reglab/statecodes huggingface dataset:
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-190 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69O-190.065 - Distribution of Surplus Monies by Self-Insurers Funds

Current through Reg. 50, No. 138; July 16, 2024
(1) Any surplus monies for a fund year in
				excess of the amount necessary to fulfill all obligations under the Law for
				that fund year may be declared refundable to members by the trustees at any
				time. The amount of such declaration shall be a liability of the fund at the
				time of the declaration. Date of payment shall be as agreed by the trustees and
				the Division subject to this section.
(2) Distribution of dividends are subject to
				the following conditions:
(a) Dividends of
				surplus premium (i.e., underwriting profit) shall be payable only to employers
				who paid premium to the fund during the year the underwriting profit
				occurred.
(b) Dividends of surplus
				investment or miscellaneous income may be paid to any member who meets the
				criteria established by the fund pursuant to paragraph
				69O-190.065(2)(c),
				F.A.C. Payment of any such dividend shall be subject to a plan filed with and
				approved in writing by the Division. Any such plan shall comply with Rule
				69O-190.072, F.A.C.
(c) Eligibility for dividends pursuant to
				paragraphs (a) and (b), shall be based on criteria which meet the following
				conditions:
1. The criteria shall be objective
				and measurable such as an employer's accident record, the amount of premium
				paid, or any other criteria which encourages workplace safety or cost
				containment.
2. The criteria shall
				only apply to fund membership; and,
3. The amount of dividend otherwise earned
				shall be prorated based upon the length of membership of the member in the
				fund.
(d) All dividends
				from policy years beginning on or after October 1, 1989, whether from premium,
				investment income or miscellaneous income, shall be payable to employers who
				were members of the fund at the end of the policy year in question but have
				since left the fund and are otherwise entitled to receive a dividend according
				to the criteria established by the trustees.
(e) No fund shall offer to provide a dividend
				or seek to enlist a new member based upon the promise of payment of a dividend.
				No fund may promise, or make any representation of, a specific amount of
				dividend for which a potential member may become eligible. A fund may disclose
				in its solicitation of new members, the formula which it intends to use to
				calculate a member's future dividend pursuant to paragraph
				(2)(c).
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-190 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69O-190.067 - Member's Qualifications and Responsibilities

Current through Reg. 50, No. 138; July 16, 2024
(1) All members of a self-insurers fund shall
				have common interest. Different businesses which are owned or controlled by the
				same interests shall be eligible for membership in a self-insurers fund
				provided one of them is eligible.
(2) Unless the context clearly indicates to
				the contrary, the requirements imposed by these rules shall apply to the
				self-insurer as defined by Section 440.02(7)(b)3., F.S. The duties,
				responsibilities and requirements of the members as defined by Section
				440.02(7)(b)2., F.S., are as provided by the indemnity agreement as specified
				in Rule 69O-190.068, F.A.C.
(3) Self-insurers funds are authorized only
				to accept liability and extend coverage for injuries under Chapter 440, F.S. No
				fund shall accept as a member any employer who is known to have United States
				Longshoremen and Harbor Workers Act or Jones Act exposure for which the fund
				may be liable. Whenever a fund determines that a member has United States
				Longshoremen and Harbor Workers Act or Jones Act exposure for which the fund
				was or may be liable, then that member shall be issued a notice of termination
				by the fund unless such exposure was a one time occurrence and will not be
				repeated or unless the member secures acceptable insurance coverage for the
				continuing United States Longshoremen and Harbor Workers Act or Jones Act
				exposure.
(4) Self-insurers funds
				shall use form BSI-31 to assure itself that any person claiming exemption from
				Chapter 440, F.S., pursuant to Section
				440.05, F.S., is entitled to
				such an exemption.
Rulemaking Authority 624.4621 FS. Law Implemented 440.05,
					 440.09(2), 624.4621 FS.
New 10-1-82, Amended 12-25-84, Formerly 38F-5.67, Amended
					 12-19-93, Formerly 38F-5.067, 4-190.067.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-190 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69O-190.069 - Self-Insurers Fund Member Experience Records

Current through Reg. 50, No. 138; July 16, 2024
(1) Employers participating in a
				self-insurers fund under the provisions of Section
				624.4621, F.S., shall be subject
				to the Experience Rating Plan and the payroll classification and premium
				determination system established by the National Council on Compensation
				Insurance (NCCI).
(2) The Office
				shall determine an experience modification for each qualified member of a
				self-insurers fund annually, or as otherwise provided, on the same basis as if
				the employer were insured under the provisions of Section
				440.38(1)(a),
				F.S., and such modification is to be used to determine the employer's standard
				premium as provided by these rules and the indemnity agreement. Funds shall
				submit only those members who qualify for experience rating in accordance with
				the NCCI Experience Rating Plan Manual.
(3) For any fund member who's experience must
				be combined with the experience modification factor of an insured group because
				of ownership requirements under the NCCI Experience Rating Plan, the fund must
				provide its experience to NCCI and have a combined experience modification
				factor calculated by NCCI. Any expenses of this transaction shall be the
				responsibility of the fund.
(4)
				Each self-insurers fund administrator and each self-insurers fund service
				company, if applicable, may be furnished a copy of the experience rating
				calculations.
(5) Should a member
				cease to participate in a self-insurers fund and purchase standard insurance
				coverage, the Experience Rating Plan provides that self-insured experience may
				be used in the employer's future experience rating calculation.
(6) Loss experience tabulations will be
				furnished upon request of the employer and a fee for such services may be
				assessed to defray preparing such tabulations, such cost to be actual
				reimbursement to the Office.
Rulemaking Authority 440.38(2)(b), 624.4621 FS. Law
					 Implemented 440.49(7)(h)2.,
					 440.51,
					 624.4621
					 FS.
New 10-1-82, Formerly 38F-5.69, Amended 12-19-93, Formerly
					 38F-5.069, 4-190.069.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-190 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69O-190.072 - Miscellaneous Income of a Self-Insurers Fund

Current through Reg. 50, No. 138; July 16, 2024
(1) Miscellaneous income is all income
				received by a fund other than premium paid by members.
(2) If the Office determines that a fund
				shall allocate miscellaneous income to fund a deficit or contingent liability,
				then the amount allocated shall be part of the fund's security deposit and
				shall be encumbered for use only as specified by the Division.
(3) All unencumbered miscellaneous income may
				be disbursed at the discretion of the trustees in any manner not contrary to
				the rules or to the purpose for which the fund was established.
(4) Investment income earned after the end of
				the last policy year shall be disbursed only for essential fund operating
				expenses and dividends pursuant to subsection
				69O-190.065(6),
				F.A.C. These expenses shall include payment of claims and claims expenses,
				service fees, administrative overhead, marketing costs, promotional costs,
				commissions, and other expenses related to the direct operating costs of the
				fund. Essential fund operating expenses shall not include refunds, dividends,
				bonuses, or other similar expenses.
Rulemaking Authority 624.4621 FS. Law Implemented 624.4621
					 FS.
New 12-25-84, Formerly 38F-5.72, Amended 12-19-93, Formerly
					 38F-5.072, 4-190.072.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-190 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69O-190.073 - Premium Audit

Current through Reg. 50, No. 138; July 16, 2024
(1) All
				self-insurers funds shall determine the normal premium due from each member in
				each policy year based on actual audited payroll. Audits shall consist of
				physical, onsite audits or mail self-audits. The requirements set forth in this
				rule shall apply to the fund and its present or former members. Funds shall be
				responsible for the compliance with this rule of contracted audit personnel or
				firms.
(2) Physical, onsite audits
				shall be required for all members who meet one of the following conditions:
(a) New members (new businesses or members
				who had coverage with another fund or carrier when they joined the current
				fund) who are eligible for experience rating at policy inception.
(b) New members in the construction industry.
				Any employer with classification codes subject to the Florida Contractors
				Classification Premium Adjustment program shall be deemed to be in the
				construction industry.
(c) All
				renewal members (members who were in the same fund for the new and prior policy
				period) who are eligible for experience rating at policy renewal.
(d) Any member may be audited at the
				discretion of the fund.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-190 - RULES FOR SELF-INSURERS UNDER THE WORKERS' COMPENSATION ACT › Section 69O-190.074 - Forms, Manuals and Instructions Adopted

Current through Reg. 50, No. 138; July 16, 2024
(1) OIR forms adopted. The OIR forms set
				forth in paragraphs (a) through (aa) of this subsection, as well as the
				accompanying instructions to the forms, are hereby incorporated into rule
				Chapter 69O-190, F.A.C., by reference. Copies of the forms are available from
				the Bureau of P & L Insurer Solvency, Office of Insurance Regulation,
				Tallahassee, Florida 32399-0300.
(a) OIR Form
				BSI-1, Application for Self-Insurance.
(b) OIR Form BSI-2, Employer Application for
				Group Coverage.
(c) OIR Form BSI-3,
				Membership Application.
(d) OIR
				Form BSI-3A, Self-Insurers Fund Member Application Monthly Change
				Sheet.
(e) OIR Form BSI-4, Revised
				Self-Insurers Surety Bond (Guaranty Fund Member).
(f) OIR Form BSI-4A, Self-Insurers Surety
				Bond (Guaranty Fund Non-Member).
(g) OIR Form BSI-4B, Self-Insurers Surety
				Bond.
(h) OIR Form BSI-5, Payroll
				Report, and the accompanying instructions.
(i) OIR Form BSI-6, Self-Insurance Letter of
				Credit.
(j) OIR Form BSI-11,
				Indemnity Agreement.
(k) OIR Form
				BSI-12, Drug-Free Workplace Program.
(l) OIR Form BSI-17, Unit Statistical Report,
				and the accompanying instructions.
(m) OIR Form BSI-19, Certification of
				Servicing for Self-Insurance.
(n)
				OIR Form BSI-20, Report of Workers' Compensation Liabilities.
(o) OIR Form BSI-21, Breakdown of Policy Year
				Expenses.
(p) OIR Form BSI-22,
				Service Company Application.
(q)
				OIR Form BSI-23, Service Company Annual Report Form.
(r) OIR Form BSI-24, Quarterly Status
				Report.
(s) OIR Form BSI-24A,
				Preferred Payment Plan Quarterly Report.
(t) OIR Form BSI-26, Checklist for the
				Submission of Loss Reserve Reports.
(u) OIR Form BSI-27, Biographical
				Statement.
(v) OIR Form BSI-28,
				Quarterly Financial Statement.
(w)
				OIR Form BSI-29, Annual Financial Statement.
(x) OIR Form BSI-30, Report on Preferred
				Payment Plan.
(y) OIR Form BSI-31,
				Audit Procedures for Contractor/Independent Contractor Relationship.
(z) OIR Form BCM 201, Notice of Termination.
(aa) OIR Form BSI 206, Certificate
				of Self-Insurance, and the accompanying instructions.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.021 - Scope (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 641.36 FS. Law Implemented 641.36
					 FS.
New 2-22-88, Formerly 4-31.021, 4-191.021, Repealed
					 9-28-22.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.027 - Application for Certificate of Authority

Current through Reg. 50, No. 138; July 16, 2024
(1) An application for a person applying for
				a certificate of authority as a health maintenance organization consists of the
				following:
(a) Form OIR-C1-942, "Application
				for Certificate of Authority Health Maintenance Organization," effective 07/23,
				hereby incorporated by reference and available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-16320
;
(b) Form OIR-B2-1093, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(c) Form OIR-C1-905, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(d) Form OIR-C1-938, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(e) Form OIR-C1-1423, "incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(f) Form OIR-C1-0500, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(g) Form OIR-C1-0501, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(h) Form OIR-C1-0502, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(i) Form OIR-C1-0503, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(j) Form OIR-C1-0504, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(k) Form OIR-C1-0505, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(l) Form OIR-C1-0506, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(m) Form OIR-C1-0507, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
(n) Form OIR-C1-0509, incorporated by
				reference in Rule 69O-136.100, F.A.C.;
				and
(o) Form OIR-C1-2221,
				incorporated by reference in Rule
				69O-136.100,
				F.A.C.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.028 - Standards for Fingerprint Cards for New Applicants and Acquisition Applications (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 641.36 FS. Law Implemented
					 641.21(1)(d) FS.
New 5-28-92, Formerly 4-191.028, Repealed
					 9-28-22.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.029 - Maintaining Eligibility for Certificate of Authority

Current through Reg. 50, No. 138; July 16, 2024
The HMO place of business shall be located in this state and
				  shall be actively engaged in managed care within six months of licensure,
				  except as provided in Section
				  641.221(2),
				  F.S. The HMO shall maintain a place of business, the location of which is
				  identifiable by and accessible to the public as determined by the Office. Any
				  HMO holding an existing Certificate of Authority which has not become
				  operational as of the effective date of this rule shall be required to comply
				  within one (1) year of this date.
Rulemaking Authority 641.36 FS. Law Implemented 641.19(7),
					 641.2015, 641.221 FS.
New 5-28-92, Formerly 4-191.029, Amended
					 5-7-18.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.030 - Governing Body

Current through Reg. 50, No. 138; July 16, 2024
(1) Each HMO shall
				have a governing body that sets policy and has overall responsibility for the
				organization, including the following:
(a)
				Adopting organizational bylaws, rules and regulations, or similar form of
				document which provides a clear concise statement of the mission, goals, and
				objectives of the organization.
(b)
				Adopting a quality assurance program, as required by Chapter 641, Part IV,
				F.S., that monitors the key areas of the health care delivery system, to
				identify problems and ensure early recognition of opportunities to improve the
				delivery of quality health care services.
(c) Maintaining ultimate responsibility for
				ongoing licensing and credentialing programs.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.033 - Standards for Subscriber Contracts

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Group and non-group subscriber contracts shall include all elements contained
				in this section.
(a) Definitions;
(b) Effective date and term of contract. The
				benefit and renewal periods shall be no less than twelve months for non-group
				and group subscriber contracts, unless otherwise requested by the subscriber in
				writing. HMOs shall not offer or initiate this request during initial
				solicitation or prior to renewal;
(c) Space for rate to be charged;
(d) Mode of payment (monthly, quarterly,
				etc., with provision for change of mode if applicable);
(e) Eligibility requirements for enrollment,
				including waiting periods for receiving services and any other
				restrictions;
(f) Grace period for
				late payment;
(g) Co-payment
				features, if any;
(h) Renewal,
				re-enrollment, termination, cancellation, and disenrollment
				conditions;
(i) Services to be
				furnished and how physicians licensed under Chapters 458 or 459, 460 and 461,
				F.S., will be made available, as detailed in Rule 69O-191.046,
				F.A.C.;
(j) The contract,
				certificate, or handbook shall state where and in what manner the comprehensive
				health care services may be obtained;
(k) Factors pertaining to pre-existing
				conditions, if applicable. Pre-existing conditions cannot be excluded longer
				than two years;
(l) All
				limitations, exclusions, and exceptions;
(m) Provisions covering in and out of area
				emergencies, which includes a definition of emergency;
(n) Provisions for adding new family members,
				including newborn and adopted children;
(o) Subscriber grievance procedures, formal
				and informal;
(p) Any other factors
				necessary for complete understanding of what is covered and what is excluded by
				the contract;
(q) Provisions
				relating to coordination of benefits if applicable;
(r) Provisions relating to the right of
				subrogation shall be allowed, providing it is not in conflict with any
				applicable Florida Statute or the decisions of courts of competent jurisdiction
				which eliminate or restrict such rights;
(s) Provisions relating to the right of
				reimbursement pursuant to Section
				641.31(8),
				F.S., shall be allowed, providing it is not in conflict with any applicable
				Florida Statute or the decisions of courts of competent jurisdiction which
				eliminate or restrict such rights;
(t) Arbitration provisions, if any, shall
				include a statement that arbitration shall not preclude review pursuant to Rule
				69O-191.081, F.A.C., and shall be conducted pursuant to Chapter 682,
				F.S.;
(u) Conversion and extension
				of benefit privileges;
(v) Optional
				benefits pursuant to Sections
				627.668 and
				627.669, F.S., for group
				contracts; and,
(w) Complications
				of pregnancy which must be treated the same as any other
				illness.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.035 - Co-Payments

Current through Reg. 50, No. 138; July 16, 2024
(1) If required, co-payments will be paid
				when health care services and benefits are rendered. The HMO or contracted
				provider may assess the usual co-payment when a subscriber fails to keep a
				physician office visit or appointment, provided this is a standard procedure
				and a prior reminder was issued to the subscriber of the scheduled
				appointment.
(2) The contract shall
				clearly define the co-payment required to be paid by the
				subscriber/member.
(3) The contract
				shall clearly define any cost sharing features, the financial responsibility of
				the subscriber/member, and how the subscriber/member obligation is
				determined.
(4) In the case of a
				high deductible contract, as defined in Section
				641.20185, F.S., the deductible
				established under the contract must be satisfied before the application of any
				co-payments.
Rulemaking Authority 641.36 FS. Law Implemented 641.19(18),
					 641.20185, 641.31(4) FS.
New 5-28-92, Amended 8-15-02, Formerly
					 4-191.035.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.037 - Mandatory Coverage of Diabetes Treatment

Current through Reg. 50, No. 138; July 16, 2024
(1) Section
				641.31(26)(a),
				F.S., prohibits the application of monetary limitations to limit coverage of
				medically appropriate and necessary equipment, supplies, and services used to
				treat diabetes, if the patient's primary care physician or physician
				specializing in diabetes to whom the patient has been referred certifies that
				the equipment, supplies, or services are necessary.
(2) The term "appropriate" as used in this
				rule excludes unproven technology, such as experimental treatment or non-FDA
				approved treatment.
(3) Coverage
				for equipment meeting the standard in Section
				641.31(26)(a),
				F.S., shall not be limited by monetary limitations for durable medical
				equipment or other limitations in a health maintenance organization or prepaid
				health plan contract.
(4) Section
				641.31(26)(a),
				F.S., does not prohibit the application of deductibles or copayments to
				equipment, supplies, and services meeting the criteria in that
				paragraph.
(5) Payments for
				equipment meeting the standard in Section
				641.31(26)(a),
				F.S., can be used by an HMO to apply toward limits for durable medical
				equipment which does not meet that standard.
(6) Nothing in this rule shall prohibit a
				health maintenance organization or prepaid health plan from utilizing contract
				providers for equipment, supplies, and services certified as necessary by the
				patient's primary care physician or the physician to whom the patient has been
				referred who specializes in treating diabetes, if such equipment, supplies and
				services are available from the contract provider.
Rulemaking Authority 624.308, 641.36 FS. Law Implemented
					 624.307(1), 641.31(26)(a) FS.
New 7-31-02, Formerly
					 4-191.037.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.039 - Certificate and Member Handbook Standards

Current through Reg. 50, No. 138; July 16, 2024
When certificates or member handbooks are given to the
				  subscriber in lieu of a subscriber contract, the certificate or member handbook
				  shall contain a description of the following:
(1) Definitions;
(2) Eligibility requirements for enrollment,
				including waiting periods for receiving services and any other
				limitations;
(3) Health care
				services to be provided;
(4)
				Renewal, re-enrollment, termination, cancellation, and disenrollment
				conditions;
(5) Provisions for
				adding new family members;
(6)
				Benefits for newborn and adopted children;
(7) Grace period;
(8) Limitations, exceptions, or exclusions,
				such as waiting periods, specific conditions not covered and limitations on
				length of stay and all other qualifying or limiting features;
(9) Provisions relating to pre-existing
				conditions, if applicable;
NOTE: Pre-existing conditions cannot be excluded for longer
				  than two years;
(10)
				Provisions relating to coordination of benefits;
(11) Provisions relating to the right of
				subrogation shall be allowed, providing it is not in conflict with any
				applicable Florida Statute or the decisions of courts of competent jurisdiction
				which eliminate or restrict such rights;
(12) Provisions relating to the right of
				reimbursement pursuant to Section
				641.31(8),
				F.S., shall be allowed, providing it is not in conflict with any applicable
				Florida Statute or the decisions of courts of competent jurisdiction which
				eliminate or restrict such rights;
(13) Arbitration provisions, if any, shall
				include a statement that arbitration shall not preclude review pursuant to Rule
				69O-191.081, F.A.C., and shall be conducted pursuant to Chapter 682,
				F.S.;
(14) Conversion and extension
				of benefit privileges;
(15)
				Subscriber grievance procedures, formal and informal;
(16) Any applicable co-payments;
(17) The names, addresses, and telephone
				numbers of any primary care physicians licensed under Chapters 458 or 459, 460
				and 461, F.S., clinics, hospitals, and other providers to be used by the
				subscribers. This specific list may be added as a supplement to the certificate
				or member handbook; and,
(18) The
				term of coverage shall be no less than for a period of twelve months for
				non-group and group plans unless otherwise requested by the subscriber in
				writing. HMOs shall not offer or initiate this request during initial
				solicitation or prior to renewal.
Rulemaking Authority 641.36 FS. Law Implemented
					 641.21(1)(e), 641.22(9), 641.31(3)(b)5., (4), (5),
					 641.3111
					 FS.
New 2-22-88, Amended 10-25-89, Formerly 4-31.039, Amended
					 5-28-92, Formerly 4-191.039.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.042 - Reasons for Cancellation of Eligibility of a Subscriber Member

Current through Reg. 50, No. 138; July 16, 2024
Upon written notice, an HMO may cancel or terminate the
				  coverage of a subscriber for the following reasons:
(1) The HMO may disenroll a subscriber if the
				subscriber's behavior is disruptive, unruly, abusive, unlawful, fraudulent or
				uncooperative to the extent that his continuing membership in the HMO seriously
				impairs the HMO's ability to furnish services to either the subscriber or other
				subscribers. Prior to disenrolling a member, the following are required:
(a) An effort to resolve the problem. The HMO
				shall make a reasonable effort to resolve the problem presented by the
				subscriber, including the use or attempted use of subscriber grievance
				procedures.
(b) Consideration of
				extenuating circumstances. The HMO should ascertain, to the extent possible,
				that the subscriber's behavior is not related to the use of medical services or
				mental illness.
(c) Documentation.
				The HMO shall document the problems, efforts, and medical conditions as
				described in this rule chapter;
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.045 - Newborn and Adopted Children Coverage

Current through Reg. 50, No. 138; July 16, 2024
(1) Each HMO shall comply with the
				requirements of Section
				641.31(9), F.S.
				If the HMO does not require pre-enrollment for newborns, newborn coverage will
				commence from the moment of birth in accordance with the subscriber
				contract.
(2) If the HMO does have
				a pre-enrollment requirement, the subscriber must be allowed to pre-enroll the
				newborn up to the moment of birth. The HMO must notify the subscriber of any
				pre-enrollment requirement, both in the subscriber contract and handbook.
				Additionally, the HMO should emphasize the pre-enrollment requirements after
				the subscriber or covered family member is known by the HMO to be
				pregnant.
(3) Failure to comply
				with pre-enrollment procedures shall require the newborn to be enrolled during
				the subscriber's next open enrollment period.
(4) Coverage for adopted children shall be
				provided pursuant to the requirements enumerated in Section
				641.31(17),
				F.S.
Rulemaking Authority 641.36 FS. Law Implemented 641.31(9),
					 (17) FS.
New 2-22-88, Amended 10-25-89, Formerly 4-31.045, Amended
					 5-28-92, Formerly 4-191.045.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.049 - Services of Specified Non-Contracted Hospital Based Physician Providers

Current through Reg. 50, No. 138; July 16, 2024
(1) A subscriber of a HMO who is authorized
				to receive services from a hospital under contract with the HMO may not be
				denied medically necessary covered health care services or be responsible for
				payment to any physician provider, or agent thereof, other than payment for
				services which are not covered by the HMO subscriber contract or which the
				subscriber has requested or agreed to receive.
(2) In the event the HMO has not contracted
				directly with a hospital based physician provider delivering services in the
				hospital, including, but not limited to, pathologists, radiologists,
				anesthesiologists, and emergency room physicians, the HMO shall pay for
				medically necessary and approved physician care rendered to a non-medicare
				subscriber at a contracted hospital which services are covered by the HMO
				subscriber contract.
Rulemaking Authority 641.36 FS. Law Implemented 641.315
					 FS.
New 5-28-92, Formerly
					 4-191.049.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.051 - Filing, Approval of Subscriber Contract and Related Forms

Current through Reg. 50, No. 138; July 16, 2024
(1) Every subscriber group, individual, or
				conversion contract and every rider, endorsement, certificate, application or
				other forms (including the initial subscriber communication outlining their
				rights and responsibilities under the grievance process) to be used or issued
				in connection with any subscriber contract shall be filed by the HMO for
				approval by the Office. The form may be used immediately upon filing, but is
				subject to disapproval by the Office. If disapproved, use of the form shall be
				discontinued immediately. Documentation evidencing any proposed rates or rate
				changes as required in Rule
				69O-191.054, F.A.C., shall
				accompany the form filing for approval by the Office.
(2) Every form required to be filed by the
				HMO shall be identified by a unique form number, placed in the lower left hand
				corner of each form.
(3) One copy
				of each form filing shall be submitted at the time of filing. HMOs in
				possession of a Certificate of Authority shall submit all contract filings to
				the Office electronically through http://www.floir.com/iportal.
(4)
(a)
				Each HMO shall provide one copy of a written informed consent notice used to
				disclose the intent of testing a person for HIV infection or other specific
				sickness as required in Section
				641.3007(4)(b),
				F.S. The form shall include the following:
1.
				Explanation of the testing;
2.
				Purpose of the test;
3. Potential
				uses of the form information and limitations;
4. The meaning of the test results;
				and,
5. Person's rights to
				confidential treatment of the information obtained.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.054 - Rates

Current through Reg. 50, No. 138; July 16, 2024
(1) Before charging or quoting premiums to
				subscribers, an HMO shall file for approval the rating methodology by which
				those premiums were determined with the Office.
(a) All materials submitted shall be legible.
				A filing which is illegible or which contains illegible material will be
				disapproved without any further processing.
(b) For purposes of this rule, Rule
				69O-191.055, F.A.C., and the
				time periods established in Section
				641.31, F.S., a filing is
				considered "filed" with the Office upon receipt of the material required in
				paragraph (2)(a), below. For purposes of this rule and Rule
				69O-191.055, F.A.C., the term
				"filed" does not mean "approved."
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.0545 - Healthy Lifestyle Rebate

Current through Reg. 50, No. 138; July 16, 2024
(1) Group
				Coverage is as provided by subsection
				69O-149.0055(1),
				F.A.C.
(2) Individual Coverage.
(a)
1. All
				HMOs that provide for a healthy lifestyle rebate shall file for approval the
				standards it will use for determining the level of rebate, i.e., between 0% and
				10%, for different health status indicators, which shall include reduction in
				weight, body mass index, and smoking cessation.
2. The filed standards shall provide that the
				rebate is available and attainable by all subscribers on a nondiscriminatory
				basis and be without regard to the health or claim status of the
				subscriber.
3. The filing of the
				standards shall address the method and timing of the determination and
				application of the rebate.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.055 - Actuarial Memorandum and Definitions

Current through Reg. 50, No. 138; July 16, 2024
(1)
(a) In
				order for a rate filing to be reviewed properly by the Office, the actuarial
				memorandum required by subparagraph
				69O-191.054(2)(a)
				2., F.A.C., shall contain the items listed in subsection (2), below, for a new
				product filing, a rate revision or justification of existing rates.
(b)
1.
				Pricing assumptions shall reflect assumptions based on sound actuarial
				principles reflecting actual anticipated experience. Pricing assumptions shall
				be based on the HMO experience to the degree credible.
2. All such items shall be adequately
				justified by supporting data. In reviewing these assumptions, the Office will
				use, as an initial point of reference, comparisons of the assumptions with
				those from similar products of the same HMO, similar products of other HMO's
				and independent studies.
3. New
				forms shall include a rate and benefit comparison to other similar forms of the
				HMO. The HMO shall demonstrate that the premium rate schedules represent an
				actuarially sound relationship between the forms and between benefit options
				within forms.
4. Rate revision
				filings shall clearly list and justify all rating factors and methods proposed
				to be changed.
(c) All
				filings reviewed under Rules
				69O-191.054 through
				69O-191.055, F.A.C., shall be
				reviewed in accordance with sound actuarial principles and, except where the
				context plainly does not involve an actuarial determination, all adverbs in
				these rules such as "properly" and "appropriately" shall be construed in light
				of those principles.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.057 - Standards for Marketing

Current through Reg. 50, No. 138; July 16, 2024
All health insurance agents and sales representatives of the
				  HMO engaged in sales, solicitation, and communication with current or
				  prospective subscribers are bound by the advertising rules set forth in Rule
				  69O-191.060, F.A.C. The HMO is
				  initially, and continues to be, as long as they hold a Certificate of
				  Authority, responsible for the acts of its agents and
				  representatives.
Rulemaking Authority 641.36 FS. Law Implemented 641.30(3),
					 641.3903 FS.
New 2-22-88, Formerly 4-31.057, Amended 5-28-92, Formerly
					 4-191.057.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.059 - Sales and Marketing Procedures for HMOs Regarding Medicare Subscribers

Current through Reg. 50, No. 138; July 16, 2024
(1) Every HMO shall comply with all Federal
				Statutes and Regulations governing Medicare marketing materials and obtain
				approval from the Health Care Financing Administration (HCFA).
(2) The "notice to buyer" detailed in Section
				641.309, F.S., should be printed
				in no less than 12-point type and be placed immediately above the HMO's name,
				unless otherwise approved by the Office, on the subscriber application form,
				unless such notice is in conflict with subsection (1), above.
(3) This rule applies only to Medicare
				subscribers who are enrolled by an HMO pursuant to a prepaid Medicare contract
				with HCFA.
Rulemaking Authority 641.36 FS. Law Implemented 641.309,
					 641.3901, 641.3903 FS.
New 5-28-92, Formerly
					 4-191.059.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.060 - Form and Content of Advertisements

Current through Reg. 50, No. 138; July 16, 2024
(1)
				Advertising must be truthful and not misleading in fact or implication. Words
				or phrases shall be clear and understandable without reliance upon technical
				terminology.
(2) Testimonials or
				Endorsements by Third Parties.
(a) If the
				person making a testimonial, an endorsement or an appraisal has a financial
				interest in the HMO or in a related entity as a stockholder, director, officer,
				employee, compensated party, or otherwise, such fact shall be disclosed in the
				advertisement.
(b) An advertisement
				shall not state or imply that an HMO or a contract has been approved or
				endorsed by an individual, group of individuals, society, association or other
				organization, unless the HMO or contract has been so approved or endorsed, and
				unless any proprietary relationship between an organization and the HMO is
				disclosed. Any entity which makes an endorsement or testimonial and which is
				formed, owned or controlled by the HMO or persons who own or control the HMO,
				shall disclose the ownership or controlling interest within the
				advertisement.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.063 - Advertisement Enforcement Procedures

Current through Reg. 50, No. 138; July 16, 2024
Each HMO shall maintain at its corporate or principal office
				  a complete file containing every printed, published or prepared advertisement
				  of its health benefit coverage in this State, with a notation attached to each
				  such advertisement indicating the manner and extent of distribution and the
				  form number of any policy advertised. Each piece of advertising shall have a
				  unique number or designation which will readily identify it from all other
				  advertising. Such file shall be subject to inspection by the Office of
				  Insurance Regulation. All such advertisements shall be maintained in said file
				  for a period of at least three years. The advertisement file shall contain a
				  certificate by an officer of the HMO, stating that the officer is responsible
				  for the advertising contained in the file, and the officer has designated, and
				  shall name, specific persons in the organization to act on the officer's behalf
				  to see that all advertising is in compliance with Rule
				  69O-191.060, F.A.C. The list of
				  authorized persons who have permission to develop, market and arrange
				  advertisements for or on behalf of the HMO shall be maintained current and
				  available for inspection.
Rulemaking Authority 641.36 FS. Law Implemented 641.3901,
					 641.3905 FS.
New 2-22-88, Formerly 4-31.063, Amended 5-28-92, Formerly
					 4-191.063.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.066 - Claim Payments (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 641.36 FS. Law Implemented 641.31(12),
					 641.3903(5)(c)3., 5., 6. FS.
New 2-22-88, Formerly 4-31.066, 4-191.066, Repealed
					 5-28-95.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.072 - Reinsurance (Excess Loss Insurance) (Repealed)

Current through Reg. 50, No. 138; July 16, 2024
Rulemaking Authority 641.36 FS. Law Implemented
					 641.285(5)(a)1. FS.
New 2-22-88, Amended 10-25-89, Formerly 4-31.072, Amended
					 5-28-92, Formerly 4-191.072, Repealed by Section 21, Chapter 98-159, Laws of
					 Florida, 1-1-99.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.074 - Records Retention

Current through Reg. 50, No. 138; July 16, 2024
(1) Every Health
				Maintenance Organization shall maintain complete records of its assets,
				transactions, and affairs, including but not limited to, the following:
(a) Financial records (including annual
				earned premiums and claims incurred, but not reported (IBNR));
(b) Corporate records;
(c) Insurance and reinsurance
				documents;
(d) Accounting
				documents;
(e) Member
				records;
(f) Claim and payment of
				claims files; and,
(g) Tax
				returns.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.075 - Annual and Quarterly Reports

Current through Reg. 50, No. 138; July 16, 2024
(1) Each HMO
				shall file with the Office a full and true statement of its financial
				condition, transactions, and affairs.
(a) An
				annual statement covering the preceding fiscal year shall be filed within 3
				months after the end of the fiscal year, and quarterly statements within 45
				days after the end of each of its quarterly reporting periods for the first
				three quarters of the fiscal year.
(b) The Office shall grant an extension of
				time for filing an annual or quarterly statement if there exist conditions
				beyond the control of the authorized HMO, such as rehabilitation pursuant to
				Chapter 631, F.S., or the laws of the state of domicile; severe damage to the
				HMO's physical premises by a natural or man-made disaster; or some other reason
				of similar gravity and severity. The extension shall be for the amount of time
				reasonable to file under the conditions which justified the
				extension.
(c) For purposes of this
				rule, the requirement that statements be filed with the Office means that the
				statement has been transmitted electronically to the National Association of
				Insurance Commissioners and that the executed Jurat page of said statement has
				been transmitted electronically to the Office via the Regulatory Electronic
				Filing System, "REFS." The date affixed by the Office's electronic data
				processing system shall serve as evidence of the timeliness of the statement.
				Annual and quarterly statements in any other format shall not be submitted to
				the Office.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.076 - Corrective Action Plans

Current through Reg. 50, No. 138; July 16, 2024
(1) Each HMO will be
				required to make an evaluation of its statement of total revenues and expenses
				prior to each annual report filing to ensure that the net income before taxes
				is no less than 2% of total revenues. If the HMO fails to meet the 2%
				requirement then the HMO will be required to provide the Office, as a part of
				its annual report filing, a corrective action plan. The corrective action plan
				will be reviewed in conjunction with the subsequent quarterly filings which
				will include information which indicates the progress being made, and an
				explanation as to any negative variances that exist.
(2) Any HMO whose performance over any four
				(4) quarterly reporting periods, on a cumulative basis, whose net income before
				taxes is less than 2% of total revenues may be required to file a corrective
				action plan. This plan will also be reviewed on a quarterly basis and subject
				to the same reporting requirements stated in subsection (1), above.
(3) Any HMO whose net earnings before taxes
				is less than two (2) percent of total revenues, but not a loss, and whose
				statutory surplus is 200 percent of the required amount (after dividends
				declared or taken) may request, in writing, a waiver for filing the corrective
				action plan. A waiver shall be granted if all of the following criteria are
				met:
(a) The HMO is eligible to request as
				described above;
(b) The HMO was
				not operating under a corrective plan during the preceding fiscal year;
				and,
(c) The HMO is in full
				compliance with Chapter 641, F.S., and this rule chapter except for paragraph
				(1) of this section.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.085 - Fees

Current through Reg. 50, No. 138; July 16, 2024
Checks for filing of each annual report, and for any other
				  fees collected under this law, shall be made payable to the "Florida Department
				  of Financial Services."
Rulemaking Authority 641.36 FS. Law Implemented 641.29
					 FS.
New 2-22-88, Formerly 4-31.085, 4-191.085, Amended
					 9-28-22.
Florida Administrative Code › 69 - DEPARTMENT OF FINANCIAL SERVICES › 69O - OIR - Insurance Regulation › Chapter 69O-191 - HEALTH MAINTENANCE ORGANIZATIONS › Section 69O-191.088 - Surplus Notes

Current through Reg. 50, No. 138; July 16, 2024
Funds borrowed by HMOs will be considered surplus notes if
				  guaranteed by the United States government, or its agents, or if such borrowed
				  funds result from a written instrument which includes the following:
(1) The effective date, amount, interest and
				parties involved are clearly set forth;
(2) The principal sum and/or any interest
				accrued thereon are subject to and subordinate to all other liabilities of the
				HMO, and upon dissolution or liquidation, no payment of any kind shall be made
				until all other liabilities of the HMO have been paid or otherwise
				discharged;
(3) The instrument
				states that the parties agree that all claims of subscribers and general
				creditors of the organization have been paid or otherwise discharged prior to
				any payment of interest or repayment of principal, unless specifically approved
				by the Office;
(4) The instrument
				is executed by both parties and a certified copy of the instrument is filed
				with the Office of Insurance Regulation;
(5) The parties agree not to modify,
				terminate or cancel the surplus note without the prior approval of the
				Office.
Rulemaking Authority 641.36 FS. Law Implemented 641.35
					 FS.
New 2-22-88, Amended 10-25-89, Formerly 4-31.088,
					 4-191.088.