Florida Regulations 69O-191.033: Standards for Subscriber Contracts
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(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 Fl. Admin. Code R. 69O-191.046;
(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 Florida Statutes § 641.31(8), 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 Fl. Admin. Code R. 69O-191.081, and shall be conducted pursuant to Florida Statutes Chapter 682;
(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.
(2) Group master contracts shall contain complete information as above, but a certificate or member handbook may be issued to the individual members of the group in lieu of the group master contract.
(3) Non-group contracts shall contain the entire agreement between the HMO and the subscriber.
(4) All contracts, certificates, and member handbooks shall be clear and legible. All limitations, exclusions, and exceptions shall be grouped together with captions in bold-faced type and shall be printed with at least the same prominence as provisions which describe the benefits.
(5) Contracts that contain limitations, exclusions, and/or exceptions cannot restrict those health care services which would create provisions which are unfair, inequitable, encourage misrepresentation, or are contrary to the public policy of this state.
(6) All health maintenance policies or contracts which provide coverage, benefits, or services as described in Florida Statutes § 463.002(5), shall offer to the subscriber the services of optometrists licensed pursuant to Florida Statutes Chapter 463 “”Coverage, benefits, or services as defined in Florida Statutes § 463.002(5)“” are not limited to refraction’s for eyeglasses or contact lenses, but include the full scope of services that fall within the definition of optometry as provided in Florida Statutes § 463.002(5) A health maintenance organization may not prohibit optometrists from providing the full range of existing services offered by the health maintenance organization that fall within the scope of optometric practice as defined in Florida Statutes § 463.002(5) This rule is not intended to expand contractual services required to be offered by a health maintenance organization.
Rulemaking Authority 641.36 FS. Law Implemented 641.31(19) FS. History-New 2-22-88, Amended 10-25-89, Formerly 4-31.033, Amended 5-28-92, 10-10-00, Formerly 4-191.033.
Terms Used In Florida Regulations 69O-191.033
- Contract: A legal written agreement that becomes binding when signed.
- Grace period: The number of days you'll have to pay your bill for purchases in full without triggering a finance charge. Source: Federal Reserve
- Jurisdiction: (1) The legal authority of a court to hear and decide a case. Concurrent jurisdiction exists when two courts have simultaneous responsibility for the same case. (2) The geographic area over which the court has authority to decide cases.
- Statute: A law passed by a legislature.
(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 Fl. Admin. Code R. 69O-191.046;
(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 Florida Statutes § 641.31(8), 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 Fl. Admin. Code R. 69O-191.081, and shall be conducted pursuant to Florida Statutes Chapter 682;
(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.
(2) Group master contracts shall contain complete information as above, but a certificate or member handbook may be issued to the individual members of the group in lieu of the group master contract.
(3) Non-group contracts shall contain the entire agreement between the HMO and the subscriber.
(4) All contracts, certificates, and member handbooks shall be clear and legible. All limitations, exclusions, and exceptions shall be grouped together with captions in bold-faced type and shall be printed with at least the same prominence as provisions which describe the benefits.
(5) Contracts that contain limitations, exclusions, and/or exceptions cannot restrict those health care services which would create provisions which are unfair, inequitable, encourage misrepresentation, or are contrary to the public policy of this state.
(6) All health maintenance policies or contracts which provide coverage, benefits, or services as described in Florida Statutes § 463.002(5), shall offer to the subscriber the services of optometrists licensed pursuant to Florida Statutes Chapter 463 “”Coverage, benefits, or services as defined in Florida Statutes § 463.002(5)“” are not limited to refraction’s for eyeglasses or contact lenses, but include the full scope of services that fall within the definition of optometry as provided in Florida Statutes § 463.002(5) A health maintenance organization may not prohibit optometrists from providing the full range of existing services offered by the health maintenance organization that fall within the scope of optometric practice as defined in Florida Statutes § 463.002(5) This rule is not intended to expand contractual services required to be offered by a health maintenance organization.
Rulemaking Authority 641.36 FS. Law Implemented 641.31(19) FS. History-New 2-22-88, Amended 10-25-89, Formerly 4-31.033, Amended 5-28-92, 10-10-00, Formerly 4-191.033.