reglab/statecodes huggingface dataset:
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.101 - Purpose

Current through Reg. 50, No. 138; July 16, 2024
The purpose of the provisions of this rule chapter is to
				  implement Part XVIII of Chapter 627, F.S., to promote the public interest, to
				  promote the availability of long-term care insurance coverage, to protect
				  applicants for long-term care insurance, as defined, from unfair or deceptive
				  sales or enrollment practices, to facilitate public understanding and
				  comparison of long-term care insurance coverages, and to facilitate flexibility
				  and innovation in the development of long-term care
				  insurance.
Rulemaking Authority 624.308(1), 627.9407(1), (2), (6),
					 627.9408 FS. Law Implemented
					 624.307(1),
					 627.9402,
					 627.9407(1)
					 FS.
New 1-13-03, Formerly
					 4-157.101.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.102 - Applicability and Scope

Current through Reg. 50, No. 138; July 16, 2024
(1) Except as
				otherwise specifically provided, the provisions of this rule chapter shall
				apply to long-term care insurance policies delivered or issued for delivery in
				this state, and to policies delivered or issued for delivery outside this state
				to the extent provided in Section
				627.9406, F.S., and Rule
				69O-157.114, F.A.C., by an
				insurer, a fraternal benefit society as defined in Section
				632.601, F.S., a health care
				services plan as defined in Section
				641.01, F.S., a prepaid health
				clinic as defined in Section
				641.402, F.S., or a
				multiple-employer welfare arrangement as defined in Section
				624.437, F.S.
(2) Pursuant to Section
				627.9403, F.S., the provisions
				of this rule chapter shall also apply to limited benefit policies that limit
				coverage to care in a nursing home only or to one or more lower levels of care.
				For limited benefit policies, the term and reference to Long Term Care as used
				within this rule chapter, shall be considered to be, and replaced by, the term
				Limited Benefit.
(3) The provisions
				of this rule chapter apply to policies having indemnity benefits that are
				triggered by activities of daily living and sold as disability income
				insurance, if:
(a) The benefits of the
				disability income policy are dependent upon or vary in amount based on the
				receipt of long-term care services;
(b) The disability income policy is
				advertised, marketed or offered as insurance for long-term care services;
				or
(c) Benefits under the policy
				may commence after the policyholder has reached Social Security's normal
				retirement age unless benefits are designed to replace lost income or pay for
				specific expenses other than long-term care services.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.103 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
As used in these rules and as used in long-term care
				  policies, the following terms shall have meanings no more restrictive than the
				  following:
(1) "Adult day care center"
				means a program for 6 or more individuals of social and health-related services
				provided during the day in a community group setting for the purpose of
				supporting frail, impaired elderly or other disabled adults who can benefit
				from care in a group setting outside the home.
(2) "Assisted living facility" shall be
				defined in the policy and shall be defined in relation to the services and
				facilities required to be available and the licensure or degree status of those
				providing or supervising the services.
(3)
(a)
				"Exceptional increase" means only those increases filed by an insurer as
				exceptional for which the Office determines the need for the premium rate
				increase is justified:
1. Due to changes in
				laws or regulations applicable to long-term care coverage in this state;
				or
2. Due to increased and
				unexpected utilization that affects the majority of insurers of similar
				products.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.104 - Policy Practices and Provisions

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Renewability. The terms "guaranteed renewable" and "noncancellable" shall not
				be used in any individual long-term care insurance policy without further
				explanatory language in accordance with the disclosure requirements of Rule
				69O-157.106, F.A.C.
(a) A policy issued to an individual shall
				not contain renewal provisions other than "guaranteed renewable" or
				"noncancellable."
(b) The term
				"guaranteed renewable" shall be used only when the insured has the right to
				continue the long-term care insurance in force by the timely payment of
				premiums and when the insurer has no unilateral right to make any change in any
				provision of the policy or rider while the insurance is in force, and cannot
				decline to renew, except that rates may be revised by the insurer on a class
				basis.
(c) The term
				"noncancellable" shall be used only when the insured has the right to continue
				the long-term care insurance in force by the timely payment of premiums during
				which period the insurer has no right to unilaterally make any change in any
				provision of the insurance or in the premium rate.
(d) The term "level premium" shall only be
				used when the insurer does not have the right to change the premium.
(e) In addition to the other requirements of
				this subsection 69O-157.104(1),
				F.A.C., a qualified long-term care insurance contract shall be guaranteed
				renewable within the meaning of Section
				7702B(b)(1)(C) of
				the Internal Revenue Code of 1986, as amended.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.105 - Refund of Premium (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308(1), 627.9407(1), (6), 627.9408
					 FS. Law Implemented 624.307(1),
					 627.6043,
					 627.6645,
					 627.9407
					 FS.
New 1-13-03, Formerly 4-157.105, Repealed
					 1-28-13.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.106 - Required Disclosure Provisions

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Renewability. Individual long-term care insurance policies shall contain a
				renewability provision.
(a) The provision:
1. Shall be appropriately
				captioned;
2. Shall appear on the
				first page of the policy;
3. Shall
				clearly state that the coverage is guaranteed renewable or noncancellable;
				and
4. Shall not apply to policies
				that do not contain a renewability provision, and under which the right to
				non-renew is reserved solely to the policyholder.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.109 - Prohibition Against Post-Claims Underwriting

Current through Reg. 50, No. 138; July 16, 2024
(1) All applications for long-term care
				insurance policies or certificates except those that are guaranteed issue shall
				contain clear and unambiguous questions designed to ascertain the health
				condition of the applicant.
(2)
(a) If an application for long-term care
				insurance contains a question that asks whether the applicant has had
				medication prescribed by a physician, it must also ask the applicant to list
				the medication that has been prescribed.
(b) If the medications listed in the
				application were known by the insurer, or should have been known at the time of
				application, to be directly related to a medical condition for which coverage
				would otherwise be denied, then the policy or certificate shall not be
				rescinded for that condition.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.110 - Requirements for Application Forms and Replacement Coverage

Current through Reg. 50, No. 138; July 16, 2024
(1) Application forms shall include the
				following questions designed to elicit information as to whether, as of the
				date of the application, the applicant has another long-term care insurance
				policy or certificate in force or whether a long-term care policy or
				certificate is intended to replace any other accident and sickness or long-term
				care policy or certificate presently in force. A supplementary application or
				other form to be signed by the applicant and agent containing the questions may
				be used. With regard to a replacement policy issued to a group defined by
				Section 627.9405(1)(a),
				F.S., the following questions may be modified only to the extent necessary to
				elicit information about health or long-term care insurance policies other than
				the group policy being replaced, provided that the certificateholder has been
				notified of the replacement.
(a) Do you have
				another long-term care insurance policy or certificate in force (including
				health care service contract, health maintenance organization
				contract)?
(b) Did you have another
				long-term care insurance policy or certificate in force during the last 12
				months?
1. If so, with which
				company?
2. If that policy lapsed,
				when did it lapse?
(c)
				Are you covered by Medicaid?
(d) Do
				you intend to replace any of your medical or health insurance coverage with
				this policy [certificate]?
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.1100 - Requirements for Exchange of Coverage

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a) An insurer may offer policyholders or
				certificateholders the option to exchange an existing Long-Term Care contract
				for a new Long-Term Care contract.
(b) An exchange occurs when an insurer offers
				an existing long-term care policyholder or certificateholder the option to
				replace an existing policy with a different long-term care policy or
				certificate, and the policyholder or certificateholder accepts the offer to
				terminate the existing contract and accepts the new
				contract.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.112 - Reserve Standards

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a) When long-term care benefits are provided
				through the acceleration of benefits under group or individual life policies or
				riders to such policies which meet the conditions of subsection
				69O-157.113(9),
				F.A.C., policy reserves for the benefits shall be determined in accordance with
				Section 625.121, F.S. Claim reserves
				shall also be established in the case when the policy or rider is in claim
				status.
(b)
1. Reserves for policies and riders shall be
				based on the multiple decrement model utilizing all relevant decrements except
				for voluntary termination rates.
2.
				Single decrement approximations are acceptable if the calculation produces
				essentially similar reserves, if the reserve is clearly more conservative, or
				if the reserve is immaterial.
3.
				The calculations may take into account the reduction in life insurance benefits
				due to the payment of long-term care benefits.
4. In no event shall the reserves for the
				long-term care benefit and the life insurance benefit be less than the reserves
				for the life insurance benefit assuming no long-term care
				benefit.
(c) In the
				development and calculation of reserves for policies and riders, due regard
				shall be given to the applicable policy provisions, marketing methods,
				administrative procedures, and all other considerations which have an impact on
				projected claim costs, including the following:
1. Definition of insured events;
2. Covered long-term care
				facilities;
3. Existence of home
				convalescence care coverage;
4.
				Definition of facilities;
5.
				Existence or absence of barriers to eligibility;
6. Premium waiver provision;
7. Renewability;
8. Ability to raise premiums;
9. Marketing method;
10. Underwriting procedures;
11. Claims adjustment procedures;
12. Waiting period;
13. Maximum benefit;
14. Availability of eligible
				facilities;
15. Margins in claim
				costs;
16. Optional nature of
				benefit;
17. Delay in eligibility
				for benefit;
18. Inflation
				protection provisions; and
19.
				Guaranteed insurability option.
(d) Any applicable valuation morbidity table
				shall be certified by a member of the American Academy of Actuaries as
				appropriate as a statutory valuation table.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.114 - Filing Requirement - Out of State Groups

Current through Reg. 50, No. 138; July 16, 2024
(1) No group long-term care insurance
				coverage may be offered to a resident of this state under a group policy issued
				in another state to a group described in Section
				627.9405(1)(c) or
				(d), F.S., unless this state or such other
				state having statutory and regulatory long-term care insurance requirements
				substantially similar to those adopted in this state has made a determination
				that the requirements have been met. Evidence to this effect shall be filed by
				the insurer with the Office pursuant to the procedures specified in Section
				627.410, F.S. The evidence shall
				consist of:
(a) Filing of policy and
				certificate forms, including rates and rate development information, as though
				the policy/certificate were issued in this state, which demonstrate that the
				requirements of Sections
				627.9401 -
				627.9408, F.S., and these rules
				have been met; or
(b)
1. Filing of a truthful certification by an
				officer of the insurer that another state having statutory and regulatory
				long-term care insurance requirements substantially similar to those adopted in
				Florida has made a determination that such requirements have been met;
				and
2. Filing of the policy and
				certificate forms to be issued and delivered, including rates and rate
				development information, which demonstrate that the requirements of another
				state having statutory and regulatory long-term care insurance requirements
				substantially similar to those adopted in Florida have been
				met.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.115 - Filing Requirements for Advertising

Current through Reg. 50, No. 138; July 16, 2024
Every insurer, health care service plan or other entity
				  providing long-term care insurance or benefits in this state shall provide a
				  copy of any long-term care insurance advertisement and marketing material
				  intended for use in this state whether through written, radio, television,
				  electronic or other medium for review or approval by the Office as provided by
				  rule Chapter 69O-150, F.A.C.
Rulemaking Authority 624.308(1), 627.9407(2), 627.9408 FS.
					 Law Implemented 624.307(1), 627.9402, 627.9407(2)
					 FS.
New 1-13-03, Formerly
					 4-157.115.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.1155 - Producer Training

Current through Reg. 50, No. 138; July 16, 2024
Insurers providing Long-Term Care insurance shall maintain
				  records, subject to Office review upon request, that before any producer sells,
				  solicits or negotiates a long-term care insurance policy, that they receive
				  necessary and sufficient training to understand partnership policies and their
				  relationship to public and private coverage for long-term
				  care.
Rulemaking Authority 624.308(1), 626.9611, 627.9407,
					 627.94075, 927.9408 FS. Law Implemented
					 624.307(1),
					 626.9541,
					 626.9641
					 FS.
New 8-1-07.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.116 - Suitability

Current through Reg. 50, No. 138; July 16, 2024
(1) This rule shall not apply to life
				insurance policies that accelerate benefits for long-term care.
(2) Every insurer, health care service plan,
				or other entity marketing long-term care insurance (the "insurer") shall:
(a) Develop and use suitability standards to
				determine whether the purchase or replacement of long-term care insurance is
				appropriate for the needs of the applicant;
(b) Train its agents in the use of its
				suitability standards; and
(c)
				Maintain a copy of its suitability standards and make them available for
				inspection upon request by the Office.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.117 - Prohibition Against Preexisting Conditions and Probationary Periods in Replacement Policies or Certificates

Current through Reg. 50, No. 138; July 16, 2024
If a long-term care insurance policy or certificate replaces
				  another long-term care policy or certificate, the replacing insurer shall waive
				  any time periods applicable to time limit on certain defenses, preexisting
				  conditions and probationary periods in the new long-term care policy for
				  similar benefits to the extent that similar exclusions have been satisfied
				  under the original policy.
Rulemaking Authority 624.308(1), 626.9611, 627.9407(1),
					 627.9408 FS. Law Implemented
					 624.307(1),
					 626.9541(1)(a),
					 (g),
					 627.9402,
					 627.9407(1),
					 627.94076,
					 627.9408
					 FS.
New 1-13-03, Formerly 4-157.117, Amended
					 9-16-08.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.118 - Nonforfeiture Benefit Requirement

Current through Reg. 50, No. 138; July 16, 2024
(1) This
				rule does not apply to life insurance policies or riders meeting the conditions
				of subsection 69O-157.113(9),
				F.A.C., containing accelerated long-term care benefits.
(2)
(a) All
				insurers offering long term care insurance in this state shall offer a
				nonforfeiture protection provision at the time of issue as required by Section
				627.94072, F.S.
(b) If the insurer offers an option other
				than the shortened benefit period option, the nonforfeiture protection option
				offered shall be determined such that the benefits provided are determined at
				time of issue to be actuarially equivalent to those provided by the shortened
				benefit period option.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.119 - Additional Standards for Benefit Triggers for Qualified Long-Term Care Insurance Contracts

Current through Reg. 50, No. 138; July 16, 2024
(1) A qualified long
				term care insurance contract shall pay only for qualified long term care
				services received by a chronically ill individual provided pursuant to a plan
				of care prescribed by a licensed health care practitioner.
(2)
(a)
1. A qualified long-term care insurance
				contract shall condition the payment of benefits on a determination of the
				insured's being chronically ill as defined in Section
				627.9404(4),
				F.S.
2. Certifications regarding
				activities of daily living and cognitive impairment shall be performed by a
				licensed health care practitioner as defined by Section
				627.9404(6),
				F.S.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.120 - Standard Format Outline of Coverage

Current through Reg. 50, No. 138; July 16, 2024
This rule implements, interprets, and makes specific, the
				  provisions of Section
				  627.9407(10),
				  F.S., in prescribing a standard format and the content of an outline of
				  coverage.
(1) The outline of coverage
				shall be a freestanding document, using no smaller than 10-point
				type.
(2) The outline of coverage
				shall contain no material of an advertising nature.
(3) Text that is capitalized or underscored
				in the standard format outline of coverage may be emphasized by other means
				that provide prominence equivalent to the capitalization or
				underscoring.
(4) Use of the text
				and sequence of text of the standard format outline of coverage is mandatory,
				unless otherwise specifically indicated.
(5) Format for outline of coverage shall be
				as contained in Appendix I, which is incorporated herein by
				reference.
Rulemaking Authority 624.308(1), 627.9407(1), 627.9408 FS.
					 Law Implemented 624.307(1), 627.9402, 627.9407
					 FS.
New 1-13-03, Formerly
					 4-157.120.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.121 - Requirement to Deliver Shopper's Guide

Current through Reg. 50, No. 138; July 16, 2024
(1) A long-term care insurance shopper's
				guide in the format developed by the National Association of Insurance
				Commissioners (2001), which is incorporated herein by reference, or a guide
				developed by the Office, shall be provided to all prospective applicants of a
				long-term care insurance policy or certificate.
(a) An agent shall deliver the shopper's
				guide prior to the presentation of an application or enrollment form.
(b) In the case of direct response
				solicitations, the shopper's guide shall be presented in conjunction with any
				application or enrollment form.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.122 - Penalties

Current through Reg. 50, No. 138; July 16, 2024
In addition to any other penalties provided by the laws of
				  this state, any insurer and any agent found to have violated any requirement of
				  this state relating to the regulation of long-term care insurance or the
				  marketing of such insurance shall be subject to a fine of up to 3 times the
				  amount of any commissions paid for each policy involved in the violation or up
				  to $10,000, whichever is greater, however, such penalty shall not exceed the
				  amounts specified in Section
				  624.4211 or
				  626.9521(2),
				  F.S.
Rulemaking Authority 624.308(1), 626.9611, 627.9407(1),
					 627.9408 FS. Law Implemented
					 624.307(1),
					 626.9521,
					 627.9402
					 FS.
New 1-13-03, Formerly
					 4-157.122.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.201 - Standards for Approved Long-Term Care Partnership Program Policies

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a) A
				policy or certificate, herein referred to as policy, marketed or represented to
				qualify as an approved long-term care partnership program policy as provided by
				Section 409.9102, F.S., hereinafter
				referred to as a 'partnership', shall be a policy where:
1. Such form and rates are filed and approved
				pursuant to the provisions of Part II of this rule chapter and Chapter 69O-149,
				F.A.C.,
2. The policy is intended
				to be a qualified long-term care insurance policy under the provisions of
				Section 627.9404(12),
				F.S.,
3. The insured individual was
				a resident of Florida or another state that has entered into a reciprocal
				agreement with Florida when coverage first became effective under the policy.
				If the policy is later exchanged for a different long-term care policy, the
				individual was a resident of Florida or another state that has entered into a
				reciprocal agreement with Florida when coverage under the earliest policy
				became effective,
4. The policy is
				issued with and retains inflation coverage which meets the inflation standards
				based on the insured's then attained age as defined in subsection (4)
				below,
5. The effective date of the
				coverage is on or after January 1, 2007, and
6. Compliance is met with the provisions of
				these rules.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.302 - Facility Only Rates (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 627.9408(1) FS. Law Implemented
					 627.9407(7) FS.
New 11-1-07, Amended 5-31-09, 7-19-10, Repealed
					 11-3-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.303 - Home Health Care Only Rates (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 627.9408(1) FS. Law Implemented
					 627.9407(7) FS.
New 11-1-07, Amended 5-31-09, 7-19-10, Repealed
					 11-3-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.304 - Comprehensive Only Rates (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 627.9408(1) FS. Law Implemented
					 627.9407(7) FS.
New 11-1-07, Amended 5-31-09, 7-19-10, Repealed
					 11-3-15.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-158 - EXCHANGE OF MEDICAID DATA WITH INSURERS › Section 69O-158.001 - Purpose

Current through Reg. 50, No. 138; July 16, 2024
The purpose of these rules is to enable the Agency for Health
				  Care Administration, with the assistance of the Office of Insurance Regulation,
				  to obtain information from health insurers and other entities which provide
				  similar coverage so that AHCA may determine whether health insurance or health
				  care services provided pursuant to Chapter 641, F.S., could be, should be, or
				  have been claimed and paid with respect to medical care and services furnished
				  to any person eligible under Section
				  409.903, F.S.
Rulemaking Authority 409.910, 624.308 FS. Law Implemented
					 409.910, 624.424(9), 641.261, 641.411
					 FS.
New 11-14-89, Formerly 4-80.001,
					 4-158.001.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-158 - EXCHANGE OF MEDICAID DATA WITH INSURERS › Section 69O-158.002 - Scope

Current through Reg. 50, No. 138; July 16, 2024
These rules apply to all insurers authorized to transact
				  health insurance, multiple employer welfare arrangements, health maintenance
				  organizations, and pre-paid health clinics as defined in Sections
				  624.603,
				  624.437,
				  641.19(6),
				  641.402(5),
				  F.S.
Rulemaking Authority 409.910, 624.308 FS. Law Implemented
					 409.910, 624.424(9), 641.261, 641.411
					 FS.
New 11-14-89, Formerly 4-80.002,
					 4-158.002.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-158 - EXCHANGE OF MEDICAID DATA WITH INSURERS › Section 69O-158.003 - Definitions

Current through Reg. 50, No. 138; July 16, 2024
The following definitions shall apply to this rule
				  chapter:
(1) "Office" shall mean the
				Office of Regulation.
(2) "AHCA"
				shall mean the Agency for Health Care Administration.
(3) "Insurer" shall mean an entity authorized
				by the Office to transact health insurance, multiple employer welfare
				arrangement, health maintenance organization, and prepaid health clinic
				insurance.
(4) "Policy" shall mean
				health insurance policy, health maintenance contract as defined in Section
				641.19(5),
				F.S., prepaid health clinic contract as defined in Section
				641.402(6),
				F.S., and multiple employer welfare arrangement policy or contract issued
				pursuant to Sections 624.436-.446, F.S.
(5) "Medical assistance" shall mean payment
				by AHCA for medical services to any person eligible for Medicaid or for
				assistance from the Public Medical Assistance Trust Fund pursuant to Section
				409.918,
				F.S.
Rulemaking Authority 409.910, 624.308 FS. Law Implemented
					 409.910, 624.424(9), 641.261, 641.411
					 FS.
New 11-14-89, Formerly 4-80.003,
					 4-158.003.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.001 - Purpose

Current through Reg. 50, No. 138; July 16, 2024
The purpose of this chapter is to establish uniform claim
				  forms for claims relating to health insurance and industrial life insurance
				  policies, to establish guidelines for all prior authorization forms which
				  ensure the general uniformity of such forms, and to adopt a prior authorization
				  form for use by health insurance issuers which do not provide an electronic
				  prior authorization process for use by its contracted
				  providers.
Rulemaking Authority 624.308(1), 627.647, 627.42392 FS. Law
					 Implemented 624.307(1), 627.42392, 627.510(2), 627.647
					 FS.
New 4-25-88, Formerly 4-74.001, Amended 6-8-94, Formerly
					 4-161.001, Amended 1-11-17.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.002 - Scope

Current through Reg. 50, No. 138; July 16, 2024
This chapter applies to all insurance companies authorized to
				  write health insurance or industrial life insurance in
				  Florida.
Rulemaking Authority 624.308(1), 627.647 FS. Law
					 Implemented 624.307(1), 627.510(2), 627.647
					 FS.
New 4-25-88, Formerly 4-74.002, Amended 6-8-94, Formerly
					 4-161.002.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.003 - Use of Industrial Life Insurance Claim Form

Current through Reg. 50, No. 138; July 16, 2024
All companies writing industrial life insurance shall use the
				  Uniform Life Insurance Claim Form (OIR Form 4-371) (2/94) which is hereby
				  incorporated and made part of this rule chapter by reference.
Rulemaking Authority 624.308(1) FS. Law Implemented
					 624.307(1), 627.510(2) FS.
New 4-25-88, Formerly 4-74.003, Amended 6-8-94, Formerly
					 4-161.003.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.004 - Use of Health Insurance Claim Form

Current through Reg. 50, No. 138; July 16, 2024
All companies writing health insurance shall accept the
				  Uniform Health Insurance Claim Form (Form HCFA-1500) (12/90), which is hereby
				  incorporated and made part of this rule chapter by reference.
Rulemaking Authority 624.308(1), 627.647 FS. Law
					 Implemented 624.307(1), 627.647 FS.
New 6-8-94, Formerly
					 4-161.004.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.005 - Use of Dental Claim Form

Current through Reg. 50, No. 138; July 16, 2024
All companies writing dental insurance shall accept Form HCFA
				  1500 (12/90) and the American Dental Association Dental Claim Form (Form J510,
				  J511, or J512) (1/94). For informational purposes only, the Florida Medicaid
				  dental program shall accept the Non-Institutional Dentist Claim Form (Form 111)
				  (1/89) and Form HCFA 1500. All said forms are hereby incorporated and made part
				  of this rule chapter by reference.
Rulemaking Authority 624.308(1), 627.647 FS. Law
					 Implemented 624.307(1), 627.647 FS.
New 6-8-94, Amended 12-5-95, Formerly
					 4-161.005.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.006 - Use of Pharmacy Claim Form

Current through Reg. 50, No. 138; July 16, 2024
All companies writing health insurance shall accept the
				  Universal Pharmacy Claim Form (Form DAH) (2/89) and Form HCFA 1500, which are
				  hereby incorporated and made part of this rule chapter by
				  reference.
Rulemaking Authority 624.308(1), 627.647 FS. Law
					 Implemented 624.307(1), 627.647 FS.
New 6-8-94, Formerly
					 4-11.006.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.007 - Use of Hospital Claim Form

Current through Reg. 50, No. 138; July 16, 2024
All companies writing health insurance shall accept the
				  Uniform Hospital Claim Form (Form UB-92, HCFA 1450) (2/94), which is hereby
				  incorporated and made part of this rule chapter by reference.
Rulemaking Authority 624.308(1), 627.647 FS. Law
					 Implemented 627.647 FS.
New 6-8-94, Formerly
					 4-161.007.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.008 - Additional Information

Current through Reg. 50, No. 138; July 16, 2024
Nothing in this rule chapter shall prevent an insurance
				  company from requesting additional information which is not contained on the
				  forms specified by this rule chapter in order to determine the eligibility of
				  the patient or the medical necessity of the service rendered.
Rulemaking Authority 624.308(1), 627.647 FS. Law
					 Implemented 624.307(1), 627.647 FS.
New 6-8-94, Formerly
					 4-161.008.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.009 - Form Availability

Current through Reg. 50, No. 138; July 16, 2024
All forms referenced in this rule chapter may be obtained at
www.floir.com/iportal
.
Rulemaking Authority 624.308(1), 627.647 FS. Law
					 Implemented 624.307(1), 627.510(2), 627.647
					 FS.
New 6-8-94, Formerly 4-161.009, Amended
					 1-11-17.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.010 - Guidelines for Prior Authorization Forms

Current through Reg. 50, No. 138; July 16, 2024
(1) Scope: This rule applies to all insurance
				companies, health maintenance organizations, and managed care entities
				authorized to write health insurance in Florida.
(2) Definitions: As used in this rule:
(a) "Health Insurer" means an authorized
				insurer offering health insurance as defined in Section
				624.603, F.S., a managed care
				plan as defined in Section
				409.962(9),
				F.S., or a health maintenance organization as defined in Section
				641.19(12)
				F.S.
(b) "Utilization review
				entity" means any person that performs prior authorization for a health
				insurer.
(c) "Person" has the same
				meaning as defined in Section
				624.04, F.S.
(d) "Prior authorization" means any practice
				implemented by a health insurer or a health insurer's utilization review entity
				in which coverage of a health care service, device, or drug is dependent upon a
				covered person or health care practitioner obtaining approval from the health
				insurer or utilization review entity prior to the service, device, or drug
				being performed, received, or prescribed, as applicable. "Prior authorization"
				includes prospective or utilization review procedures conducted prior to
				providing a health care service, device, or drug.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-161 - UNIFORM INSURANCE CLAIM FORMS AND PRIOR AUTHORIZATION FORMS › Section 69O-161.011 - Use of Prior Authorization Form

Current through Reg. 50, No. 138; July 16, 2024
All authorized insurers offering health insurance as defined
				  in Section 624.603, F.S., managed care
				  plans as defined in Section
				  409.962(9),
				  F.S., and health maintenance organizations as defined in Section
				  641.19(12),
				  F.S., which do not provide an electronic prior authorization process for use by
				  its contracted providers shall use only the Prior Authorization Form (OIR Form
				  OIR-B2-2180) (12/16), Prior Authorization Form for Medical Procedures, Courses
				  of Treatment, or Prescription Drug Benefits,
http://www.flrules.org/Gateway/reference.asp?No=Ref-07606
,
				  which is hereby incorporated and made part of this rule chapter by
				  reference.
Rulemaking Authority 624.308(1), 627.42392 FS. Law
					 Implemented 624.307(1), 627.42392 FS.
New 1-11-17.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.001 - Scope

Current through Reg. 50, No. 138; July 16, 2024
The following Rules and Regulations shall govern the issuance
				  and delivery of Variable Annuity Contracts pursuant to the authority set forth
				  in Chapter 627, Part XIV, Florida Statutes.
Specific Authority 627.805 FS. Law Implemented 627.801
					 FS.
Repromulgated 12-24-74, Formerly 4-10.01, 4-10.001,
					 4-162.001.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.002 - Policy Form and Application; Prior Approval; Disapproval or Withdrawal of Filing

Current through Reg. 50, No. 138; July 16, 2024
No variable annuity contract shall be delivered or issued for
				  delivery in this state by any insurance company until a copy of the form
				  thereof (and, in the case of a contract on a group basis, the form of any
				  certificates evidencing variable benefits issued pursuant thereto) and any form
				  of application for such variable annuity contract shall have been filed with
				  the Director. No such form shall be issued or used until the Director shall
				  give his prior written approval of such form. The Director shall disapprove or
				  withdraw approval of any such contract form, application or certificate
				  if:
(1) Such variable annuity contract
				or application or certificate contains provisions which are ambiguous,
				misleading or deceptive or likely to mislead or deceive the policyholder,
				certificate holder, or applicant; or if sales of such contracts are being
				solicited by any means of advertising, communication or dissemination of
				information which involves misleading or inadequate description of the
				provisions of the contract,
(2) The
				Director, in such event, shall, by written order, promptly notify the company,
				specifying the particulars of his disapproval. It shall be unlawful for such
				company thereafter to issue any contract or certificate thereunder or use any
				application in the form so disapproved.
Specific Authority 624.308(1), 627.805 FS. Law Implemented
					 624.307(1), 627.803, 627.410, 627.411
					 FS.
Repromulgated 12-24-74, Formerly 4-10.02, 4-10.002, Amended
					 4-9-97, Formerly 4-162.002.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.003 - Illustrations of Benefits

Current through Reg. 50, No. 138; July 16, 2024
Illustrations of benefits payable under any variable contract
				  shall not involve projections of past investment experience into the
				  future.
Specific Authority 626.9611, 627.805 FS. Law Implemented
					 627.803, 626.9541(1) FS.
Repromulgated 12-24-74, Formerly 4-10.03, 4-10.003,
					 4-162.003.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.004 - Grace Period and Nonforfeiture Values

Current through Reg. 50, No. 138; July 16, 2024
No individual variable annuity contract shall be delivered or
				  issued for delivery in this state unless it contains in substance the following
				  provisions:
(1) That, in the event of
				default in the payment of any consideration beyond the period of grace allowed
				by the contract for the payment thereof, the insurance company will make
				payment of the value of the contract in accordance with a plan provided by the
				contract commencing not later than the date contractual payments by the company
				were otherwise to have commenced in accordance with the contract.
(2) That, upon request of the contract holder
				received by the insurance company at least four months prior to the date
				contractual payments by the company were otherwise to have commenced, the
				company will make payment of the value of the contract in accordance with a
				plan provided by the contract and selected by the contract holder commencing as
				of the first day of the first month which is at least four months after the
				date of receipt of such request, unless another date of commencement is
				requested by the contract holder and agreed to by the company.
(3) That the insurance company will mail to
				the holder of the contract at least once in each contract year after the first,
				at his last address known to the company, a report in a form approved by the
				Director, which shall include a statement of the number of units credited to
				such contract and the dollar value of a unit as of a date not more than two
				months previous to the date of mailing and the statement shall be in a form and
				of a date approved by the Director of the investments held in the appropriate
				variable contract account.
Specific Authority 624.308(1), 627.805 FS. Law Implemented
					 624.307(1), 627.802, 627.804, 627.475
					 FS.
Repromulgated 12-24-74, Formerly 4-10.04, 4-10.004,
					 4-162.004.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.006 - Notice of Variable Values Required

Current through Reg. 50, No. 138; July 16, 2024
Any variable annuity contract delivered or issued for
				  delivery in this state, and any application for such contract, and any group
				  annuity certificate, shall contain on its first page, in a prominent position
				  in ten (10) point type or larger, a clear statement that the annuity benefits
				  of values thereunder are on a variable basis.
Suggested wording is as follows: "ANNUITY PAYMENTS AND
				  TERMINATION VALUES PROVIDED BY THIS CONTRACT ARE VARIABLE AND ARE NOT
				  GUARANTEED AS TO FIXED DOLLAR AMOUNT."
Specific Authority 626.9611, 627.805 FS. Law Implemented
					 626.9541(1), 627.803 FS.
Repromulgated 12-24-74, Formerly 4-10.06, 4-10.006,
					 4-162.006.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.008 - Contract Provision; Expense, Mortality and Investment Increment Factor

Current through Reg. 50, No. 138; July 16, 2024
Any individual or group variable annuity contract delivered
				  or issued for delivery in this state shall stipulate the expense, mortality,
				  and investment increment factors to be used in computing the dollar amount of
				  variable benefits or other contractual payments or values thereunder, and shall
				  guarantee that expense and mortality results shall not adversely affect such
				  dollar amounts. The mortality and investment increment factors used in
				  computing the dollar amount of variable benefits or other contractual payments
				  or values under an individual variable contract shall not produce a larger
				  initial payment than would be produced by the use of annuity mortality tables
				  in Rule 69O-162.108, F.A.C., for
				  policies issued on or before December 31, 2016 and annuity mortality tables for
				  use in determining reserve liabilities in accordance with the NAIC Valuation
				  Manual as adopted by Section
				  625.1212, F.S., for policies
				  issued on or after January 1, 2017 and an annual investment increment
				  assumption of 3 1/2 %. "Expense" as used in this subsection may exclude some or
				  all taxes as stipulated in the contract.
Rulemaking Authority 624.308(1), 627.805 FS. Law
					 Implemented 624.307(1), 627.803, 627.804, 627.413
					 FS.
New 12-24-74, Formerly 4-10.08, 4-10.008, 4-162.008,
					 Amended 11-21-17.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.009 - Licensing of Agents

Current through Reg. 50, No. 138; July 16, 2024
Sales of variable annuity contracts shall be made or
				  solicited only by persons authorized under licenses from the Department of
				  Financial Services to sell life insurance only after certification by the
				  Department as having satisfactorily completed an examination given or
				  authorized by the Department relating to variable annuity
				  contracts.
Specific Authority 627.805 FS. Law Implemented 626.221,
					 626.241 FS.
Repromulgated 12-24-74, Formerly 4-10.09, 4-10.009,
					 4-162.009.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-162 - ANNUITY CONTRACTS › Section 69O-162.010 - Selling Methods and Advertising

Current through Reg. 50, No. 138; July 16, 2024
(1) All
				companies authorized to issue and deliver contracts on a variable basis, all
				contracts, certificates and other forms in connection therewith, and all agents
				and other representatives are subject to the provisions of Chapter 626, Part
				VII, Florida Statutes.
(2)
				Illustration of benefits payable under any variable annuity contract shall not
				involve projections of past investment experience into the future or attempted
				predictions of future investment experience.
(3) No advertising, sales literature, or
				sales presentation for contracts on a variable basis shall be misleading,
				deceptive or inadequate in any way.
Specific Authority 627.805 FS. Law Implemented 626.9521,
					 626.9541 FS.
Repromulgated 12-24-74, Formerly 4-10.10, 4-10.010,
					 4-162.010.