Florida Administrative Code

(1) When used in this rule, the following words or terms shall have the meaning as described herein: (a) Loss fund - the retention under the terms of an aggregate excess contract, or if no aggregate excess is purchased, the amount remaining from normal premium in each fund year a…

(1) Reports as to payroll records, coverage, accident experience and compensation payment and such periodic reports as are required to be filed with the Office shall be made as follows: (a) Summary loss data shall be filed with the Office on each fund member within 60 days after …

(1) All bonds or securities issued by the State of Florida or the United States Government which are posted as security deposits shall be reviewed annually by the Office to determine market value. In the event market value is less than the deposit requirement, the Office may requ…

(1) The board of trustees shall have complete authority over and shall retain ultimate control of the assets of the fund and shall be responsible for all operations of the fund. (2) The trustees shall have the authority to approve applications for membership in the fund. The trus…

(1) Any surplus monies for a fund year in excess of the amount necessary to fulfill all obligations under the Law for that fund year may be declared refundable to members by the trustees at any time. The amount of such declaration shall be a liability of the fund at the time of t…

(1) The trustees shall not allow a premium discount to any member for the period beginning on September 1, 1990 and ending on December 31, 1991. Beginning on January 1, 1992, if a self-insurer's fund allows premium discounts to its members, the trustees shall allow a premium disc…

(1) All members of a self-insurers fund shall have common interest. Different businesses which are owned or controlled by the same interests shall be eligible for membership in a self-insurers fund provided one of them is eligible. (2) Unless the context clearly indicates to the …

(1) Each self-insurers fund member shall enter into an indemnity agreement jointly and severally binding the self-insurers fund and each member thereof to comply with the provisions of the Florida Workers' Compensation Law and rules of the Office. Employers in the public sector w…

(1) Employers participating in a self-insurers fund under the provisions of Section 624.4621, F.S., shall be subject to the Experience Rating Plan and the payroll classification and premium determination system established by the National Council on Compensation Insurance (NCCI).…

(1) The trustees of a fund are authorized to invest the assets of the fund only in the manner prescribed by these rules. (2) Monies allocated to claims reserves net of excess recoveries for all policy years prior to the current year, the current year loss fund, all security depos…

(1) Miscellaneous income is all income received by a fund other than premium paid by members. (2) If the Office determines that a fund shall allocate miscellaneous income to fund a deficit or contingent liability, then the amount allocated shall be part of the fund's security dep…

(1) All self-insurers funds shall determine the normal premium due from each member in each policy year based on actual audited payroll. Audits shall consist of physical, onsite audits or mail self-audits. The requirements set forth in this rule shall apply to the fund and its pr…

The NAIC handbooks, instructions and manual set forth in subsections (1) through (4) of this rule are hereby adopted and incorporated by reference. The office has determined that posting the incorporated material would be a violation of federal copyright law. The handbooks, instr…

Rulemaking Authority 641.36 FS. Law Implemented 641.36 FS. History-New 2-22-88, Formerly 4-31.021, 4-191.021, Repealed 9-28-22.

(1) All terms defined in the Health Maintenance Organization Act, Part I, Chapter 641, F.S., which are used in these rules shall have the same meaning as in the Act. (2) Advertising. Advertising includes but is not limited to printed and published material, descriptive literature…

Rulemaking Authority 627.6699, 641.36 FS. Law Implemented 627.6699, 641.21, 641.22, 641.227, 641.29(1) FS. History-New 2-22-88, Amended 10-25-89, Formerly 4-31.027, Amended 5-28-92, Formerly 4-191.027, Amended 9-28-22, 1-28-24, Transferred to 69O-136.040.

Rulemaking Authority 641.36 FS. Law Implemented 641.21(1)(d) FS. History-New 5-28-92, Formerly 4-191.028, Repealed 9-28-22.

The HMO place of business shall be located in this state and shall be actively engaged in managed care within six months of licensure, except as provided in Section 641.221(2), F.S. The HMO shall maintain a place of business, the location of which is identifiable by and accessibl…

(1) Each HMO shall have a governing body that sets policy and has overall responsibility for the organization, including the following: (a) Adopting organizational bylaws, rules and regulations, or similar form of document which provides a clear concise statement of the mission, …

(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 ot…

(1) If required, co-payments will be paid when health care services and benefits are rendered. The HMO or contracted provider may assess the usual co-payment when a subscriber fails to keep a physician office visit or appointment, provided this is a standard procedure and a prior…

(1) Section 641.31(26)(a), F.S., prohibits the application of monetary limitations to limit coverage of medically appropriate and necessary equipment, supplies, and services used to treat diabetes, if the patient's primary care physician or physician specializing in diabetes to w…

When certificates or member handbooks are given to the subscriber in lieu of a subscriber contract, the certificate or member handbook shall contain a description of the following: (1) Definitions; (2) Eligibility requirements for enrollment, including waiting periods for receivi…

Upon written notice, an HMO may cancel or terminate the coverage of a subscriber for the following reasons: (1) The HMO may disenroll a subscriber if the subscriber's behavior is disruptive, unruly, abusive, unlawful, fraudulent or uncooperative to the extent that his continuing …

(1) Each HMO shall comply with the requirements of Section 641.31(9), F.S. If the HMO does not require pre-enrollment for newborns, newborn coverage will commence from the moment of birth in accordance with the subscriber contract. (2) If the HMO does have a pre-enrollment requir…

(1) A subscriber of a HMO who is authorized to receive services from a hospital under contract with the HMO may not be denied medically necessary covered health care services or be responsible for payment to any physician provider, or agent thereof, other than payment for service…

(1) Every subscriber group, individual, or conversion contract and every rider, endorsement, certificate, application or other forms (including the initial subscriber communication outlining their rights and responsibilities under the grievance process) to be used or issued in co…

(1) Before charging or quoting premiums to subscribers, an HMO shall file for approval the rating methodology by which those premiums were determined with the Office. (a) All materials submitted shall be legible. A filing which is illegible or which contains illegible material wi…

(1) Group Coverage is as provided by subsection 69O-149.0055(1), F.A.C. (2) Individual Coverage. (a)1. All HMOs that provide for a healthy lifestyle rebate shall file for approval the standards it will use for determining the level of rebate, i.e., between 0% and 10%, for differe…

(1)(a) In order for a rate filing to be reviewed properly by the Office, the actuarial memorandum required by subparagraph 69O-191.054(2)(a)2., F.A.C., shall contain the items listed in subsection (2), below, for a new product filing, a rate revision or justification of existing …

All health insurance agents and sales representatives of the HMO engaged in sales, solicitation, and communication with current or prospective subscribers are bound by the advertising rules set forth in Rule 69O-191.060, F.A.C. The HMO is initially, and continues to be, as long a…

(1) Every HMO shall comply with all Federal Statutes and Regulations governing Medicare marketing materials and obtain approval from the Health Care Financing Administration (HCFA). (2) The "notice to buyer" detailed in Section 641.309, F.S., should be printed in no less than 12-…

(1) Advertising must be truthful and not misleading in fact or implication. Words or phrases shall be clear and understandable without reliance upon technical terminology. (2) Testimonials or Endorsements by Third Parties. (a) If the person making a testimonial, an endorsement or…

Each HMO shall maintain at its corporate or principal office a complete file containing every printed, published or prepared advertisement of its health benefit coverage in this State, with a notation attached to each such advertisement indicating the manner and extent of distrib…

(1) Each HMO, in order to obtain its Certificate of Authority, shall furnish evidence of adequate insurance coverage or an adequate plan for self-insurance to respond to claims for injuries arising out of the furnishing of comprehensive health care. Once the HMO obtains its Certi…

Rulemaking Authority 641.36 FS. Law Implemented 641.285(5)(a)1. FS. History-New 2-22-88, Amended 10-25-89, Formerly 4-31.072, Amended 5-28-92, Formerly 4-191.072, Repealed by Section 21, Chapter 98-159, Laws of Florida, 1-1-99.

(1) Every Health Maintenance Organization shall maintain complete records of its assets, transactions, and affairs, including but not limited to, the following: (a) Financial records (including annual earned premiums and claims incurred, but not reported (IBNR)); (b) Corporate re…

(1) Each HMO shall file with the Office a full and true statement of its financial condition, transactions, and affairs. (a) An annual statement covering the preceding fiscal year shall be filed within 3 months after the end of the fiscal year, and quarterly statements within 45 …

(1) Each HMO will be required to make an evaluation of its statement of total revenues and expenses prior to each annual report filing to ensure that the net income before taxes is no less than 2% of total revenues. If the HMO fails to meet the 2% requirement then the HMO will be…

Every HMO shall have a subscriber grievance procedure. A detailed description of the HMO's subscriber grievance procedure shall be included in all group and individual contracts as well as in any certificate or member handbook provided to subscribers. This procedure shall be admi…

Checks for filing of each annual report, and for any other fees collected under this law, shall be made payable to the "Florida Department of Financial Services." Rulemaking Authority 641.36 FS. Law Implemented 641.29 FS. History-New 2-22-88, Formerly 4-31.085, 4-191.085, Amended…

Funds borrowed by HMOs will be considered surplus notes if guaranteed by the United States government, or its agents, or if such borrowed funds result from a written instrument which includes the following: (1) The effective date, amount, interest and parties involved are clearly…

An HMO may participate in a cash management program with affiliated companies as long as the HMO maintains title to and control over all funds. The trustee or custodian which is to invest these funds, as allowed under Sections 641.35(9) through (17), F.S., shall maintain a separa…

In order to meet the qualifications for a guaranteeing organization, an entity shall comply with the following: (1) The guarantor shall comply with Section 641.19(10), F.S., by appointing the Chief Financial Officer as its agent for service of process in Florida. The entity must …

(1) No name other than that listed on the HMO's Certificate of Authority or those approved by the Office pursuant to subsections (2) and (3) of this rule shall be used by the HMO. (2) The name of the HMO shall not be changed without prior approval of the Office. The approval proc…

Every licensed HMO shall notify the Office of Insurance Regulation, Life and Health Financial Oversight, in writing, 60 days prior to such change, of any change in its Florida principal or corporate business address. Any health service clinics or centers owned or controlled by th…

Rulemaking Authority 641.36 FS. Law Implemented 628.4615 FS. History-New 2-22-88, Amended 10-25-89, Formerly 4-31.097, Amended 5-28-92, Formerly 4-191.097, Repealed 9-28-22.

In order to establish that the exemption from the requirement for a Certificate of Authority applies, an entity shall notify the Office that it is operating as an HMO in compliance with Section 641.38, F.S. The notification shall include conclusive proof that there has been no ch…

(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 a…

Rulemaking Authority 624.308(1), 641.36 FS. Law Implemented 624.424, 627.410(6), (7), 627.413(4), 627.4145, 627.6699(12), 627.6735, 627.682, 627.9407(2), 628.4615, 641.19(13)(d), 641.21(1), 641.26(1), (2), 641.29 FS. History-New 2-22-88, Amended 10-25-89, Formerly 4-31.107, Amend…