Florida Administrative Code

Every application for an individual policy, or an in-state group Medicare Supplement policy or contract or enrollment form for an out-of-state group contract which does not comply with Section 627.6515(2), F.S., must be taken by a Florida resident agent. Therefore, to assure comp…

(1) Advertising File. Each insurer shall maintain at its home or principal office a complete file containing every printed, published, or prepared advertisement of its individual policies and typical printed, published, or prepared advertisements of its blanket, franchise, and gr…

(1) Every insurer providing Medicare supplement insurance or benefits in this state shall provide a copy of any advertisement no later than 10 calendar days prior to its use in this state to the Office of Insurance Regulation for review by the Commissioner. Such advertisement sha…

If any section or portion of a section of these rules or any amendments thereto, or the applicability thereof to any person or circumstance is held invalid by a court, the remainder of the rules, or the applicability of such provision to other persons or circumstances, shall not …

These rules supersede and constitute a revision of all prior rules pertaining to solicitation and sale of Medicare Supplemental Insurance Policies. Rulemaking Authority 624.308(1), 626.9611 FS. Law Implemented 624.307(1), 626.9541(1)(a), (b), (e), (k), (l), 626.9641(1) FS. Histor…

The purpose of these rules is: (1) To implement Part XVIII of Chapter 627, F.S., pertaining to requirements of long-term care insurance policies, (2) To promote the public interest, (3) To promote the availability of long-term care insurance policies, (4) To protect applicants fo…

(1) Except as otherwise specifically provided, the provisions of Chapter 69O-157, F.A.C., shall apply to long-term care insurance policies delivered or issued for delivery in this state, and to policies delivered or issued for delivery outside this state to the extent provided in…

As used in these rules and as used in long-term care policies, the following terms shall have meanings no more restrictive than the following: (1) "Applicant" means: (a) In the case of an individual long-term care insurance policy, the person who seeks to contract for benefits. (…

(1) No group long-term care insurance coverage may be offered to a resident of this state under a group policy issued in another state to a group described in Section 627.9405(1)(c) or (d), F.S., unless this state or such other state having statutory and regulatory long-term care…

No long-term care policy may contain a renewal provision less favorable to the insured than a right of renewal upon timely payment of premium, except that rates may be revised by the insurer on a class basis. However, the Office may authorize nonrenewal on a statewide basis, on t…

(1) No long-term care insurance policy or certificate other than a policy or certificate thereunder issued to a group as defined in Section 627.9405(1)(a), F.S., shall use a definition of "preexisting condition" which is more restrictive than the following: "Preexisting condition…

(1) A policy covering one or more members of the insured's family shall include provisions which specify the identity and qualifications applicable to those family members who may become insured under the policy initially or by subsequent addition. (a) Eligible family members may…

(1) In addition to any other provisions not prohibited by law or rules, an insurer may avoid duplication of benefits in an expense-incurred insurance policy with respect to losses for which benefits are payable under any workers' compensation, occupational disease, employers' lia…

(1) All long-term care policies shall provide coverage for at least 24 consecutive months for each covered person for care in a nursing home. (2) All long-term care policies shall provide coverage for at least one type of lower level of care in addition to coverage for care in a …

(1) Group long-term care insurance issued in this state shall provide covered individuals with a basis for continuation or conversion of coverage. (2) For the purposes of this rule, "a basis for continuation of coverage" means a policy provision which maintains coverage under the…

The term "waiting period" or "probationary period" as used in a long-term care policy shall be that period of time which follows the date a person is initially insured under the policy before the coverage or coverages of the policy shall become effective as to such person. The wa…

(1) Exclusions, limitations, reductions, generally - (a) Any exclusions, limitations, or reductions on the risk undertaken whether applicable to amounts, duration of benefits, age, or other matters, must be specified with clarity and certainty in appropriately entitled provision …

As used in any long-term care policies, the term "elimination period" means the number of days at the beginning of a period of confinement for which no benefits are payable. No policy shall contain an elimination period in excess of the maximum time period specified in Section 62…

If a policy contains provisions relating to an "elimination period" or a "prior institutionalization" requirement, or a similar provision that establishes a condition that must be met before benefits are payable, such provision may not be applied more than once unless the utiliza…

Termination of a group long-term care policy contract shall be without prejudice to any benefits payable for services which began while the contract was in force and continue without interruption after termination. Such extension of benefits beyond the period the contract was in …

(1) An application form for coverage subject to these rules shall contain a question to elicit information as to whether the insurance to be issued is to replace any insurance presently in force. If replacement of existing coverage is indicated, the application shall state the co…

(1) No contract issued as a long-term care insurance policy shall condition any benefits upon prior institutionalization for a total period of time longer than three days. (2) If a contract provides benefits only following institutionalization of three days, or less, then benefit…

Rulemaking Authority 624.308(1), 627.9407(1) FS. Law Implemented 624.307(1), 627.9407(1), (7) FS. History-New 5-17-89, Formerly 4-81.018, 4-157.018, Repealed 1-28-13.

All long-term care contracts shall contain the following statements prominently displayed on the face page of the contract: (1) The policy has been approved as a "Long-Term Care Insurance Policy" meeting the requirements of Florida law. (2) Notice to Buyer: This policy may not co…

An outline of coverage shall be delivered to an applicant for an individual long-term care insurance policy at the time of application for an individual policy. In the case of direct response solicitations, the insurer shall deliver the outline of coverage upon the applicant's re…

A certificate issued pursuant to a group long-term care insurance policy, which policy is delivered or issued for delivery in this state, shall include: (1) A description of the principal benefits and coverage provided in the policy; (2) A statement of the principal exclusions, r…

Benefits under long-term care insurance policies shall be deemed reasonable in relation to premiums charged provided the expected loss ratio is at least sixty percent for individual policies and for group policies, calculated in a manner which provides for adequate reserving of t…

(1) Every insurer shall maintain records for each agent of that agent's amount of replacement sales as a percentage of the agent's total annual sales in this state and the amount of lapses of long-term care insurance policies sold by the agent as a percentage of the agent's total…

The purpose of the provisions of this rule chapter is to implement Part XVIII of Chapter 627, F.S., to promote the public interest, to promote the availability of long-term care insurance coverage, to protect applicants for long-term care insurance, as defined, from unfair or dec…

(1) Except as otherwise specifically provided, the provisions of this rule chapter shall apply to long-term care insurance policies delivered or issued for delivery in this state, and to policies delivered or issued for delivery outside this state to the extent provided in Sectio…

As used in these rules and as used in long-term care policies, the following terms shall have meanings no more restrictive than the following: (1) "Adult day care center" means a program for 6 or more individuals of social and health-related services provided during the day in a …

(1) Renewability. The terms "guaranteed renewable" and "noncancellable" shall not be used in any individual long-term care insurance policy without further explanatory language in accordance with the disclosure requirements of Rule 69O-157.106, F.A.C. (a) A policy issued to an in…

Rulemaking Authority 624.308(1), 627.9407(1), (6), 627.9408 FS. Law Implemented 624.307(1), 627.6043, 627.6645, 627.9407 FS. History-New 1-13-03, Formerly 4-157.105, Repealed 1-28-13.

(1) Renewability. Individual long-term care insurance policies shall contain a renewability provision. (a) The provision: 1. Shall be appropriately captioned; 2. Shall appear on the first page of the policy; 3. Shall clearly state that the coverage is guaranteed renewable or nonc…

(1) Other than policies for which no applicable premium rate or rate schedule increases can be made, insurers shall provide all of the information listed in this rule to the applicant at the time of application or enrollment, unless the method of application does not allow for de…

(1) An insurer shall provide the information listed in this subsection for approval pursuant to Section 627.410, F.S., prior to making a long-term care insurance form available for sale. (a) A filing made pursuant to rule Chapter 69O-149, F.A.C., with the actuarial material ident…

(1) All applications for long-term care insurance policies or certificates except those that are guaranteed issue shall contain clear and unambiguous questions designed to ascertain the health condition of the applicant. (2)(a) If an application for long-term care insurance conta…

(1) Application forms shall include the following questions designed to elicit information as to whether, as of the date of the application, the applicant has another long-term care insurance policy or certificate in force or whether a long-term care policy or certificate is inte…

(1)(a) An insurer may offer policyholders or certificateholders the option to exchange an existing Long-Term Care contract for a new Long-Term Care contract. (b) An exchange occurs when an insurer offers an existing long-term care policyholder or certificateholder the option to r…

(1) Every insurer shall maintain records for each agent of that agent's amount of replacement sales as a percentage of the agent's total annual sales in this state and the amount of lapses of long-term care insurance policies sold by the agent as a percentage of the agent's total…

(1)(a) When long-term care benefits are provided through the acceleration of benefits under group or individual life policies or riders to such policies which meet the conditions of subsection 69O-157.113(9), F.A.C., policy reserves for the benefits shall be determined in accorda…

(1) An insurer shall file with the Office for approval any premium rate schedule increase, including an exceptional increase, pursuant to Section 627.410, F.S. The filing shall include: (a) A filing made pursuant to rule Chapter 69O-149, F.A.C., with the actuarial information ide…

(1) No group long-term care insurance coverage may be offered to a resident of this state under a group policy issued in another state to a group described in Section 627.9405(1)(c) or (d), F.S., unless this state or such other state having statutory and regulatory long-term care…

Every insurer, health care service plan or other entity providing long-term care insurance or benefits in this state shall provide a copy of any long-term care insurance advertisement and marketing material intended for use in this state whether through written, radio, television…

Insurers providing Long-Term Care insurance shall maintain records, subject to Office review upon request, that before any producer sells, solicits or negotiates a long-term care insurance policy, that they receive necessary and sufficient training to understand partnership polic…

(1) This rule shall not apply to life insurance policies that accelerate benefits for long-term care. (2) Every insurer, health care service plan, or other entity marketing long-term care insurance (the "insurer") shall: (a) Develop and use suitability standards to determine whet…

If a long-term care insurance policy or certificate replaces another long-term care policy or certificate, the replacing insurer shall waive any time periods applicable to time limit on certain defenses, preexisting conditions and probationary periods in the new long-term care po…