant Regarding Replacement of Life Insurance," rev.
				07/23, hereby incorporated by reference and available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-16290
.
				The form may be obtained from
https://www.floir.com
.
(2) Form OIR-B2-313, "Comparative Information
				Form for Proposed Insurance," rev. 07/23, hereby incorporated by reference and
				available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-16291
.
				The form may be obtained from
https://www.floir.com
.
Rulemaking Authority 624.308, 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.99
					 FS.
New 7-9-81, Amended 11-5-82, 2-2-83, Formerly 4-24.21,
					 Amended 3-11-91, Formerly 4-24.021, 4-151.010, Amended
					 1-4-24.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.012 - Separability (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308, 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.9641
					 FS.
New 7-9-81, Formerly 4-24.20, 4-24.020, 4-151.012, Repealed
					 1-4-24.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.101 - Purpose (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.9641
					 FS.
New 2-1-79, Formerly 4-44.01, 4-44.001, 4-151.101, Repealed
					 1-4-24.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.102 - Scope

Current through Reg. 50, No. 138; July 16, 2024
Rules
				  69O-151.102 through
				  69O-151.104, F.A.C., apply to
				  the solicitation of accident and health insurance covering residents of this
				  state. They do not apply to the solicitation of the following accident and
				  health insurance:
(1) Group, blanket
				or franchise;
(2) Accident
				only;
(3) Single premium
				nonrenewable;
(4) Conversion to
				another individual or family policy issued by the same insurer with continuous
				coverage;
(5) Conversion to an
				individual or family policy from a group, blanket or group type policy;
				and,
(6) Conversion to a Medicare
				Supplement policy to replace a basic or major-medical accident and health
				policy.
Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.9641
					 FS.
New 2-1-79, Formerly 4-44.02, 4-44.002, 4-151.102, Amended
					 1-4-24.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.103 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
As used in these rules:
(1) "Replacement" is any transaction wherein
				new accident and health insurance is to be purchased and it is known to the
				agent, broker or insurer at the time of application that, as a part of the
				transaction, existing accident and health insurance has been or is to be lapsed
				or the benefits thereof substantially reduced.
(2) "Direct response insurance" is insurance
				issued to an applicant who has completed the application and forwarded it
				directly to the insurer's agent in response to a solicitation coming into the
				applicant's possession by any means of mass communication.
(3) "Continuous coverage" means that the
				benefits are not less than the benefits under the previous policy, and the
				policy also covers loss resulting from injury sustained or sickness contracted
				while coverage was in force under the previous policy to the extent such loss
				is not covered under any extended benefit or similar provision of the previous
				policy.
(4) As used in this rule
				chapter the terms "accident and health insurance," 'accident and sickness
				insurance," and "disability insurance" each shall include the
				others.
Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.9641
					 FS.
New 2-7-79, Formerly 4-44.03, 4-44.003,
					 4-151.103.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.104 - Insurance Application

Current through Reg. 50, No. 138; July 16, 2024
An application form for insurance subject to these rules
				  shall contain a question to elicit information as to whether the insurance to
				  be issued is to replace any insurance presently in force. If replacement of
				  existing coverage is indicated the application shall state the Company name and
				  policy number. A supplementary application or other form to be signed by the
				  applicant and made a part of the company's file containing such a question may
				  be used.
Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.9641
					 FS.
New 2-1-79, Formerly 4-44.04, 4-44.004,
					 4-151.104.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.106 - Violation (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.9641
					 FS.
New 2-1-79, Formerly 4-44.06, 4-44.006, 4-151.106, Repealed
					 1-4-24.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.107 - Effective Date (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308(1), 626.9611, 626.9641 FS. Law
					 Implemented 624.307(1), 626.9521, 626.9541, 626.9641
					 FS.
New 2-1-79, Formerly 4-44.07, 4-44.007, 4-151.107, Repealed
					 1-4-24.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.201 - Purpose and Scope

Current through Reg. 50, No. 138; July 16, 2024
(1) Rules
				69O-151.201, and
				69O-151.202, F.A.C., apply to
				any and all types of policies which include a policy value feature,
				irrespective of the marketing method by which such policies or contracts are
				sold.
(2) Rules
				69O-151.201, and
				69O-151.202, F.A.C., shall not
				apply to:
(a) Conversions of group or
				individual term policies; or
(b)
				Group permanent life, group variable life, group fixed annuities and group
				variable annuities wherein the group master policyholder retains ownership of
				the contract.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.202 - Requirements

Current through Reg. 50, No. 138; July 16, 2024
(1) Each insurer shall adopt written
				procedures to reasonably avoid and discourage the practice of churning, as
				defined in Section 626.9541(1)(aa),
				F.S.
(2)
(a) Form OIR-D0-1180, "Policy Disclosure Form
				and Instructions," rev. 07/23, hereby incorporated by reference and available
				at
http://www.flrules.org/Gateway/reference.asp?No=Ref-16292
,
				shall be completed by the insurer or its licensed and appointed agent and
				provided to the applicant prior to or contemporaneous with the time the
				applicant signs any application for the purchase of an additional life
				insurance policy or annuity contract to be funded through the use of values
				accessed in an existing and in-force policy with that same insurer. Form
				OIR-D0-1180, rev. 07/23 shall be completed for each existing and in-force
				policy to be utilized as a funding source for the purchase of additional
				insurance contract(s). Any required replacement and sales forms must also be
				completed. One copy of Form OIR-D0-1180, rev. 07/23 is to be delivered to the
				policyowner and one copy must be maintained by the insurer.
(b) If there is a material change in the
				information originally disclosed to the policyowner on Form OIR-D0-1180 as a
				result of the underwriting and policy issuance process, an insurer may cause an
				amended Form OIR-D0-1180, rev. 07/23 to be reissued, delivered and executed by
				the agent or corporate officer and the policyowner, and such amended Form
				OIR-D0-1180, rev. 07/23 shall constitute the required disclosure under this
				rule. An insurer must maintain any and all amended versions of Form
				OIR-D0-1180, rev. 07/23 in accordance with this rule.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-151 - REQUIREMENTS FOR REPLACEMENT OF LIFE AND HEALTH COVERAGE › Section 69O-151.203 - Adoption of Form OIR-D0-1180 (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308(1), 626.9541(1)(aa)2. FS.,
					 Chapter 95-219, Laws of Florida. Law Implemented
					 624.307(1),
					 626.9541(1)(aa),
					 627.4554
					 FS.,
New 2-19-96, Formerly 4-151.203, Repealed
					 1-4-24.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-153 - DECEPTIVE INSURANCE PRACTICES › Section 69O-153.001 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
For purposes of this chapter:
(1) The term "False Claim" means any written
				statement which is a part of or supports a claim for payment or other benefit
				pursuant to an insurance policy or health maintenance organization coverage
				document for commercial or personal insurance or health maintenance
				organization coverage and which is knowingly presented or prepared with
				knowledge or belief that it will be presented to an insurer, health maintenance
				organization, or third party, and which the preparer or presenter knows to
				contain materially false information or omissions, as part of or in support of
				or concerning that claim.
(2) The
				term "claimant" includes but is not limited to a patient, a health care
				provider to whom, or a health care facility to which the patient has either
				assigned his claim for payment or is otherwise entitled to care under a health
				maintenance organization coverage document.
(3) The term "Health Care Provider" means a
				physician or any recognized practitioner who provided skilled services pursuant
				to the prescription of or under the supervision or direction of a
				physician.
(4) The term "Health
				Care Facility" means any hospital licensed under Chapter 395, F.S., and any
				health care institution licensed under Chapter 400, F.S.
(5) The term "Pre-provision of services
				agreement" means an agreement made or understood to exist in advance of the
				provision of health care services between the health care provider or health
				care facility and the patient to waive in whole or in part that patient's
				payment of the co-payment or deductible amount provided for in the contractual
				agreement otherwise known as the "policy", or "health maintenance organization
				coverage document" between the patient and the insurer, health maintenance
				organization or third party, or an agreement to give the patient a discount for
				the immediate payment of fees for services rendered.
(6) The term "Third Party" means any
				individual who, or entity which, collects premiums, assumes financial risks,
				pays claims, or provides administrative services relative to any insurance
				policy, insurance contract, health prepayment contract, health car plan,
				nonprofit health care plan, nonprofit health service plan contract, or employee
				welfare plan.
(7) The term
				"insurer, health maintenance organization, or third party" as used in this rule
				does not include any federally-funded programs, such as Medicare and CHAMPUS or
				any state-funded programs for the medically indigent or disabled, such as
				Medicaid, or the agents, contractors, or administrators of these
				federally-funded or state-funded programs.
Specific Authority 626.9611, 641.36 FS. Law Implemented
					 624.307(1), 626.9541(1)(u), 641.3903(11)
					 FS.
New 2-28-90, Formerly 4-86.001,
					 4-153.001.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-153 - DECEPTIVE INSURANCE PRACTICES › Section 69O-153.002 - Deceptive Acts or Practices

Current through Reg. 50, No. 138; July 16, 2024
The preparation of a false claim for presentation to an
				  insurer, health maintenance organization, or third party and the presentation
				  of a false claim to an insurer, health maintenance organization, or third party
				  by an agent, physician, claimant or other person are deceptive acts or
				  practices involving the business of insurance prohibited by the Insurance
				  Code.
Specific Authority 626.9611, 641.36 FS. Law Implemented
					 624.307(1), 626.9541(1)(u), 641.3903(11)
					 FS.
New 2-28-90, Formerly 4-86.002,
					 4-153.002.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-153 - DECEPTIVE INSURANCE PRACTICES › Section 69O-153.003 - Example of a False Claim

Current through Reg. 50, No. 138; July 16, 2024
The submission or presentation for payment to an insurer,
				  health maintenance organization or third party of a claim form, bill, or other
				  statement for services rendered, prepared or signed by a health care provider
				  or health care facility which does not disclose a pre-provision of services
				  agreement between the health care provider or health care facility and the
				  patient to accept less for the health care services rendered than is reflected
				  on the claim form, bill or statement is an example of a false claim. The
				  submission of a claim form, bill or other statement shall not be considered a
				  false claim merely because the application of a federal or state statutory
				  sliding-scale fee or other federal or state mandated statutory discount for
				  health care services rendered has not been disclosed. The submission of a claim
				  form, bill or other statement shall, also, not be considered a false claim
				  because of failure to disclose the forgiveness or writing-off of all or any
				  portion of the unpaid deductible portion of the patient's bill after reasonable
				  collection efforts have been made. The disclosure of the existence of a
				  pre-provision of services agreement in accordance with Rule
				  69O-153.004, F.A.C., neither
				  precludes nor requires an insurer, health maintenance organization, or other
				  third party from considering that agreement in determining the actual or usual
				  and customary charge under the terms of the insurance policy, or health
				  maintenance organization coverage document.
Specific Authority 626.9611, 641.36 FS. Law Implemented
					 624.307(1), 626.9541(1)(u), 641.3903(11)
					 FS.
New 2-28-90, Formerly 4-86.003,
					 4-153.003.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-153 - DECEPTIVE INSURANCE PRACTICES › Section 69O-153.004 - Disclosure of Agreements

Current through Reg. 50, No. 138; July 16, 2024
A health care provider shall disclose a pre-provision of
				  services agreement by one of the following methods:
(1) Attaching a copy of the agreement to the
				claim form;
(2) Attaching a
				statement that discloses the agreement and the specific terms
				thereof;
(3) Attaching a copy of
				the policy which provides for the waiver of all or some portion of a deductible
				or co-payment for employees of the hospital and others and a representation
				that the waiver is authorized by the policy as to that provider;
(4) Disclosure on the Office's approved
				uniform claim form when modified to effectuate such disclosure in a uniform
				manner as to all claims.
Specific Authority 626.9611, 641.36 FS. Law Implemented
					 624.307(1), 626.9541(1)(u), 641.3903(11)
					 FS.
New 2-28-90, Formerly 4-86.004,
					 4-153.004.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.001 - Statement That Application Has Been Read Must Be Attached to Each Policy

Current through Reg. 50, No. 138; July 16, 2024
(1) It is the opinion of the Insurance
				Commission that purchasers of disability insurance in this state should realize
				the importance of the application for insurance, therefore, no policy of
				disability insurance shall be delivered to any person in this state unless a
				notice stating as follows is attached to the policy:
IMPORTANT NOTICE
Please read the copy of the application attached to this
				  policy. Carefully check the application and write to the company ___ (address)
				  ___ within 10 days, if any information shown on it is not correct and complete,
				  or if any past medical history has been left out of the application. This
				  application is a part of the policy and the policy was issued on the basis that
				  the answers to all questions and the information shown on the application are
				  correct and complete. This statement, preferably in the form of a sticker to be
				  placed on the policy, shall be printed in a prominent manner on paper or in ink
				  of a contrasting color. Any wording of similar import or any procedure whereby
				  the equal results are obtained may be used upon approval by the
				  Director.
(a) This rule shall not
				apply where the application for insurance is not attached to and made a part of
				the contract.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.002 - Statement of Terms; Acknowledgment by Insured Required

Current through Reg. 50, No. 138; July 16, 2024
It is the opinion of the Director that the citizens of this
				  state should be aware and should have full knowledge of the meaning of the
				  terms, "This policy is renewable at the option of the company," "This policy is
				  cancellable by the company," or similar captions on renewable term policies
				  issued or issued for delivery in this state. To accomplish this, it shall be
				  the duty of an agent writing such application to obtain from each applicant for
				  such a policy a simple signed statement acknowledging that he knows and
				  understands that upon proper notice the company may terminate the insurance at
				  the end of any period for which the premium has been paid, or may cancel the
				  policy if it contains the cancellation provision. Such statement may be a part
				  of the application itself or may be separate. This statement may be obtained at
				  the time of the application, before the policy is delivered, or when the policy
				  is delivered. The wording of the statement will be as follows: "I am aware that
				  the company may terminate this insurance at the end of any period for which the
				  premium has been paid." Different wording of similar import may be approved so
				  as to accurately describe different renewal conditions or provisions in line
				  with the terms of the contract. If this statement is on the application, it
				  must be isolated or separated, and a separate signature is required at the end
				  of such statement. Such signed statement is to be kept on file by the
				  insurer.
Rulemaking Authority 624.308 FS. Law Implemented
					 624.307(1), 627.6043, 627.608 FS.
New 12-24-74, Formerly 4-8.02, 4-8.002,
					 4-154.002.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.003 - Insured's Right to Return Policy; Notice

Current through Reg. 50, No. 138; July 16, 2024
It is the opinion of the Director that it will be in the
				  public interest and of benefit to all if the person to whom the policy is
				  issued has the opportunity to return the policy if he is not satisfied with it,
				  provided such return is made within a reasonable length of time after receipt
				  of the policy; therefore, each and every company issuing or issuing for
				  delivery a disability policy in this state is requested to have printed or
				  stamped thereon or attached thereto a notice in a prominent place stating in
				  substance that the person to whom the policy or contract is issued shall be
				  permitted to return the policy or contract within ten (10) days of its delivery
				  to said purchaser and to have the premium paid refunded if, after examination
				  of the policy or contract, the purchaser is not satisfied with it for any
				  reason. The notice may provide that if the insured or purchaser pursuant to
				  such notice returns the policy or contract to the insurer at its home office or
				  branch office or to the agent through whom it was purchased, it shall be void
				  from the beginning and the parties shall be in the same position as if no
				  policy or contract had been issued. This rule shall not apply to either single
				  premium non-renewable policies or contracts or travel accident policies or
				  contracts. Notices in this Rule
				  69O-154.003 and in Rule
				  69O-154.001, F.A.C., may be
				  combined.
Rulemaking Authority 624.308 FS. Law Implemented
					 624.307(1), 626.9541(1), 627.421 FS.
New 12-24-74, Formerly 4-8.03, 4-8.003,
					 4-154.003.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.004 - Non-cancellable or Non-cancellable and Guaranteed Renewable Policies; Use of Terms

Current through Reg. 50, No. 138; July 16, 2024
The terms "non-cancellable" or "non-cancellable and
				  guaranteed renewable" may be used only in a policy which the insured has the
				  right to continue in force by the timely payment of premiums set forth in the
				  policy until at least age 50, or in the case of a policy issued after age 44,
				  for at least five years the insurer has no right to make unilaterally any
				  change in any provision of the policy while the policy is in force. Except as
				  provided above, the term "guaranteed renewable" may be used only in a policy in
				  which the insured has the right to continue in force by the timely payment of
				  premiums until at least age 50, or in the case of a policy issued after age 44,
				  for at least five years from its date of issue, during which period the insurer
				  has no right to make unilaterally any change in any provision of the policy
				  while the policy is in force, except that the insurer may make changes in
				  premium rates by classes. The foregoing limitation on use of the term
				  "non-cancellable" shall also apply to any synonymous term such as "not
				  cancellable" and the limitation on use of the term "guaranteed renewable" shall
				  also apply to any synonymous term such as "guaranteed continuable." Nothing
				  herein contained is intended to restrict the development of policies having
				  other guarantees of renewability, or to prevent the accurate description of
				  their terms of renewability or the classification of such policies as
				  guaranteed renewable or non-cancellable for any period during which they may
				  actually be such, provided the terms used to describe them in policy contracts
				  and advertising are not such as may readily be confused with the above
				  terms.
Rulemaking Authority 624.308 FS. Law Implemented
					 624.307(1), 627.602 FS.
New 12-24-74, Formerly 4-8.04, 4-8.004,
					 4-154-004.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.005 - Report of Training Instructions Required

Current through Reg. 50, No. 138; July 16, 2024
Every company writing disability insurance in this state
				  shall complete and file with its annual statement a questionnaire concerning
				  its course of training and instruction given its agents. Such questionnaire
				  forms shall be supplied by the Director.
Rulemaking Authority 624.308 FS. Law Implemented
					 624.307(1), 624.424 FS.
New 12-24-74, Formerly 4-8.05, 4-8.005,
					 4-154.005.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.006 - Exemptions

Current through Reg. 50, No. 138; July 16, 2024
Rules
				  69O-154.001 -.003, F.A.C., do
				  not apply to group, franchise, or blanket disability
				  insurance.
Rulemaking Authority 624.308 FS. Law Implemented
					 624.307(1), 624.424, 627.601 FS.
New 12-24-74, Formerly 4-8.06, 4-8.006,
					 4-154.006.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.102 - Applicability and Scope

Current through Reg. 50, No. 138; July 16, 2024
(1) These rules
				shall apply to all individual and family accident and health insurance
				policies, subscriber contracts of medical, surgical, or health maintenance
				organizations and to franchise insurance policies issued or issued for delivery
				in this state on and after the effective date hereof (except for policies
				issued to employees or members who are being added to existing franchise
				plans). The requirements contained in these rules shall be in addition to any
				other applicable rules previously adopted.
(2) Rules
				69O-154.110 through
				69O-154.112 and
				69O-154.114 through
				69O-154.116, F.A.C., shall also
				apply to insurance coverage subject to the provisions of Section
				627.6487, F.S. Notwithstanding
				the foregoing, nothing in this rule chapter shall be construed to establish
				that the Office has rate approval authority over any rate applicable to a group
				policy issued outside this state, where that authority is not separately
				conferred by statute.
Rulemaking Authority 624.308, 627.643 FS. Law Implemented
					 624.307(1), 627.642, 627.6425, 627.643, 627.6487
					 FS.
New 1-1-75, Formerly 4-37.02, 4-37.002, Amended 9-19-00,
					 2-13-03, Formerly 4-154.102.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.104 - Definition of Terms

Current through Reg. 50, No. 138; July 16, 2024
(1) Accident,
				accidental injury, accidental means:
(a) The
				definition shall employ "result" language and shall not include words which
				establish an "accidental means" test or use words such as "external, violent,
				visible wounds" or similar words of description or characterization.
(b) The definition shall not be more
				restrictive than the following: "injury or injuries for which benefits are
				provided means accidental bodily injuries sustained by the insured person which
				are the direct cause independently of disease, bodily infirmity or other cause
				of the loss and occur while the insurance is in force."
(c) Such definitions may provide that
				injuries shall not include:
1. Injuries for
				which benefits are provided under:
a. Any
				workers' compensation, employers' liability or similar law; or
b. Florida Automobile Reparations Reform Act
				(motor vehicle no-fault plan or similar law); or
2. Injuries occurring while the insured
				person is engaged for wage or profit in any activity pertaining to any trade,
				business, employment or occupation.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.106 - Minimum Standards for Benefits

Current through Reg. 50, No. 138; July 16, 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.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.107 - Outline of Coverage Required

Current through Reg. 50, No. 138; July 16, 2024
(1) An
				outline of coverage, as required by Section
				627.642, F.S., shall be
				delivered either at the time the application for the policy is taken or at the
				time such policy is delivered. Such outline of coverage shall be clearly
				identified as such and accurately describe the policy or contract and its
				provisions in a clear and concise manner. If the outline is delivered at the
				time the application is taken, there must be either a certification of delivery
				by the agent, or an acknowledgement of receipt by the applicant. Such
				certification or acknowledgement may be a separate document or by certification
				in the application.
(2) The
				requirement of the outline of coverage as set forth in Section
				627.642, F.S., shall include the
				following information:
(a) The name and
				principal address of the insurer or service association.
(b) A statement of identification of the
				policy or contract as described in Rule
				69O-154.106, F.A.C., of this
				rule.
(c) A description of each of
				the principal benefits and coverages, including the benefit amounts, duration
				or limits, elimination periods, inner limits and any other items appropriate to
				the coverage provided.
(d) A
				description of the terms and conditions or renewability of the policy or
				contract, including any limitations by age, time or event, rights to change
				premium, status requirements and any other matters appropriate to the terms and
				conditions of renewability (including any rights of cancellation reserved to
				the insurer).
(e) A description of
				the principal exceptions, reductions and limitations contained in the policy or
				contract, including the pre-existing conditions, if any, and the circumstances
				under which any reduction provisions become operative.
(f) A statement that the Outline of Coverage
				is only a brief summary of the policy and is not the contract of insurance. The
				policy or contract itself sets forth the rights and obligations of the insured
				and insurer.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.110 - Certificate of Creditable Coverage (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308, 627.6561(8)(e),
					 641.31071(8)(a), (e), (10)(b) FS. Law Implemented
					 624.307(1),
					 627.64871,
					 627.6561(8),
					 641.31071
					 FS.
New 9-19-00, Formerly 4-154.110, Repealed
					 11-21-17.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.111 - Demonstration of Creditable Coverage If Certificate is not Provided (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308, 627.6561(5)(b), (7)(b),
					 (8)(a), (e), (9)(b), 641.31071(8)(a), (e), (10)(b) FS. Law Implemented
					 624.307(1),
					 627.64871,
					 641.31071
					 FS.
New 9-19-00, Formerly 4-154.111, Repealed
					 11-21-17.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.112 - Guaranteed Availability of Individual Health Coverage to Eligible Individuals

Current through Reg. 50, No. 138; July 16, 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.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.113 - Discontinuance or Modification of Policy Form

Current through Reg. 50, No. 138; July 16, 2024
If an issuer elects to discontinue an individual health
				  insurance policy form by consolidation with another policy form, the rate for
				  the benefits shall be actuarially justified and approved by the Office for the
				  consolidated group.
Rulemaking Authority 624.308(1) FS. Law Implemented
					 624.307(1), 627.410 FS.
New 9-19-00, Formerly
					 4-154.113.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.114 - Withdrawal From the Individual Market

Current through Reg. 50, No. 138; July 16, 2024
(1) If a health insurance issuer elects to
				withdraw from the individual health insurance market, the issuer must provide
				180 days' written notice to the Office and to all policyholders,
				certificateholders and beneficiaries provided coverage by the issuer in that
				market.
(2) A notice of withdrawal
				from the individual market means an issuer may then non-renew coverage upon the
				next renewal date of policies affected by the withdrawal.
(3) A policy may not be terminated except at
				the next renewal date following the 180 day notice period.
(4) Notice to the Office must include a copy
				of all forms issued in that market.
(5) With respect to notice to policyholders,
				certificateholders, beneficiaries, a mailing to one household constitutes a
				mailing to all covered persons residing in the household.
(6) A separate mailing is required for each
				separate household.
(7) If the
				issuer elects to exit or withdraw from the individual market, re-entry into
				that market is prohibited for five years from the last date of coverage
				provided in that market.
(8) The
				filing shall be submitted to the Office electronically through
				http://www.floir.com/iportal.
Rulemaking Authority 624.308(1) FS. Law Implemented
					 624.307(1), 624.424, 627.6425 FS.
New 3-1-98, Formerly 4-154.114, Amended
					 7-30-17.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.115 - Designation of Election to Become a Risk-Assuming or Reinsuring Carrier

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a) All
				individual health insurance issuers shall file a designation with the Office of
				their election to become either a risk-assuming or a reinsuring
				carrier.
(b) The individual issuer
				desiring to be a risk-assuming or reinsuring carrier shall use Form OIR-B2-1311
				(rev. 8/03),
http://www.flrules.org/Gateway/reference.asp?No=Ref-08294
,
				State of Florida/Individual Carrier's Application to Become a Risk Assuming
				Carrier or a Reinsuring Carrier, which is hereby adopted and incorporated and
				may be obtained from the Office's website: http://www.floir.com/iportal, as
				required by Section 627.6475(5),
				F.S.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.116 - Change of Status of Individual Issuer's Election to Become Risk-Assuming Carrier or Reinsuring Carrier

Current through Reg. 50, No. 138; July 16, 2024
(1) Any
				individual issuer seeking to change the election made by the carrier under
				Section 627.6475(5)(a),
				F.S., to become either a risk-assuming carrier or a reinsuring carrier shall
				request a change of status on Form OIR-B2-1304 (rev. 10/98), State of
				Florida/Individual Issuer's Application to Modify Previous Election to Become a
				Risk Assuming or a Reinsuring Carrier which is hereby adopted and incorporated
				by reference and may be obtained from http://www.floir.com/iportal, as required
				by Section 627.6475(5),
				F.S.
(2)
(a) Within 60 days from the date on which the
				form and its attached information is filed with the Office, the Office shall
				hold a hearing on the request.
(b)
				Within 30 days after the conclusion of the hearing and the submission of any
				post-hearing documentation or argument, the Office shall approve or disapprove
				the request, based on the criteria set forth in Section
				627.6475(6)(b),
				F.S.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.201 - Scope

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a)
				This rule chapter applies to all individual and group health insurance
				policies, including single premium credit disability insurance. All other
				credit insurance is not subject to this rule chapter. Credit disability is
				defined under Section
				627.677(2),
				F.S.
(b) This rule chapter is
				effective December 31, 1998, for policies and contracts in force and issued
				thereafter.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.203 - Categories of Reserves

Current through Reg. 50, No. 138; July 16, 2024
Adequacy of an insurer's health insurance reserves shall be
				  determined on the basis of all three categories combined. However, these
				  standards emphasize the importance of determining appropriate reserves for each
				  of the three categories separately.
(1) Claim Reserves.
(a) General.
1. Claim reserves are required for all
				incurred but unpaid claims on all health insurance policies.
2. Appropriate claim expense reserves are
				required with respect to the estimated expense of settlement of all incurred
				but unpaid claims.
3. All reserves
				for prior valuation years shall be tested for adequacy and reasonableness along
				the lines of claim runoff schedules in accordance with the financial statement
				pursuant to Section 625.121(14),
				F.S., including consideration of any residual unpaid
				liability.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.204 - Specific Minimum Standards for Morbidity, Mortality and Interest

Current through Reg. 50, No. 138; July 16, 2024
Specific minimum standards for morbidity, mortality and
				  interest which apply to claim reserves according to year of incurral and to
				  contract reserves according to year of issue:
(1) Morbidity.
(a) Minimum morbidity standards for valuation
				of specified individual contract health insurance benefits are as follows:
1. Disability Income Benefits Due to Accident
				or Sickness.
a. Contract Reserves:
(I) Contracts issued on or after January 1,
				1965, and prior to January 1, 1998: The 1964 Commissioners Disability Table (64
				CDT), incorporated by reference in Rule
				69O-154.210, F.A.C., or a table
				acceptable to the Office as specified in paragraph
				69O-154.204(1)(c),
				F.A.C.
(II) Contracts issued on or
				after January 1, 1999:
(A) The 1985
				Commissioners Individual Disability Tables A (85CIDA), incorporated by
				reference in Rule 69O-154.210, F.A.C; or
(B) The 1985 Commissioners Individual
				Disability Tables B (85CIDB), incorporated by reference in Rule
				69O-154.210,
				F.A.C.
(III) Contracts
				issued on or after January 1, 1998 and prior to January 1, 1999 inclusive:
				Optional use of either the 1964 Table or the 1985 Tables, or a table acceptable
				to the Office as specified in paragraph
				69O-154.204(1)(c),
				F.A.C.
(IV) Each insurer may elect,
				with respect to all individual contracts issued in any one statement year,
				whether it will use Tables A or Tables B as the minimum standard. The insurer
				shall, however, elect to use the other tables with respect to any subsequent
				statement year.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.205 - Reserves for Waiver of Premium

Current through Reg. 50, No. 138; July 16, 2024
Waiver of premium reserves involve several special
				  considerations.
(1) The disability
				valuation tables promulgated by the National Association of Insurance
				Commissioners are based on exposures that include contracts on premium waiver
				as in-force contracts. Therefore, contract reserves based on these tables are
				not reserves on "active lives" but rather reserves on contracts "in force."
				This is true for the 1964 Commissioner's Disability Table and for both the 1985
				CIDA and CIDB tables.
(2)
				Accordingly, tabular reserves using any of these tables shall value reserves on
				the following basis:
(a) Claim reserves shall
				include reserves for premiums expected to be waived, valuing as a minimum the
				valuation net premium being waived.
(b) Premium reserves shall include contracts
				on premium waiver as in-force contracts, valuing as a minimum the unearned
				modal valuation net premium being waived.
(c) Contract reserves shall include
				recognition of the waiver of premium benefit in addition to other contract
				benefits provided for, valuing as a minimum the valuation net premium to be
				waived.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.206 - Reinsurance

Current through Reg. 50, No. 138; July 16, 2024
Increases to or credits against reserves carried arising
				  because of reinsurance assumed or reinsurance ceded, except as noted below,
				  shall be determined in a manner consistent with these minimum reserve standards
				  and with all applicable provisions of the reinsurance contracts which affect
				  the insurer's liabilities. If increases to or credits against reserves are not
				  determined in a manner consistent with these minimum reserve standards, the
				  insurer will be required to demonstrate to the Office that assumed reserves are
				  not less than those required and ceded reserves are not greater than those
				  required by these minimum reserve standards.
Rulemaking Authority 624.308(1), 625.121(14), 625.081 FS.
					 Law Implemented 624.307(1), 625.081, 625.121
					 FS.
New 4-14-99, Formerly
					 4-154.206.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.210 - Tables

Current through Reg. 50, No. 138; July 16, 2024
(1) The following tables are hereby adopted
				and incorporated by reference:
(a) 1964
				Commissioners Disability Table;
(b)
				1985 Commissioners Individual Disability Tables A;
(c) 1985 Commissioners Individual Disability
				Tables B;
(d) 1956 Intercompany
				Hospital-Surgical Tables;
(e) 1974
				Medical Expense Tables, Table A,
Transactions of the Society of
				Actuaries,
Volume XXX, page 63;
(f) "Development of the 1974 Medical Expense
				Benefits", Houghton and Wolfe,
Transactions of the Society of
				Actuaries,
Volume XXX, page 9;
(g) 1985 NAIC Cancer Claim Cost
				Tables;
(h) 1959 Accidental Death
				Benefits Table;
(i) 1987
				Commissioners Group Disability Income Table;
(j) 1983 Group Annuity Mortality
				Table.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.302 - Applicability and Scope

Current through Reg. 50, No. 138; July 16, 2024
The provisions of this Part shall apply to any small employer
				  group in force on January 1, 1997, as defined in Section
				  627.6699, F.S., which cover
				  fewer than 20 employees.
Rulemaking Authority 624.308(1), 627.6692(9) FS. Law
					 Implemented 624.307(1), 627.6692 FS.
New 4-24-97, Formerly
					 4-154.302.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-154 - HEALTH INSURANCE POLICIES › Section 69O-154.303 - Initial Notice (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308(1), 627.6692(9) FS. Law
					 Implemented 624.307(1), 627.6692(8) FS.
New 4-24-97, Formerly 4-154.303, Repealed
					 5-4-06.