reglab/statecodes huggingface dataset:
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.108 - Advertisements of Benefits Payable, Losses Covered or Premiums Payable

Current through Reg. 50, No. 138; July 16, 2024
(1) Deceptive Words, Phrases, or
				Illustrations Prohibited.
(a) No advertisement
				shall omit information or use words, phrases, statements, references or
				illustrations if the omission of such information or use of such words,
				phrases, statements, references, or illustrations has the capacity, tendency,
				or effect of misleading or deceiving purchasers or prospective purchasers as to
				the nature or extent of any policy benefit payable, loss covered or premium
				payable. The fact that the policy offered is made available to a prospective
				insured for inspection prior to consummation of the sale or an offer is made to
				refund the premium if the purchaser is not satisfied, does not remedy
				misleading statements.
(b) No
				advertisement shall contain or use words or phrases such as "all", "full",
				"complete", "comprehensive", "unlimited", "up to", "as high as", "this policy
				will help pay your hospital and surgical bills," "this policy will help fill
				some of the gaps that Medicare and your present insurance leave out," or
				similar words and phrases, in a manner which exaggerates any benefits beyond
				the terms of the policy.
(c) An
				advertisement which also is an invitation to join an association, trust, or
				discretionary group must solicit insurance coverage on a separate and distinct
				application which requires signatures for each application. The insurance
				program must be presented so as not to mislead or deceive the prospective
				members regarding the fact that they are purchasing insurance as well as
				applying for membership, if that is the case.
(d) An advertisement shall not contain
				descriptions of policy limitations, exceptions, or reductions, worded in a
				positive manner to imply that it is a benefit, such as describing a waiting
				period as a "benefit builder" or stating "even pre-existing conditions are
				covered after a limited period of time." Words and phrases used in an
				advertisement to describe such policy limitations, exceptions and reductions
				shall fairly and accurately describe the negative features of such limitations,
				exceptions, or reductions of the policy offered.
(e) An advertisement of medicare supplement
				insurance sold by direct response shall not use the phrases, "no salesman will
				call," or "no agent will call," or "by eliminating the agent and/or commission
				we can offer this low cost plan" or similar wording in a misleading
				manner.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.109 - Necessity for Disclosing Policy Provisions Relating to Renewability, Cancellability, and Termination

Current through Reg. 50, No. 138; July 16, 2024
An advertisement which is an invitation to contract shall
				  disclose the provisions relating to renewability, cancellability, and
				  termination and any modification of benefits, losses covered or premiums
				  because of age or for other reasons, in a manner which shall not minimize or
				  render obscure the qualifying conditions.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1)
					 FS.
New 6-12-88, Formerly 4-46.008,
					 4-156.109.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.110 - Testimonials or Endorsements by Third Parties

Current through Reg. 50, No. 138; July 16, 2024
(1) Testimonials and endorsements used in
				advertisements must be genuine, represent the current opinion of the author, be
				applicable to the policy advertised and be accurately reproduced. The insurer,
				in using a testimonial or endorsement, makes as its own all of the statements
				contained therein, and the advertisement, including such statement, is subject
				to all the provisions of these rules. When a testimonial or endorsement is used
				more than one year after it was originally given, a confirmation must be
				obtained.
(2) A person shall be
				deemed a "spokesperson" if the person making the testimonial or endorsement:
(a) Has a financial interest in the insurer
				or a related entity as a stockholder, director, officer, employee or otherwise;
				or
(b) Is an entity formed by the
				insurer, is owned or controlled by the insurer, its employees, or the person or
				persons who own or control the insurer; or
(c) Is in a policy-making position who is
				affiliated with the insurer in any of the above described capacities;
				or
(d) Is in any way directly or
				indirectly compensated for making a testimonial or
				endorsement.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.111 - Use of Statistics

Current through Reg. 50, No. 138; July 16, 2024
(1) An advertisement
				relating to the dollar amounts of claims paid, the number of persons insured,
				or similar statistical information relating to any insurer or policy or
				contract shall not use irrelevant facts, and shall not be used unless it
				accurately reflects all of the relevant facts. Such an advertisement shall not
				imply that such statistics are derived from a policy or contract advertised
				unless such is the fact, and when applicable to other policies or contracts or
				plans shall specifically so state.
(a) An
				advertisement shall specifically identify the policy to which statistics relate
				and, where statistics are given which are applicable to a different policy, it
				must be stated clearly that the data do not relate to the policy being
				advertised.
(b) An advertisement
				shall not contain statements which are untrue in fact, or by implication
				misleading, with respect to assets, corporate structure, financial standing,
				age or relative position of the insurer in the insurance
				business.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.112 - Identification of Plan or Number of Policies

Current through Reg. 50, No. 138; July 16, 2024
When a choice of the amount of benefits is referred to, an
				  advertisement shall disclose that the amount of benefits provided depends upon
				  the plan selected and that the premium will vary with the amount of the
				  benefits selected.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1)
					 FS.
New 6-12-88, Formerly 4-46.011,
					 4-156.112.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.113 - Disparaging Comparisons and Statements

Current through Reg. 50, No. 138; July 16, 2024
(1) An advertisement shall not directly or
				indirectly make unfair or incomplete comparisons of policies or contracts or
				benefits or comparisons of non-comparable policies or contracts of other
				insurers, and shall not disparage competitors, their policies or contracts,
				services or business methods, and shall not disparage or unfairly minimize
				competing methods of marketing insurance.
(2) An advertisement should not contain
				statements such as "no red tape" or "here is all you do to receive
				benefits."
(3) Advertisements which
				state or imply that competing insurance coverages customarily contain certain
				exceptions, reductions or limitations not contained in the advertised policies
				are unacceptable unless such exceptions, reductions or limitations are
				contained in a substantial majority of such competing coverages.
(4) Advertisements which state or imply in a
				misleading or incomplete manner that an insurer's premiums are lower or that
				its loss ratios are higher because its organizational structure differs from
				that of competing insurers shall not be used.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1)
					 FS.
New 6-12-88, Formerly 4-46.012,
					 4-156.113.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.114 - Jurisdictional Licensing and Status of Insurer

Current through Reg. 50, No. 138; July 16, 2024
(1) An advertisement which is intended to be
				seen or heard beyond the limits of the jurisdiction in which the insurer is
				licensed shall not imply licensing beyond those limits.
(2) An advertisement shall not create the
				impression directly or indirectly that the insurer, its financial condition or
				status, or the payment of its claims, or the merits, desirability, or
				advisability of its policy forms or kinds of plans of insurance are approved,
				endorsed, or accredited by any division or agency of this State or the United
				States Government or if such relationship exists, such advertisement shall not
				exaggerate or otherwise mislead with respect to the nature or extent of such
				relationship.
(3) An advertisement
				shall not imply in a misleading manner that approval, endorsement, or
				accreditation of policy forms or advertising has been granted by any division
				or agency of the state or federal government. "Approval" of either policy forms
				or advertising shall not be used by an insurer to imply or state that a
				governmental agency has endorsed or recommended the insurer, its policies,
				advertising or its financial conditions.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1)(a),
					 (c), (e), (h) FS.
New 6-12-88, Formerly 4-46.013,
					 4-156.114.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.115 - Identity of Insurer

Current through Reg. 50, No. 138; July 16, 2024
(1) The name of the
				actual insurer shall be stated in all of its advertisements. The form number or
				numbers of the policy advertised shall be stated in any invitation to contract.
				An advertisement shall not use a trade name, any insurance group designation,
				name of the parent company of the insurer, name of a particular division of the
				insurer, service mark, slogan, symbol or other device which would have the
				capacity and tendency to mislead or deceive as to the true identity of the
				insurer.
(2) No advertisement shall
				use any combination of words, symbols, or physical materials which by their
				content, phraseology, shape, color or other characteristics are so similar to
				combination of words, symbols, or physical materials used by agencies of the
				federal government or of this State, or otherwise appear to be of such a nature
				that it tends to confuse or mislead prospective insureds into believing that
				the solicitation is in some manner connected with an agency of the municipal,
				county, state, or federal government, or if such relationship exists, such
				advertisement shall not exaggerate or otherwise be misleading with respect to
				the nature or extent of such relationship.
(3) Advertisements, envelopes, or stationery
				which utilize words, letters, initials, symbols, or other devices which are so
				similar to those used by governmental agencies or other insurers are not
				permitted if they may tend to mislead or confuse the public into believing:
(a) That the advertised coverages are somehow
				provided by or are endorsed by such governmental agencies or such other
				insurers; or
(b) That the
				advertiser is the same as, is connected with, or is endorsed by such
				governmental agencies or such other insurers.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.116 - Group or Quasi-Group Implications

Current through Reg. 50, No. 138; July 16, 2024
(1) An
				advertisement of a particular policy shall not state or imply that prospective
				insureds become group or quasi-group members covered under a group policy and
				as such enjoy special rates or underwriting privileges, unless such is the
				fact.
(2) No solicitation of a
				particular class, such as governmental employees, shall state or imply that the
				occupational status of group members entitles them to reduced rates on a group
				or other basis when, in fact, the policy being advertised is sold only on an
				individual basis at regular rates.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l)
					 626.9641(1)
					 FS.
New 6-12-88, Formerly 4-46.015,
					 4-156.116.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.118 - Statements About an Insurer

Current through Reg. 50, No. 138; July 16, 2024
An advertisement shall not contain statements which are
				  untrue in fact, or by implication misleading, with respect to the assets,
				  corporate structure, financial standing, age or relative position of the
				  insurer in the insurance business. An advertisement shall not contain a
				  recommendation by any commercial rating system unless it clearly indicates the
				  purpose of the recommendation and the limitations of the scope and extent of
				  the recommendation.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.830, 626.9541(1)(a), (b), (e), (k), (l),
					 626.9641(1) FS.
New 6-12-88, Formerly 4-46.017,
					 4-156.118.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.119 - Application in Advertisement

Current through Reg. 50, No. 138; July 16, 2024
Every application for an individual policy, or an in-state
				  group Medicare Supplement policy or contract or enrollment form for an
				  out-of-state group contract which does not comply with Section
				  627.6515(2),
				  F.S., must be taken by a Florida resident agent. Therefore, to assure
				  compliance with F.S., no advertisement for a Medicare Supplement policy or
				  contract in this State containing an application for a Medicare Supplement
				  either for individual coverage, coverage under an in-state group policy or
				  out-of-state group policy which does not comply with Section
				  627.6515(2),
				  F.S., shall be used unless such application contains the name of the Florida
				  resident agent or a space for the Florida resident agent's signature, and the
				  completed application shall be returned to the Florida resident
				  agent.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 624.428, 626.830, 626.9541(1)(a), (b), (c), (e), (k),
					 (l), 626.9641(1), 627.6515(6) FS.
New 6-12-88, Formerly 4-46.018,
					 4-156.119.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.120 - Enforcement Procedures

Current through Reg. 50, No. 138; July 16, 2024
(1) Advertising
				File. Each insurer shall maintain at its home or principal office a complete
				file containing every printed, published, or prepared advertisement of its
				individual policies and typical printed, published, or prepared advertisements
				of its blanket, franchise, and group policies hereafter disseminated in this or
				any other state, whether or not licensed in such other state, with a notation
				attached to each such advertisement which shall indicate the manner and extent
				of distribution and the form number of any policy advertised. Such file shall
				be available for inspection by this Office. All such advertisements shall be
				maintained in said file for a period of either four years or until the filing
				of the next regular report of examination of the insurer, whichever is the
				longer period of time.
(2)
				Certificate of Compliance. Each insurer required to file an Annual Statement
				which is now or which hereafter becomes subject to the provisions of these
				rules must file with this Office, with its Annual Statement, a Certificate of
				Compliance executed by an authorized officer of the insurer wherein it is
				stated that, to the best of his knowledge, information and belief, the
				advertisements which were disseminated by the insurer during the preceding
				statement year complied or were made to comply in all respects with the
				provisions of these rules and the Insurance Laws of this State as implemented
				and interpreted by these rules.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 624.317, 626.9541(1)(a), (b), (e), (k), (l),
					 626.9641(1) FS.
New 6-12-88, Formerly 4-46.019,
					 4-156.120.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.121 - Filing for Review

Current through Reg. 50, No. 138; July 16, 2024
(1) Every insurer
				providing Medicare supplement insurance or benefits in this state shall provide
				a copy of any advertisement no later than 10 calendar days prior to its use in
				this state to the Office of Insurance Regulation for review by the
				Commissioner. Such advertisement shall comply with all applicable laws of this
				state.
(2) All advertising
				material, whether print, or radio or television, shall be received by the
				Office no later than 5 p.m. on the day which is the 10th calendar day prior to
				its intended use. If the insurer files at least 10 calendar days prior to use,
				and the Office has not issued a preliminary notice of violation within 10
				calendar days after such filing, and there are no material changes in the print
				or production of the advertisement, the insurer shall not be penalized for any
				use of the advertisement which occurs within 30 calendar days after the
				insurer's receipt of any subsequent preliminary notice asserting that the
				advertisement is in violation of any applicable laws of this state.
(3) All television or radio advertisements
				shall be filed on audio or audio/visual tapes as appropriate using either the
				actual spokesperson or a "stand-in." An audio/visual tape shall be on VHS
				format.
Rulemaking Authority 624.308(1), 626.9611, 627.6735 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1),
					 627.6735 FS.
New 6-12-88, Amended 9-4-89, Formerly 4-46.020,
					 4-156.121.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.122 - Severability

Current through Reg. 50, No. 138; July 16, 2024
If any section or portion of a section of these rules or any
				  amendments thereto, or the applicability thereof to any person or circumstance
				  is held invalid by a court, the remainder of the rules, or the applicability of
				  such provision to other persons or circumstances, shall not be affected
				  thereby.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1)
					 FS.
New 6-12-88, Formerly 4-46.021,
					 4-156.122.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-156 - MEDICARE SUPPLEMENT INSURANCE › Section 69O-156.123 - Prior Rules

Current through Reg. 50, No. 138; July 16, 2024
These rules supersede and constitute a revision of all prior
				  rules pertaining to solicitation and sale of Medicare Supplemental Insurance
				  Policies.
Rulemaking Authority 624.308(1), 626.9611 FS. Law
					 Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1)
					 FS.
New 6-12-88, Formerly 4-46.022,
					 4-156.123.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.001 - Purpose

Current through Reg. 50, No. 138; July 16, 2024
The purpose of these rules is:
(1) To implement Part XVIII of Chapter 627,
				F.S., pertaining to requirements of long-term care insurance
				policies,
(2) To promote the public
				interest,
(3) To promote the
				availability of long-term care insurance policies,
(4) To protect applicants for long-term care
				insurance from unfair or deceptive sales or enrollment practices,
(5) To establish standards for long-term care
				insurance,
(6) To facilitate public
				understanding and comparison of long-term care insurance policies,
				and
(7) To facilitate flexibility
				and innovation in the development of long-term care insurance
				coverage.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9402, 627.9407(1)
					 FS.
New 5-17-89, Formerly 4-81.001, Amended 1-13-03, Formerly
					 4-157.001.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.002 - Applicability and Scope

Current through Reg. 50, No. 138; July 16, 2024
(1) Except as
				otherwise specifically provided, the provisions of Chapter 69O-157, F.A.C.,
				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-157.004, 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. A policy which is
				advertised, marketed, or offered as a long-term care policy and as a Medicare
				supplement policy shall meet the requirements of the rules contained in this
				chapter and such statutes or rules specifically applicable to Medicare
				supplement policies and, to the extent of a conflict, be subject to the
				requirement that is more favorable to the policyholder or certificate
				holder.
(2) The provisions of
				Chapter 69O-157, F.A.C., shall apply to such long-term care policies issued or
				renewed on or after the effective date of Chapter 69O-157, F.A.C.; however, the
				provisions of Chapter 69O-157, F.A.C., do not apply to any policy that is not
				subject to the provisions of Sections
				627.9401 -
				627.9408, F.S., as presently
				existing or as hereafter amended.
(3) The provisions of Part I shall apply to
				all long-term care policies and certificates issued in this state which are not
				included in the scope of Part II.
(4) All appendices incorporated by reference
				are available from the Division of Life and Health Product Review, Larson
				Building, 200 East Gaines Street, Tallahassee, Florida
				32399-0328.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9403, 627.9406, 627.9407(1)
					 FS.
New 5-17-89, Formerly 4-81.002, Amended 1-13-03, Formerly
					 4-157.002.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.003 - Definition of Terms

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) "Applicant" means:
(a) In the case of an individual long-term
				care insurance policy, the person who seeks to contract for benefits.
(b) In the case of a group long-term care
				insurance policy, the proposed certificate holder.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.004 - Out-of-State Group Long-Term Care Insurance

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 such 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. Such evidence
				shall consist of:
(a) Filing of policy and
				certificate forms, including rates and rate development information, which
				demonstrate that the requirements of Sections 627.9401-.9408, F.S., and these
				rules have been met, except Section
				627.9405(2)
				F.S.; 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-157.005 - Qualified Right of Renewal

Current through Reg. 50, No. 138; July 16, 2024
No long-term care policy may contain a renewal provision less
				  favorable to the insured than a right of renewal upon timely payment of
				  premium, except that rates may be revised by the insurer on a class basis.
				  However, the Office may authorize nonrenewal on a statewide basis, on terms and
				  conditions deemed necessary by the Office, to best protect the interests of the
				  insureds, if the insurer demonstrates:
(1) That renewal will jeopardize the
				insurer's solvency; or
(2) That:
(a) The actual paid claims and expenses have
				substantially exceeded the premium and investment income associated with the
				policies; and
(b) The policies will
				continue to experience substantial and unexpected losses over their lifetime;
				and
(c) The projected loss
				experience of the policies cannot be significantly improved or mitigated
				through reasonable rate adjustments or other reasonable methods; and
(d) The insurer has made repeated and good
				faith attempts to stabilize loss experience of the policies, including the
				timely filing for rate adjustments.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.006 - Pre-existing Conditions

Current through Reg. 50, No. 138; July 16, 2024
(1) No long-term
				care insurance policy or certificate other than a policy or certificate
				thereunder issued to a group as defined in Section
				627.9405(1)(a),
				F.S., shall use a definition of "preexisting condition" which is more
				restrictive than the following: "Preexisting condition" means the existence of
				symptoms which would cause an ordinarily prudent person to seek diagnosis,
				care, or treatment, or a condition for which medical advice or treatment was
				recommended by or received from a provider of health care services within 6
				months preceding the effective date of coverage of an insured person.
(2) No long-term care insurance policy or
				certificate other than a policy or certificate thereunder issued to a group as
				defined in Section 627.9405(1)(a),
				F.S., may exclude coverage for a loss or confinement which is the result of a
				preexisting condition unless such loss or confinement begins within 6 months
				following the effective date of coverage of an insured
				person.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1), (4)
					 FS.
New 5-17-89, Formerly 4-81.006,
					 4-157.006.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.007 - Conditions of Eligibility

Current through Reg. 50, No. 138; July 16, 2024
(1) A policy
				covering one or more members of the insured's family shall include provisions
				which specify the identity and qualifications applicable to those family
				members who may become insured under the policy initially or by subsequent
				addition.
(a) Eligible family members may
				include:
1. The insured;
2. The insured's spouse;
3. Children of the insured or of the
				insured's spouse who are over a specified age not to exceed 21, unless a
				dependency test is specified;
4.
				Parents or grandparents of the insured or the insured's spouse; and
5. Any other person dependent upon the
				insured.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.008 - Nonduplication of Coverage Provisions

Current through Reg. 50, No. 138; July 16, 2024
(1) In
				addition to any other provisions not prohibited by law or rules, an insurer may
				avoid duplication of benefits in an expense-incurred insurance policy with
				respect to losses for which benefits are payable under any workers'
				compensation, occupational disease, employers' liability or similar laws or
				payable pursuant to the Florida motor vehicle no-fault law, and any national,
				state or other governmental plan (except Medicaid) not limited to civilian
				governmental employees or their families. An insurer may, alternatively, afford
				excess insurance to benefits afforded under any workers' compensation,
				occupational disease, employers' liability or similar laws or any national,
				state or other governmental plan or Florida motor vehicle no-fault law, as well
				as other insurance or employer- employee or union welfare plans.
(2) Nonduplication may involve an
				interrelation, as related above and as appropriate to the coverage afforded,
				with other benefit programs including but not limited to individual or family
				insurance, group insurance, hospital service, medical service, group practice,
				individual practice and other prepayment plans, employee or employer benefit
				organizations, union or association welfare plans, Medicare, Florida motor
				vehicle no-fault law, and similar benefit programs, except
				Medicaid.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1)
					 FS.
New 5-17-89, Formerly 4-81.008,
					 4-157.008.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.009 - Minimum Coverage

Current through Reg. 50, No. 138; July 16, 2024
(1) All long-term
				care policies shall provide coverage for at least 24 consecutive months for
				each covered person for care in a nursing home.
(2) All long-term care policies shall provide
				coverage for at least one type of lower level of care in addition to coverage
				for care in a nursing home.
(3) No
				long-term care policy may provide significantly more coverage for care in a
				nursing home than coverage for lower levels of care. In furtherance of this
				requirement, benefits for all lower levels of care, in the aggregate, shall
				provide a level of benefits equivalent to 50 percent of the benefits provided
				for nursing home coverage. For the purposes of applying this 50 percent
				equivalency requirement, if a long-term care policy provides nursing home
				coverage for an unlimited duration, the nursing home benefit shall be
				considered to be payable for ten years. A long-term care policy may use an
				overall lifetime benefit maximum which may be exhausted by any combination of
				benefits.
(4) For the purposes of
				this rule, "lower level(s) of care" means the following:
(a) Nursing service;
(b) Adult congregate living
				facility;
(c) Home health
				agency;
(d) Adult day care
				center;
(e) Adult foster
				home;
(f) Community care for the
				elderly;
(g) Personal care and
				social services;
(h) Such other
				lower levels of care as approved by the Office.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.011 - Waiting Period

Current through Reg. 50, No. 138; July 16, 2024
The term "waiting period" or "probationary period" as used in
				  a long-term care policy shall be that period of time which follows the date a
				  person is initially insured under the policy before the coverage or coverages
				  of the policy shall become effective as to such person. The waiting period
				  shall be specified in the policy and:
(1) A waiting period shall not be used with
				respect to any loss resulting from accidental injuries as defined in the
				policy;
(2) A waiting period shall
				not exceed one year; and
(3) There
				shall be no policy provision to establish a new waiting period in the event
				existing coverage is converted to or replaced by new or other forms within the
				same company, except with respect to an increase in benefits voluntarily
				selected by the insured individual or group policyholder.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1)
					 FS.
New 5-17-89, Formerly 4-81.011,
					 4-157.011.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.012 - Exclusions, Limitations, Reductions

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Exclusions, limitations, reductions, generally -
(a) Any exclusions, limitations, or
				reductions on the risk undertaken whether applicable to amounts, duration of
				benefits, age, or other matters, must be specified with clarity and certainty
				in appropriately entitled provision or provisions of the contract;
(b) Such principal exclusions, limitations,
				or reductions shall be included in the applicable "Outline of Coverage"
				delivered to an applicant for an individual policy or included in the
				"Certificate" issued pursuant to a group policy delivered or issued for
				delivery in this state; and
(c) Any
				exclusion, limitation, or reduction must be clearly expressed as part of the
				benefit provision to which it applies or, if applicable, to more than one
				benefit provision, shall be set forth as a separate provision and appropriately
				captioned.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.013 - Elimination Period

Current through Reg. 50, No. 138; July 16, 2024
As used in any long-term care policies, the term "elimination
				  period" means the number of days at the beginning of a period of confinement
				  for which no benefits are payable. No policy shall contain an elimination
				  period in excess of the maximum time period specified in Section
				  627.9407(3),
				  F.S., as presently existing or as hereafter amended. Such elimination period or
				  periods must be clearly expressed in the policy schedule or benefits page and
				  clearly expressed or referenced in the benefit or benefits provision to which
				  such elimination period or periods apply.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1), (3)
					 FS.
New 5-17-89, Formerly 4-81.013,
					 4-157.013.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.014 - Recurrent Utilization

Current through Reg. 50, No. 138; July 16, 2024
If a policy contains provisions relating to an "elimination
				  period" or a "prior institutionalization" requirement, or a similar provision
				  that establishes a condition that must be met before benefits are payable, such
				  provision may not be applied more than once unless the utilization of covered
				  services is separated by a period greater than 180 days.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1)
					 FS.
New 5-17-89, Formerly 4-81.014,
					 4-157.014.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.015 - Extension of Benefits

Current through Reg. 50, No. 138; July 16, 2024
Termination of a group long-term care policy contract shall
				  be without prejudice to any benefits payable for services which began while the
				  contract was in force and continue without interruption after termination. Such
				  extension of benefits beyond the period the contract was in force may be
				  limited to the duration of benefit period, or the payment of the maximum
				  benefit, whichever is less.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1)
					 FS.
New 5-17-89, Formerly 4-81.015,
					 4-157.015.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.017 - Prior Institutionalization

Current through Reg. 50, No. 138; July 16, 2024
(1) No
				contract issued as a long-term care insurance policy shall condition any
				benefits upon prior institutionalization for a total period of time longer than
				three days.
(2) If a contract
				provides benefits only following institutionalization of three days, or less,
				then benefits may not be conditioned upon admission to a facility for the same
				or related condition within a period of less than 30 days after discharge from
				the prior institution.
(3) An
				entity that advertises, markets, or solicits long-term care coverage in this
				state which provides benefits only following institutionalization shall also
				offer to each policyholder, as part of the application, a contract which does
				not require prior institutionalization as a condition to any
				benefit.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(5)
					 FS.
New 5-17-89, Formerly 4-81.017,
					 4-157.017.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.018 - Right to Return Policy - Free Look (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1), (7)
					 FS.
New 5-17-89, Formerly 4-81.018, 4-157.018, 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-157.019 - Long-term Care Policies - Statements Required

Current through Reg. 50, No. 138; July 16, 2024
All long-term care contracts shall contain the following
				  statements prominently displayed on the face page of the contract:
(1) The policy has been approved as a
				"Long-Term Care Insurance Policy" meeting the requirements of Florida
				law.
(2) Notice to Buyer: This
				policy may not cover all of the costs associated with long-term care which may
				be incurred by the buyer during the period of coverage. The buyer is advised to
				periodically review this policy in relation to the changes in the cost of
				long-term care.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1), (8)
					 FS.
New 5-17-89, Formerly 4-81.019,
					 4-157.019.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.020 - Outline of Coverage

Current through Reg. 50, No. 138; July 16, 2024
An outline of coverage shall be delivered to an applicant for
				  an individual long-term care insurance policy at the time of application for an
				  individual policy. In the case of direct response solicitations, the insurer
				  shall deliver the outline of coverage upon the applicant's request, but
				  regardless of request, shall make such delivery no later than at the time of
				  policy delivery. Such outline of coverage shall include:
(1) The name and principal address of the
				insurer or service association;
(2)
				A statement of identification of the policy or contract;
(3) A policy form number;
(4) A description of the principal benefits
				and coverage provided in the policy;
(5) A statement of the principal exclusions,
				reductions, and limitations contained in the policy;
(6) If the policy is not expected to cover
				100 percent of the cost of services for which coverage is provided, as
				statement clearly describing any such limitations;
(7) A statement of the renewal provisions,
				including any reservation in the policy of a right to change
				premiums;
(8) A statement that the
				outline of coverage is a summary of the policy issued or applied for and that
				the policy should be consulted to determine governing contractual provisions;
				and
(9) A statement that the policy
				has been approved as a long-term care insurance policy meeting the requirements
				of Florida Law.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1), (9)
					 FS.
New 5-17-89, Formerly 4-81.020,
					 4-157.020.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.021 - Certificate

Current through Reg. 50, No. 138; July 16, 2024
A certificate issued pursuant to a group long-term care
				  insurance policy, which policy is delivered or issued for delivery in this
				  state, shall include:
(1) A
				description of the principal benefits and coverage provided in the
				policy;
(2) A statement of the
				principal exclusions, reductions, and limitations contained in the
				policy;
(3) A statement that the
				description of principal benefits is a summary of the policy and that the group
				master policy should be consulted to determine governing contractual
				provisions;
(4) Person
				insured;
(5) Person to whom
				benefits are payable;
(6) Group
				contract number;
(7) Certificate
				number;
(8) Effective date;
				and
(9) Time certificate is
				effective.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(1), (10)
					 FS.
New 5-17-89, Formerly 4-81.021,
					 4-157.021.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.022 - Loss Ratio Requirements

Current through Reg. 50, No. 138; July 16, 2024
Benefits under long-term care insurance policies shall be
				  deemed reasonable in relation to premiums charged provided the expected loss
				  ratio is at least sixty percent for individual policies and for group policies,
				  calculated in a manner which provides for adequate reserving of the long-term
				  care insurance risk. In determining whether loss ratio requirements are being
				  met, the Office will exercise its best judgment as to the credibility of the
				  data submitted and what constitutes a reasonable rate structure for the
				  benefits being provided. In evaluating the expected loss ratio, due
				  consideration shall be given to all relevant factors, including:
(1) Statistical credibility of incurred
				claims experience and earned premiums;
(2) The period for which rates are computed
				to provide coverage;
(3)
				Experienced and projected trends;
(4) Concentration of experience within early
				policy duration;
(5) Expected claim
				fluctuation;
(6) Experience
				refunds, adjustment or dividends;
(7) Renewability features;
(8) All appropriate expense
				factors;
(9) Interest;
(10) Experimental nature of the
				coverage;
(11) Policy
				reserves;
(12) Mix of business by
				risk classification; and
(13)
				Product features such as long elimination periods, high deductibles and high
				maximum limits.
Rulemaking Authority 624.308(1), 627.9407(1) FS. Law
					 Implemented 624.307(1), 627.9407(6), 627.411
					 FS.
New 5-17-89, Formerly 4-81.022,
					 4-157.022.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-157 - LONG-TERM CARE INSURANCE › Section 69O-157.023 - Reporting

Current through Reg. 50, No. 138; July 16, 2024
(1) Every insurer shall maintain records for
				each agent of that agent's amount of replacement sales as a percentage of the
				agent's total annual sales in this state and the amount of lapses of long-term
				care insurance policies sold by the agent as a percentage of the agent's total
				annual sales in this state.
(2)
				Every insurer shall report annually by June 30 the 10 percent of its agents
				with the greatest percentages of lapses and replacements as measured by
				subsection 69O-157.023(1),
				F.A.C., in the format prescribed by Appendix J, "Long-Term Care Insurance
				Replacement and Lapse Reporting Form OIR-B2-1555," which is incorporated by
				reference in Rule 69O-157.111, F.A.C.
(3) Reported replacement and lapse rates do
				not alone constitute a violation of insurance laws or necessarily imply
				wrongdoing. The reports are for the purpose of reviewing more closely agent
				activities regarding the sale of long-term care insurance in this
				state.
(4) Every insurer shall
				report annually by June 30 the number of lapsed policies as a percentage of its
				total annual sales and as a percentage of its total number of policies in force
				as of the end of the preceding calendar year in this state in the format
				prescribed in Appendix J.
(5) Every
				insurer shall report annually by June 30 the number of replacement policies
				sold as a percentage of its total annual sales and as a percentage of its total
				number of policies in force as of the preceding calendar year in this state in
				the format as prescribed in Appendix J.
(6) Every insurer shall report annually by
				June 30, for qualified long-term care insurance contracts, the number of claims
				denied for each class of business, expressed as a percentage of claims denied
				in this state, in the format as prescribed in Appendix E, "Annual Long-Term
				Care Claims Denial Reporting Form" OIR-B2-1553, which is incorporated by
				reference in Rule 69O-157.111, F.A.C.
(7) For purposes of this section:
(a) "Policy" means only long-term care
				insurance;
(b) "Claim" means,
				subject to paragraph 69O-157.023(8)(c),
				F.A.C., a request for payment of benefits under an in force policy regardless
				of whether the benefit claimed is covered under the policy or any terms or
				conditions of the policy have been met;
(c) "Denied" means the insurer refuses to pay
				a claim for any reason other than claims not paid for failure to meet the
				elimination period or because of an applicable preexisting condition;
				and
(d) "Report" means on a
				statewide basis.