Florida Regulations 69O-154.106: Minimum Standards for Benefits
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An individual policy of accident and health insurance or nonprofit, medical, surgical, or hospital service corporation contract shall not be delivered or issued for delivery in this state unless the outline of coverage required by Florida Statutes § 627.642, labels and describes the policy or contract in accordance with the specified categories of coverage contained in this rule. Nothing in this rule shall preclude the issuance of any policy or contract combining two or more categories of coverage set forth in Florida Statutes § 627.643(2) This rule does not apply to policies issued pursuant to a conversion privilege. Types of policies controlled by this rule are as follows:
(1) Basic Hospital Expense Insurance – “”Basic Hospital Expense Insurance”” is a policy of accident and health insurance which provides coverage for a period of not less than 31 days during any one period of confinement for each person insured under the policy for the expense incurred for necessary treatment and services rendered as a result of an injury or sickness for at least the following:
(a) Daily hospital room and board in an amount not less than the lesser of the average semi-private room rate in the community in which the insured resides or $30.00 per day; and,
(b) Miscellaneous hospital service in an amount not less than ten times the daily hospital room and board benefit for the expense incurred for the charges made by the hospital for services and supplies rendered by the hospital and provided for use only during the period of confinement; and,
(c) Hospital outpatient services up to an amount of $50.00 for hospital-rendered services as an outpatient incurred within 72 hours of any one accident. Benefits provided under paragraphs (a) and (b) above may be provided subject to a combined deductible amount in excess of $100.00. This section does not prohibit a policy or rider especially designed to provide benefits for an insured person to supplement existing in force coverage.
(2) Basic Medical Expense Insurance – “”Basic Medical Expense Insurance”” is a policy of accident and health insurance which provides coverage for each person insured under the policy for the expense incurred for the necessary services and treatment of an injury or sickness for at least the following: In-hospital medical services, consisting of physician services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical care is required, in an amount not less than $5.00 per call, one call per day, for at least 21 such calls during “”one period of confinement”” or similar benefit acceptable to the Office.
(3) Basic Surgical Expense Insurance – “”Basic Surgical Expense Insurance”” is a policy of accident and health insurance which provides coverage for each insured under the policy for the expense incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the following:
(a) Surgical procedures for the treatment of a sickness, or injury, and endoscopic procedures including any preoperative and postoperative care usually rendered in connection with such operation or procedure, in an amount (a) not less than 75% of the reasonable charges or (b) if specified in dollar amounts, a fee schedule providing amounts for any procedure at least equal to those provided in a fee schedule with a maximum of $400.00 based on a relative value schedule acceptable to the Commissioner of Insurance.
(b) Anesthetic services, consisting of administration of necessary general anesthetics and related procedures in connection with covered surgical service rendered by a physician other than the physician (or his assistant) performing the surgical services, of at least 15 percent of the surgical service benefit provided. Surgical schedules contained in the policy shall include a provision providing coverage for procedures not specifically listed in the schedules and not otherwise excluded by the policy, and benefits therefore shall be consistent with the benefits for comparable procedures. Whenever a policy is written that provides at least the coverages required for both basic hospital expense coverage and basic medical and/or basic surgical expense coverages, the allowable deductible may be applied to the combined coverage.
(4) Hospital Confinement Indemnity Insurance – “”Hospital Confinement Indemnity Insurance”” is a policy of accident and health insurance which provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $10.00 per day and not less than 31 days during any one period of confinement for each person insured under the policy and with no elimination period unless benefit period is 365 days or more, in which case, a three day elimination period will be acceptable.
(5) Major Medical Expense Insurance:
(a) “”Major Medical Expense Insurance”” is a policy of accident and health insurance which provides hospital, medical and surgical coverage as follows:
1. The aggregate maximum is not less than $10,000 per covered person.
2. The co-payment by a covered person is not more than 25 percent of covered charges except that the co-payment percentage applicable to subparagraph (5)(b)7. of this section may not be more than 50 percent.
3. The deductible is stated on a per person, per family, per illness, per benefit period or per year basis, or a combination of such basis, and, other than as specified in the next sentence, is not more than 10 percent of the maximum limit under the coverage. In lieu of a fixed dollar amount, the deductible amount may be expressed as (a) the higher of a fixed dollar amount of basic deductible and the policy’s covered charges paid by other medical expense coverage; or (b) not more than $500 plus the policy’s covered charges paid by other medical expense coverage.
4. The maximum benefit period of an “”each cause”” type of policy (where a separate deductible is required for different sicknesses and accidents) is not less than 18 months and the maximum benefit period for an “”all cause”” type of policy (where separate deductibles are not required for different sicknesses or accidents) is not less than the number of days remaining in the calendar or policy year after the deductible has been met.
5. The period allowed to satisfy the deductible is not less than 90 days.
(b) Major Medical Expense Insurance must provide for each covered person coverage of:
1. Hospital room and board expenses, prior to application of the co-payment percentage, for not less than $40.00 daily (or in lieu thereof the average daily cost of semiprivate room rate in the area where the insured resides) for a period of not less than 30 days for any period of continuous hospital confinement;
2. Miscellaneous hospital services, prior to application of the co-payment percentage, for an aggregate maximum of not less than $1,500 or 15 times the daily room and board rate if specified in dollar amounts;
3. Surgical fees, prior to application of the co-payment percentage, to a maximum of not less than $600.00 for the most severe operation with the amounts provided for other operations reasonably related to such maximum amount;
4. Anesthetic services, prior to application of the co-payment percentage of at least 15 percent of the covered surgical fees or, alternatively, if the surgical schedule is based on relative values, not less than the amount provided therein for anesthetic services at the same unit value as used for the surgical schedule;
5. Doctor visits, in or out of the hospital, with minimum dollar amounts per visit, prior to application of the co-payment percentage, equal to not less than $8.00 per visit, covering not less than one visit per day and for an aggregate maximum of such covered charges of not less than $600.00;
6. Out-of-hospital diagnostic x-rays and tests, prior to application of the co-payment percentage, for an aggregate maximum of such covered charges of not less than $600.00;
7. No fewer than three of the following additional benefits, prior to application of the co-payment percentage, for an aggregate maximum of such covered charges of not less than $1,000:
a. Private duty registered or if not available, licensed practical nurse services performed by other than a family member while insured is hospital confined;
b. Convalescent nursing home care;
c. Diagnosis and treatment by a radiologist or physiotherapist;
d. Rental of special medical equipment, as defined by the insurer in the policy;
e. Artificial limbs or eyes, casts, splints, trusses or braces;
f. Treatment for functional nervous disorders, and mental and emotional disorders;
g. Out-of-hospital prescription drugs and medications.
(6) Disability Income Protection Insurance:
(a) “”Disability Income Protection Insurance”” is a policy of health insurance identified in the outline of coverage, as to scope of coverage, if limited (e.g., accident only or sickness only), which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from sickness or injury or a combination thereof.
(b) Such coverage shall not require a loss from accidental injury to commence within less than 30 days after the date of an accident.
(c) No reduction in benefits shall be put into effect because of an increase in Social Security disability benefits during a benefit period.
(7) Accident Only Insurance:
(a) “”Accident Only Insurance”” is a policy of accident insurance which provides coverage, singly or in combination, for death, dismemberment, disability or hospital and medical care caused by accident.
(b) Accidental death and dismemberment benefits shall be payable if the loss occurs within a period of time of not less than 90 days from the date of the accident, irrespective of total disability. Disability income benefits, if provided, shall not require the loss to commence less than 30 days after the date of the accident.
(c) The amount of the accidental death benefit shall not be less than $1,000.00.
(d) The amount of the dismemberment benefit shall not be less than:
1. $500.00 in the case of a single dismemberment; and,
2. $1,000.00 in the case of a double dismemberment.
(e) Specified dismemberment benefits shall not be in lieu of other benefits unless the specific benefit exceeds the other benefit.
(8) Limited Benefit Insurance – “”Limited Benefit Insurance”” is that form of policy which provides coverage for each person insured under the policy for a specifically named disease (or diseases), specifically named accident, or specifically named limited market fulfilling an experimental or reasonable need.
(a) “”Specified Disease Insurance”” is a policy which provides coverage for each person insured under the policy for a specifically named disease (or diseases) with a deductible amount not in excess of $250.00 and an overall aggregate benefit limit of not less than $2,500.00 and a benefit period of not less than 2 years.
(b) “”Specified Accident Coverage”” is a policy which provides coverage for specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment combined, with a benefit amount of not less than $1,000 for accidental death; $1,000 for double dismemberment and $500 for single dismemberment.
(9) Supplemental Insurance – Any policy or contract which provides benefits that are less than the minimum standards for benefits required under subsections (1) through (3) of Fl. Admin. Code R. 69O-154.106, may be delivered or issued for delivery if the outline of coverage describes such policy or contract as “”supplemental hospital expense insurance””, “”supplemental medical expense insurance”” or “”supplemental surgical expense insurance”” and prominently states that it does not meet the requirements of minimum standards for the category involved.
(10) Non-Conventional Coverage – Nothing contained in this section shall prohibit the issuance of a policy or contract that does not fall within subsections (1) through (9) of Fl. Admin. Code R. 69O-154.106, if such policy or contract is either experimental in nature or is demonstrated to be a type coverage that will fulfill a reasonable need of a person or persons to be insured and is appropriately and prominently described in the outline of coverage.
(11) Home Service Health Coverage (Exemption):
(a) “”Home Service Health Coverage”” is a policy sold by a combination debit company and shall be exempt from the minimum benefit requirements contained in Fl. Admin. Code R. 69O-154.106
(b) In order for a company to qualify as a combination debit company under this Rule, it must certify that at least 90 percent of its Florida premium income for individual health insurance arises from business produced by home service debit agents. If a combination company does not meet this requirement on an overall basis, but does meet it relative to a combination department, it may qualify under this rule relative only to that combination department; in this case, however, the applicable policy forms may be approved for use only by such combination department.
(c) Such certification as mentioned above must be included in the letter of transmittal of each policy submitted.
Rulemaking Authority 627.643, 624.308, 627.9407(1) FS. Law Implemented 624.307(1), 627.642, 627.643, 627.9404(1) FS. History-New 1-1-75, Formerly 4-37.06, Amended 5-17-89, 9-18-89, Formerly 4-37.006, Amended 3-24-99, Formerly 4-154.106.
Terms Used In Florida Regulations 69O-154.106
- Continuance: Putting off of a hearing ot trial until a later time.
- Contract: A legal written agreement that becomes binding when signed.
- Corporation: A legal entity owned by the holders of shares of stock that have been issued, and that can own, receive, and transfer property, and carry on business in its own name.
(a) Daily hospital room and board in an amount not less than the lesser of the average semi-private room rate in the community in which the insured resides or $30.00 per day; and,
(b) Miscellaneous hospital service in an amount not less than ten times the daily hospital room and board benefit for the expense incurred for the charges made by the hospital for services and supplies rendered by the hospital and provided for use only during the period of confinement; and,
(c) Hospital outpatient services up to an amount of $50.00 for hospital-rendered services as an outpatient incurred within 72 hours of any one accident. Benefits provided under paragraphs (a) and (b) above may be provided subject to a combined deductible amount in excess of $100.00. This section does not prohibit a policy or rider especially designed to provide benefits for an insured person to supplement existing in force coverage.
(2) Basic Medical Expense Insurance – “”Basic Medical Expense Insurance”” is a policy of accident and health insurance which provides coverage for each person insured under the policy for the expense incurred for the necessary services and treatment of an injury or sickness for at least the following: In-hospital medical services, consisting of physician services rendered to a person who is a bed patient in a hospital for treatment of sickness or injury other than that for which surgical care is required, in an amount not less than $5.00 per call, one call per day, for at least 21 such calls during “”one period of confinement”” or similar benefit acceptable to the Office.
(3) Basic Surgical Expense Insurance – “”Basic Surgical Expense Insurance”” is a policy of accident and health insurance which provides coverage for each insured under the policy for the expense incurred for the necessary services rendered by a physician for treatment of an injury or sickness for at least the following:
(a) Surgical procedures for the treatment of a sickness, or injury, and endoscopic procedures including any preoperative and postoperative care usually rendered in connection with such operation or procedure, in an amount (a) not less than 75% of the reasonable charges or (b) if specified in dollar amounts, a fee schedule providing amounts for any procedure at least equal to those provided in a fee schedule with a maximum of $400.00 based on a relative value schedule acceptable to the Commissioner of Insurance.
(b) Anesthetic services, consisting of administration of necessary general anesthetics and related procedures in connection with covered surgical service rendered by a physician other than the physician (or his assistant) performing the surgical services, of at least 15 percent of the surgical service benefit provided. Surgical schedules contained in the policy shall include a provision providing coverage for procedures not specifically listed in the schedules and not otherwise excluded by the policy, and benefits therefore shall be consistent with the benefits for comparable procedures. Whenever a policy is written that provides at least the coverages required for both basic hospital expense coverage and basic medical and/or basic surgical expense coverages, the allowable deductible may be applied to the combined coverage.
(4) Hospital Confinement Indemnity Insurance – “”Hospital Confinement Indemnity Insurance”” is a policy of accident and health insurance which provides daily benefits for hospital confinement on an indemnity basis in an amount not less than $10.00 per day and not less than 31 days during any one period of confinement for each person insured under the policy and with no elimination period unless benefit period is 365 days or more, in which case, a three day elimination period will be acceptable.
(5) Major Medical Expense Insurance:
(a) “”Major Medical Expense Insurance”” is a policy of accident and health insurance which provides hospital, medical and surgical coverage as follows:
1. The aggregate maximum is not less than $10,000 per covered person.
2. The co-payment by a covered person is not more than 25 percent of covered charges except that the co-payment percentage applicable to subparagraph (5)(b)7. of this section may not be more than 50 percent.
3. The deductible is stated on a per person, per family, per illness, per benefit period or per year basis, or a combination of such basis, and, other than as specified in the next sentence, is not more than 10 percent of the maximum limit under the coverage. In lieu of a fixed dollar amount, the deductible amount may be expressed as (a) the higher of a fixed dollar amount of basic deductible and the policy’s covered charges paid by other medical expense coverage; or (b) not more than $500 plus the policy’s covered charges paid by other medical expense coverage.
4. The maximum benefit period of an “”each cause”” type of policy (where a separate deductible is required for different sicknesses and accidents) is not less than 18 months and the maximum benefit period for an “”all cause”” type of policy (where separate deductibles are not required for different sicknesses or accidents) is not less than the number of days remaining in the calendar or policy year after the deductible has been met.
5. The period allowed to satisfy the deductible is not less than 90 days.
(b) Major Medical Expense Insurance must provide for each covered person coverage of:
1. Hospital room and board expenses, prior to application of the co-payment percentage, for not less than $40.00 daily (or in lieu thereof the average daily cost of semiprivate room rate in the area where the insured resides) for a period of not less than 30 days for any period of continuous hospital confinement;
2. Miscellaneous hospital services, prior to application of the co-payment percentage, for an aggregate maximum of not less than $1,500 or 15 times the daily room and board rate if specified in dollar amounts;
3. Surgical fees, prior to application of the co-payment percentage, to a maximum of not less than $600.00 for the most severe operation with the amounts provided for other operations reasonably related to such maximum amount;
4. Anesthetic services, prior to application of the co-payment percentage of at least 15 percent of the covered surgical fees or, alternatively, if the surgical schedule is based on relative values, not less than the amount provided therein for anesthetic services at the same unit value as used for the surgical schedule;
5. Doctor visits, in or out of the hospital, with minimum dollar amounts per visit, prior to application of the co-payment percentage, equal to not less than $8.00 per visit, covering not less than one visit per day and for an aggregate maximum of such covered charges of not less than $600.00;
6. Out-of-hospital diagnostic x-rays and tests, prior to application of the co-payment percentage, for an aggregate maximum of such covered charges of not less than $600.00;
7. No fewer than three of the following additional benefits, prior to application of the co-payment percentage, for an aggregate maximum of such covered charges of not less than $1,000:
a. Private duty registered or if not available, licensed practical nurse services performed by other than a family member while insured is hospital confined;
b. Convalescent nursing home care;
c. Diagnosis and treatment by a radiologist or physiotherapist;
d. Rental of special medical equipment, as defined by the insurer in the policy;
e. Artificial limbs or eyes, casts, splints, trusses or braces;
f. Treatment for functional nervous disorders, and mental and emotional disorders;
g. Out-of-hospital prescription drugs and medications.
(6) Disability Income Protection Insurance:
(a) “”Disability Income Protection Insurance”” is a policy of health insurance identified in the outline of coverage, as to scope of coverage, if limited (e.g., accident only or sickness only), which provides for periodic payments, weekly or monthly, for a specified period during the continuance of disability resulting from sickness or injury or a combination thereof.
(b) Such coverage shall not require a loss from accidental injury to commence within less than 30 days after the date of an accident.
(c) No reduction in benefits shall be put into effect because of an increase in Social Security disability benefits during a benefit period.
(7) Accident Only Insurance:
(a) “”Accident Only Insurance”” is a policy of accident insurance which provides coverage, singly or in combination, for death, dismemberment, disability or hospital and medical care caused by accident.
(b) Accidental death and dismemberment benefits shall be payable if the loss occurs within a period of time of not less than 90 days from the date of the accident, irrespective of total disability. Disability income benefits, if provided, shall not require the loss to commence less than 30 days after the date of the accident.
(c) The amount of the accidental death benefit shall not be less than $1,000.00.
(d) The amount of the dismemberment benefit shall not be less than:
1. $500.00 in the case of a single dismemberment; and,
2. $1,000.00 in the case of a double dismemberment.
(e) Specified dismemberment benefits shall not be in lieu of other benefits unless the specific benefit exceeds the other benefit.
(8) Limited Benefit Insurance – “”Limited Benefit Insurance”” is that form of policy which provides coverage for each person insured under the policy for a specifically named disease (or diseases), specifically named accident, or specifically named limited market fulfilling an experimental or reasonable need.
(a) “”Specified Disease Insurance”” is a policy which provides coverage for each person insured under the policy for a specifically named disease (or diseases) with a deductible amount not in excess of $250.00 and an overall aggregate benefit limit of not less than $2,500.00 and a benefit period of not less than 2 years.
(b) “”Specified Accident Coverage”” is a policy which provides coverage for specifically identified kind of accident (or accidents) for each person insured under the policy for accidental death or accidental death and dismemberment combined, with a benefit amount of not less than $1,000 for accidental death; $1,000 for double dismemberment and $500 for single dismemberment.
(9) Supplemental Insurance – Any policy or contract which provides benefits that are less than the minimum standards for benefits required under subsections (1) through (3) of Fl. Admin. Code R. 69O-154.106, may be delivered or issued for delivery if the outline of coverage describes such policy or contract as “”supplemental hospital expense insurance””, “”supplemental medical expense insurance”” or “”supplemental surgical expense insurance”” and prominently states that it does not meet the requirements of minimum standards for the category involved.
(10) Non-Conventional Coverage – Nothing contained in this section shall prohibit the issuance of a policy or contract that does not fall within subsections (1) through (9) of Fl. Admin. Code R. 69O-154.106, if such policy or contract is either experimental in nature or is demonstrated to be a type coverage that will fulfill a reasonable need of a person or persons to be insured and is appropriately and prominently described in the outline of coverage.
(11) Home Service Health Coverage (Exemption):
(a) “”Home Service Health Coverage”” is a policy sold by a combination debit company and shall be exempt from the minimum benefit requirements contained in Fl. Admin. Code R. 69O-154.106
(b) In order for a company to qualify as a combination debit company under this Rule, it must certify that at least 90 percent of its Florida premium income for individual health insurance arises from business produced by home service debit agents. If a combination company does not meet this requirement on an overall basis, but does meet it relative to a combination department, it may qualify under this rule relative only to that combination department; in this case, however, the applicable policy forms may be approved for use only by such combination department.
(c) Such certification as mentioned above must be included in the letter of transmittal of each policy submitted.
Rulemaking Authority 627.643, 624.308, 627.9407(1) FS. Law Implemented 624.307(1), 627.642, 627.643, 627.9404(1) FS. History-New 1-1-75, Formerly 4-37.06, Amended 5-17-89, 9-18-89, Formerly 4-37.006, Amended 3-24-99, Formerly 4-154.106.