Florida Regulations 69O-203.026: Standards for Subscriber Contracts
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(1) Group and nongroup subscriber contracts shall include all elements contained in this section.
(a) Definitions;
(b) Effective date and term of contract;
(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 the medical personnel will be made available;
(j) The contract, certificate, or handbook shall state where and in what manner the health care services may be obtained;
(k) Factors pertaining to pre-existing conditions, if applicable;
(l) All limitations, exclusions and exceptions, limitations on length of stay, and all other qualifying or limiting features which shall state coverage for pre-existing conditions cannot be excluded longer than two years;
(m) Provisions regarding in and out of area emergencies, which includes a definition of emergency, if applicable;
(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 subrogation, if applicable;
(s) Any applicable arbitration provision which shall state that any arbitration is voluntary and shall be conducted pursuant to chapter 682, F.S.; and,
(t) Conversion and extension of benefit privileges.
(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 PLHSO and the subscriber.
(4) Each PLHSO that offers a group plan within this state will offer at least one open enrollment period of not less than 30 days every 18 months. Such open enrollment periods are required for as long as the group exists unless the PLHSO and the employer mutually agree to a shorter period of time than 18 months.
(5) All contracts, certificates, and member handbooks shall be clear and legible. All limitations, exclusions, and exceptions shall be grouped together, with captions in boldfaced type, and shall be printed with at least the same prominence as provisions which describe the benefits.
(6) Contracts that contain limitations, exclusions, and/or exceptions cannot restrict those health care services that are commonly provided in the covered limited health service and which subscribers might reasonably require to maintain good health, or create provisions which are unfair, inequitable, or contrary to the public policy of this state or encourage misrepresentation.
Rulemaking Authority 636.067 FS. Law Implemented 636.016, 636.019, 636.022, 636.026, 636.034 FS. History-New 11-15-94, Formerly 4-203.026.
Terms Used In Florida Regulations 69O-203.026
- 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
(b) Effective date and term of contract;
(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 the medical personnel will be made available;
(j) The contract, certificate, or handbook shall state where and in what manner the health care services may be obtained;
(k) Factors pertaining to pre-existing conditions, if applicable;
(l) All limitations, exclusions and exceptions, limitations on length of stay, and all other qualifying or limiting features which shall state coverage for pre-existing conditions cannot be excluded longer than two years;
(m) Provisions regarding in and out of area emergencies, which includes a definition of emergency, if applicable;
(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 subrogation, if applicable;
(s) Any applicable arbitration provision which shall state that any arbitration is voluntary and shall be conducted pursuant to chapter 682, F.S.; and,
(t) Conversion and extension of benefit privileges.
(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 PLHSO and the subscriber.
(4) Each PLHSO that offers a group plan within this state will offer at least one open enrollment period of not less than 30 days every 18 months. Such open enrollment periods are required for as long as the group exists unless the PLHSO and the employer mutually agree to a shorter period of time than 18 months.
(5) All contracts, certificates, and member handbooks shall be clear and legible. All limitations, exclusions, and exceptions shall be grouped together, with captions in boldfaced type, and shall be printed with at least the same prominence as provisions which describe the benefits.
(6) Contracts that contain limitations, exclusions, and/or exceptions cannot restrict those health care services that are commonly provided in the covered limited health service and which subscribers might reasonably require to maintain good health, or create provisions which are unfair, inequitable, or contrary to the public policy of this state or encourage misrepresentation.
Rulemaking Authority 636.067 FS. Law Implemented 636.016, 636.019, 636.022, 636.026, 636.034 FS. History-New 11-15-94, Formerly 4-203.026.