Florida Administrative Code

If an issuer elects to discontinue an individual health insurance policy form by consolidation with another policy form, the rate for the benefits shall be actuarially justified and approved by the Office for the consolidated group. Rulemaking Authority 624.308(1) FS. Law Impleme…

(1) If a health insurance issuer elects to withdraw from the individual health insurance market, the issuer must provide 180 days' written notice to the Office and to all policyholders, certificateholders and beneficiaries provided coverage by the issuer in that market. (2) A not…

(1)(a) All individual health insurance issuers shall file a designation with the Office of their election to become either a risk-assuming or a reinsuring carrier. (b) The individual issuer desiring to be a risk-assuming or reinsuring carrier shall use Form OIR-B2-1311 (rev. 8/03…

(1) Any individual issuer seeking to change the election made by the carrier under Section 627.6475(5)(a), F.S., to become either a risk-assuming carrier or a reinsuring carrier shall request a change of status on Form OIR-B2-1304 (rev. 10/98), State of Florida/Individual Issuer'…

(1)(a) This rule chapter applies to all individual and group health insurance policies, including single premium credit disability insurance. All other credit insurance is not subject to this rule chapter. Credit disability is defined under Section 627.677(2), F.S. (b) This rule …

As used in this rule chapter, the following terms have the following meaning: (1) Annual Claim Cost. The net annual cost per unit of benefit before the addition of expenses, including claim settlement expenses, and a margin for profit or contingencies. For example, the annual cla…

Adequacy of an insurer's health insurance reserves shall be determined on the basis of all three categories combined. However, these standards emphasize the importance of determining appropriate reserves for each of the three categories separately. (1) Claim Reserves. (a) General…

Specific minimum standards for morbidity, mortality and interest which apply to claim reserves according to year of incurral and to contract reserves according to year of issue: (1) Morbidity. (a) Minimum morbidity standards for valuation of specified individual contract health i…

Waiver of premium reserves involve several special considerations. (1) The disability valuation tables promulgated by the National Association of Insurance Commissioners are based on exposures that include contracts on premium waiver as in-force contracts. Therefore, contract res…

Increases to or credits against reserves carried arising because of reinsurance assumed or reinsurance ceded, except as noted below, shall be determined in a manner consistent with these minimum reserve standards and with all applicable provisions of the reinsurance contracts whi…

(1) The following tables are hereby adopted and incorporated by reference: (a) 1964 Commissioners Disability Table; (b) 1985 Commissioners Individual Disability Tables A; (c) 1985 Commissioners Individual Disability Tables B; (d) 1956 Intercompany Hospital-Surgical Tables; (e) 19…

The provisions of this Part shall apply to any small employer group in force on January 1, 1997, as defined in Section 627.6699, F.S., which cover fewer than 20 employees. Rulemaking Authority 624.308(1), 627.6692(9) FS. Law Implemented 624.307(1), 627.6692 FS. History-New 4-24-9…

Each contract, policy, certificate and handbook must contain a Notice of Occurrence of a Qualifying Event provision. This provision must include the information required by Section 627.6692(5)(d)1., F.S. The beneficiary shall notify the carrier in writing within sixty-three (63) …

(1) Within 14 days of the date that the carrier receives the notice of occurrence of a qualifying event from the qualified beneficiary the carrier must send to the employee, covered spouse and covered dependents, by certified mail, the Election and Premium Notice Form OIR-B2-1261…

(1) The employee, covered spouse and covered dependents have until the 30th day, as evidenced by postmark, after receiving the Election and Premium Notice form described in Rule 69O-154.305, F.A.C., to elect coverage continuation in writing and pay the premium to the carrier. (2)…

(1) If a health insurance issuer elects to withdraw from the group market, the issuer must provide 180 days' written notice to the Office and to all policyholders, certificateholders and beneficiaries provided coverage by the issuer in that market. (2) A notice of withdrawal from…

(1) If a small employer carrier elects to withdraw from the small group health insurance market, the carrier must provide 180 days' written notice to the Office and to all policyholders, certificateholders and beneficiaries provided coverage by the carrier in that market. (2) A n…

An insurer or health maintenance organization that issues a group health insurance policy must renew or continue in force such coverage at the option of the policyholder. Employers are eligible to renew that exact coverage, subject to the participation requirement provisions of S…

The purpose of this chapter is to provide for the reasonable standardization and simplification of terms and benefits of Medicare supplement policies; to facilitate public understanding and comparison of such policies; to eliminate provisions contained in such policies which may …

(1)(a) These rules shall apply to all Medicare supplement insurance policies, including certificates issued or delivered in this state under a group Medicare supplement policy which has been effectuated within or outside this state, and other Medicare supplement health benefit pl…

For purposes of this rule: (1) "Applicant" means: (a) In the case of an individual Medicare supplement policy, the person who seeks to contract for insurance benefits, and (b) In the case of a group Medicare supplement policy, the proposed certificate holder. (2) "Bankruptcy" mea…

No policy or certificate may be advertised, solicited or issued for delivery in this state as a Medicare supplement policy or certificate unless such policy or certificate contains definitions or terms which conform to the requirements of this section. (1) "Accident," "accidental…

(1) Except for permitted preexisting condition clauses as described in paragraphs 69O-156.006(1)(b), 69O-156.007(1)(a), and 69O-156.0075(1)(a), F.A.C., of this chapter, no policy or certificate may be advertised, solicited or issued for delivery in this State as a Medicare supple…

As it relates to Pre-Standarized Medicare Supplement Benefit Plan Policies or certificates issued for delivery prior to January 1, 1992, no policy or certificate may be advertised, solicited, issued, delivered or issued for delivery in this State as a Medicare supplement policy o…

The following standards are applicable to all 1990 standardized Medicare supplement benefit plan policies or certificates delivered or issued for delivery in this state on or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010. No policy or certif…

The following standards are applicable to all 2010 Standardized Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, deliver…

The following applies to all 1990 Standardized Medicare Supplement Benefit Plan Policies or Certificates issued for delivery on or after January 1, 1992, and with an effective date for coverage prior to June 1, 2010. (1) An issuer shall make available to each prospective policyho…

The following standards are applicable to all Medicare supplement policies or certificates delivered or issued for delivery in this state with an effective date for coverage on or after June 1, 2010. No policy or certificate may be advertised, solicited, delivered or issued for d…

No policy or certificate that provides coverage of the Medicare Part B deductible may be advertised, solicited, delivered or issued for delivery in this state as a Medicare supplement policy or certificate to Newly Eligible Medicare Beneficiary. In accordance with the Medicare Ac…

(1) No issuer shall deny or condition the issuance or effectiveness of any Medicare supplement policy or certificate available for sale in this State, nor discriminate in the pricing of such a policy or certificate because of the health status, claims experience, receipt of healt…

(1) Guaranteed Issue. (a) Eligible persons are those individuals described in subsection (2) who: 1. Seek to enroll under the policy during the period specified in subsection (3); and 2. Submit evidence of the date of termination, disenrollment, or Medicare Part D enrollment with…

(1) An issuer shall comply with Section 1882(c)(3) of the Social Security Act (as enacted by Section 4081(b)(2)(C), of the Omnibus Budget Reconciliation Act of 1987 (OBRA) 1987, Pub. L. No. 100-203) by: (a) Accepting a notice from a Medicare carrier on dually assigned claims subm…

(1) Loss Ratio Standards. (a) A Medicare Supplement policy form or certificate form shall not be delivered or issued for delivery unless the policy form, certificate form, or block of pooled forms, can be expected, as estimated for the lifetime of the policy, to return to policyh…

(1) An issuer shall not deliver or issue for delivery a policy or certificate to a resident of this State unless the policy form or certificate form has been filed with and approved by the Office including any riders or amendments to policy or certificate forms to delete outpatie…

(1) An insurer or other entity may provide commission or other compensation to an agent or other representative for the sale of a Medicare supplement policy or certificate only if the first year commission or other first year compensation is no more than 200 percent (200%) of the…

(1) General Rules. (a) Medicare supplement policies and certificates shall include a renewal or continuation provision. The language or specifications of such provision shall be consistent with the type of contract issued. Such provision shall be appropriately captioned and shall…

(1) Application forms shall include the following statements and the following questions designed to elicit information as to whether, as of the date of the application, the applicant currently has Medicare supplement, or Medicare Advantage, Medicaid coverage, or another health i…

(1) An issuer, directly or through its producers, shall: (a) Establish marketing procedures to assure that any comparison of policies by its agents or other producers will be fair and accurate. (b) Establish marketing procedures to assure excessive insurance is not sold or issued…

(1) In recommending the purchase or replacement of any Medicare supplement policy or certificate an agent shall make reasonable efforts to determine the appropriateness of a recommended purchase or replacement. (2) Any sale of Medicare supplement policy or certificate that will p…

(1) On or before March 1 of each year, an issuer shall report the following information for every individual resident of this State for which the issuer has in force more than one Medicare supplement policy or certificate: (a) Policy and certificate number, and (b) Date of issuan…

(1) If a Medicare supplement policy or certificate replaces another Medicare supplement policy or certificate, the replacing issuer shall waive any time periods applicable to preexisting conditions, waiting periods, elimination periods and probationary periods in the new Medicare…

(1) An issuer of a Medicare supplement policy or certificate; (a) Shall not deny or condition the issuance or effectiveness of the policy or certificate (including the imposition of any exclusion of benefits under the policy based on a preexisting condition) on the basis of the g…

(1)(a) This rule applies to Medicare Select policies and certificates, as defined in this rule. (b) No policy or certificate may be advertised as a Medicare Select policy or certificate unless it meets the requirements of this rule. (2) For purposes of this rule: (a) "Complaint" …

If any provision of this regulation or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the regulation and the application of such provision to other persons or circumstances shall not be affected thereby. Rulemaking Aut…

The purpose of these rules is to provide prospective purchasers with clear and unambiguous statements in the advertisement and direct solicitation and sale of Medicare Supplement Insurance, and to assure the clear and truthful disclosure of the benefits, limitations and exclusion…

(1) These rules shall apply to any Medicare Supplement Insurance "advertisement" or direct solicitation and sale made or disseminated in this State which the insurer knows or reasonably should know is intended for presentation, distribution or dissemination in this State when suc…

For the purpose of these rules, the terms below are defined as follows: (1) An "Advertisement" includes: (a) Printed and published material, audio visual material and descriptive literature used by or on behalf of an insurer in direct mail, newspapers, magazines, radio scripts, T…

All information required to be disclosed by these rules shall be set out conspicuously and in close conjunction with the statements to which such information relates or under appropriate captions of such prominence that it shall not be minimized, rendered obscure or presented in …

It shall be deemed an unfair or deceptive act or practice in the direct solicitation or sale of Medicare supplement insurance policies, to: (1) Make any representation by an agent to the effect that such person is a "Counselor," "Advisor" or similar designation, for any associati…

It shall be the responsibility of each agent directly soliciting a policy of Medicare supplemental insurance to complete a form as indicated by Exhibit "A" herein. Substantially equivalent forms may be adopted with the prior approval of the Director. The original copy of such for…