Florida Regulations 69O-191.105: Individual Subscriber Enrollment Procedures
Current as of: 2024 | Check for updates
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(1) After a subscriber signs an HMO enrollment application and before the HMO can process the application changing or initiating the subscriber coverage, each HMO must verify the intent and desire of the individual subscriber to join the HMO. The verification must be in writing and conducted by someone outside the HMO’s marketing Office. Each verification shall include the following:
(a) Confirmation that the subscriber intends and desires to join the HMO;
(b) If the subscriber is a Medicare recipient, confirmation must be provided that the subscriber understands by joining the HMO they will be limited to the benefits provided by the HMO, and Medicare will pay the HMO for the subscriber coverage;
(c) Confirmation that the subscriber understands the applicable restrictions of HMOs, especially that they must use the HMO providers and secure approval from the HMO to use health care providers outside the plan; and,
(d) If the subscriber is a member of an HMO, confirmation must be provided that the subscriber understands they are transferring to another HMO.
(2) The HMO shall not pay a commission, fee, money or any other form of scheduled compensation to any health insurance agent until verification from the subscriber of their intent and desire to enroll into the HMO has been secured and the enrollment process has been completed. The HMO shall verify the intent of the subscriber to enroll with a written notice to the subscriber stating that they have transferred from their existing coverage (i.e. from Medicare, another HMO, etc.) to the new HMO. Each written verification notice shall be accompanied with printed materials explaining the nature of the HMO and any applicable restrictions and exclusions. The enrollment process shall be deemed complete seven days after the HMO mails the confirmation notice. Each HMO must notify the subscriber of the date enrollment begins and when benefits will be available. Each HMO is directly responsible for enrollment abuses.
Rulemaking Authority 641.36 FS. Law Implemented 641.3901, 641.3903(1)(d), (h), (2)(d), (4)(a), (5), (8) FS. History-New 7-6-87, Formerly 4-31.105, Amended 5-28-92, Formerly 4-191.105.
(a) Confirmation that the subscriber intends and desires to join the HMO;
(b) If the subscriber is a Medicare recipient, confirmation must be provided that the subscriber understands by joining the HMO they will be limited to the benefits provided by the HMO, and Medicare will pay the HMO for the subscriber coverage;
(c) Confirmation that the subscriber understands the applicable restrictions of HMOs, especially that they must use the HMO providers and secure approval from the HMO to use health care providers outside the plan; and,
(d) If the subscriber is a member of an HMO, confirmation must be provided that the subscriber understands they are transferring to another HMO.
(2) The HMO shall not pay a commission, fee, money or any other form of scheduled compensation to any health insurance agent until verification from the subscriber of their intent and desire to enroll into the HMO has been secured and the enrollment process has been completed. The HMO shall verify the intent of the subscriber to enroll with a written notice to the subscriber stating that they have transferred from their existing coverage (i.e. from Medicare, another HMO, etc.) to the new HMO. Each written verification notice shall be accompanied with printed materials explaining the nature of the HMO and any applicable restrictions and exclusions. The enrollment process shall be deemed complete seven days after the HMO mails the confirmation notice. Each HMO must notify the subscriber of the date enrollment begins and when benefits will be available. Each HMO is directly responsible for enrollment abuses.
Rulemaking Authority 641.36 FS. Law Implemented 641.3901, 641.3903(1)(d), (h), (2)(d), (4)(a), (5), (8) FS. History-New 7-6-87, Formerly 4-31.105, Amended 5-28-92, Formerly 4-191.105.