Florida Regulations 69O-154.112: Guaranteed Availability of Individual Health Coverage to Eligible Individuals
Current as of: 2024 | Check for updates
|
Other versions
(1)(a) Each health insurance issuer that offers individual health insurance coverage shall make available to eligible individuals the two policy forms with the largest and the next to largest premium volume of all such policy forms offered by the issuer in the state or a particular marketing or service area in the individual market.
(b) First year premium volume shall be calculated by using first year premium for the calendar year. In compiling the earned first year premium for the year, the company shall include earned premium for individuals renewing into a replacement form where a previously approved form has been discontinued.
(c) An insurer offering coverage in the individual market is not prohibited from establishing premium discounts.
(2)(a) Both policy forms shall be designed for, made generally available to, actively marketed to, and enroll both eligible and other individuals.
(b) Issuers are not required to reopen closed blocks to meet this requirement.
(c) Eligible individuals must be offered these policy forms using the rate schedule and rating manual filed with and approved by the Office. If in the application of the company’s underwriting standards, the eligible individual is determined to be uninsurable, the highest approved rate class may be used. Rates in each approved rate class must be generally applicable to all individuals and be based on sound actuarial practices without regard to the individual being an eligible individual.
(3) To enable the Office to monitor this coverage, the issuer shall file, no later than April 1 of each year, Form OIR-B2-1386, (Rev. 8/03), Individual Health Coverage Policy Forms Issued/Renewed in Florida, which is hereby adopted and incorporated by reference. All filings shall be submitted electronically to http://www.floir.com/iportal. Copies of the form may be printed from the Office’s website: http://www.floir.com/iportal.
(4)(a) If one or both of the largest first year earned premium volume policy forms are closed blocks of business, the issuer shall so inform the Office.
(b) The issuer shall provide evidence that the Office was notified of the intent to close these policy forms and shall provide the information listed in subparagraph 4. for the replacement forms.
(5)(a) If the health insurance issuer offers policy forms in the individual market that provide dependent coverage, the issuer may apply a pre-existing condition exclusion to dependents who are not eligible individuals.
(b) The issuer may not apply a preexisting condition exclusion on certain children who have less than 18 months creditable coverage but are dependents who were enrolled as a dependent under a group health plan within 30 days of birth, adoption, or placement for adoption and have not had a significant break in coverage.
(6) Each issuer offering health insurance coverage in the individual market must disclose, in writing, to all applicants at the time of application the availability of quarantee issue coverage for eligible individuals. Each issuer offering health insurance coverage in the individual market is responsible for informing the applicant at the time of application of the information necessary to determine whether an applicant for coverage is an eligible individual as defined in Florida Statutes § 627.6487(3), as follows:
(a) The issuer shall exercise reasonable diligence in making this determination.
(b) The issuer shall promptly determine whether an applicant is an eligible individual.
(c) If an issuer determines that an individual is an eligible individual, the issuer shall promptly issue a policy to that individual.
(7) If the information presented in or with an application is substantially insufficient for the issuer to make a determination, the issuer may immediately request additional information from the individual. Upon receipt of the requested information, the issuer shall act promptly to make its determination.
(8) If an entity fails to provide the applicant with the certificate required under Florida Statutes § 627.64871, the issuer is subject to the procedures set forth in Fl. Admin. Code R. 69O-154.111, concerning an individual’s right to demonstrate creditable coverage.
Rulemaking Authority 624.308, 624.424(1)(c), 627.6487(4)(b) FS. Law Implemented 624.307(1), 627.6487 FS. History-New 9-19-00, Amended 9-30-01, 2-13-03, 9-22-03, Formerly 4-154.112, Amended 9-15-05.
Terms Used In Florida Regulations 69O-154.112
- Dependent: A person dependent for support upon another.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
(c) An insurer offering coverage in the individual market is not prohibited from establishing premium discounts.
(2)(a) Both policy forms shall be designed for, made generally available to, actively marketed to, and enroll both eligible and other individuals.
(b) Issuers are not required to reopen closed blocks to meet this requirement.
(c) Eligible individuals must be offered these policy forms using the rate schedule and rating manual filed with and approved by the Office. If in the application of the company’s underwriting standards, the eligible individual is determined to be uninsurable, the highest approved rate class may be used. Rates in each approved rate class must be generally applicable to all individuals and be based on sound actuarial practices without regard to the individual being an eligible individual.
(3) To enable the Office to monitor this coverage, the issuer shall file, no later than April 1 of each year, Form OIR-B2-1386, (Rev. 8/03), Individual Health Coverage Policy Forms Issued/Renewed in Florida, which is hereby adopted and incorporated by reference. All filings shall be submitted electronically to http://www.floir.com/iportal. Copies of the form may be printed from the Office’s website: http://www.floir.com/iportal.
(4)(a) If one or both of the largest first year earned premium volume policy forms are closed blocks of business, the issuer shall so inform the Office.
(b) The issuer shall provide evidence that the Office was notified of the intent to close these policy forms and shall provide the information listed in subparagraph 4. for the replacement forms.
(5)(a) If the health insurance issuer offers policy forms in the individual market that provide dependent coverage, the issuer may apply a pre-existing condition exclusion to dependents who are not eligible individuals.
(b) The issuer may not apply a preexisting condition exclusion on certain children who have less than 18 months creditable coverage but are dependents who were enrolled as a dependent under a group health plan within 30 days of birth, adoption, or placement for adoption and have not had a significant break in coverage.
(6) Each issuer offering health insurance coverage in the individual market must disclose, in writing, to all applicants at the time of application the availability of quarantee issue coverage for eligible individuals. Each issuer offering health insurance coverage in the individual market is responsible for informing the applicant at the time of application of the information necessary to determine whether an applicant for coverage is an eligible individual as defined in Florida Statutes § 627.6487(3), as follows:
(a) The issuer shall exercise reasonable diligence in making this determination.
(b) The issuer shall promptly determine whether an applicant is an eligible individual.
(c) If an issuer determines that an individual is an eligible individual, the issuer shall promptly issue a policy to that individual.
(7) If the information presented in or with an application is substantially insufficient for the issuer to make a determination, the issuer may immediately request additional information from the individual. Upon receipt of the requested information, the issuer shall act promptly to make its determination.
(8) If an entity fails to provide the applicant with the certificate required under Florida Statutes § 627.64871, the issuer is subject to the procedures set forth in Fl. Admin. Code R. 69O-154.111, concerning an individual’s right to demonstrate creditable coverage.
Rulemaking Authority 624.308, 624.424(1)(c), 627.6487(4)(b) FS. Law Implemented 624.307(1), 627.6487 FS. History-New 9-19-00, Amended 9-30-01, 2-13-03, 9-22-03, Formerly 4-154.112, Amended 9-15-05.