Florida Administrative Code

Rulemaking Authority 624.308 FS. Law Implemented 624.307(1), 624.321(1), 627.481 FS. History-New 1-7-97, Formerly 4-202.005, Repealed 7-21-22.

Rulemaking Authority 624.308(1), 627.481(11) FS. Law Implemented 624.307(1), 627.481 FS. History-New 6-23-92, Amended 1-7-97, 12-24-03, Formerly 4-202.008, Amended 7-21-22, Transferred to 69O-136.045.

(1) Within 60 days of the end of each fiscal year, each qualifying issuer of donor annuity agreements in this state must submit Form OIR-A3-1209, "Sworn Statement in Lieu of Annual Statements for Issuers of Donor Annuity Agreements," effective 6/20, which is hereby incorporated b…

Rulemaking Authority 624.308 FS. Law Implemented 624.307(1), 624.424, 627.481 FS. History-New 7-15-90, Formerly 4-117.015, Amended 6-23-92, 1-7-97, 12-24-03, Formerly 4-202.015, Amended 7-30-17, Repealed 7-21-22.

Rulemaking Authority 636.067 FS. Law Implemented Chapter 636 FS. History-New 11-15-94, Formerly 4-203.010, Repealed 9-29-22.

(1) All terms defined in the Prepaid Limited Health Service Organization Act, Chapter 636, F.S., which are used in these rules shall have the same meaning as in the Act. (2) Advertising. This includes printed and published material, descriptive literature and sales aids, sales ta…

Rulemaking Authority 636.067 FS. Law Implemented 636.005, 636.007, 636.008, 636.009 FS. History-New 11-15-94, Formerly 4-203.020, Amended 9-29-22, 1-4-24, Transferred to 69O-136.046.

Rulemaking Authority 636.067 FS. Law Implemented 636.007, 636.008 FS. History-New 11-15-94, Formerly 4-203.021, Repealed 9-29-22.

If required by the PLHSO, co-payments will be paid when health care services and benefits are rendered. The PLHSO or contracted provider may assess a usual co-payment, as provided for in the benefits schedule, when a subscriber fails to appear for an office visit or appointment, …

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

(1) A PLHSO may inquire whether a person has been tested positive for exposure to the HIV infection or been diagnosed as having AIDS or ARC caused by the HIV infection or other sickness or medical condition derived from such infection. A PLHSO shall not inquire whether a person h…

(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 applica…

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) Definition; (2) Eligibility requirements for enrollment, including waiting periods for receivin…

Upon 45 days notice, a PLHSO may cancel or terminate the coverage of a subscriber for the following reasons: (1) The PLHSO may disenroll a subscriber for cause if the subscriber's behavior is disruptive, unruly, abusive, unlawful, fraudulent, or uncooperative to the extent that t…

(1) If the subscriber group contract is not renewed due to claim experience, the subscriber group shall be entitled to receive the loss experience of the group. If requested by a subscriber group, a detailed claim experience record may be provided at a reasonable expense. The rec…

(1) Every group or individual subscriber contract and every rider, endorsement, certificate, application, or other form to be used or issued in connection with any subscriber contract shall be filed by the PLHSO for approval by the Office before it may be delivered in this state,…

(1) Before charging premiums to subscribers, a PLHSO shall file the rating methodology by which those premiums were determined with the Office. The Office must approve the methodologies and premium rates before use. Filings of rating methodologies shall provide adequate informati…

All sales people or representatives of the PLHSO engaged in soliciting subscribers are bound by the advertising rules set forth in Rule 69O-203.050, F.A.C. The PLHSO is initially, and continues to be, as long as they hold a Certificate of Authority, responsible for the acts of it…

(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. If the person making a testimonial, an endorsement, or an…

Each PLHSO shall maintain at its home 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 distribut…

In order to assure subscriber reimbursement, when applicable, and to prevent unauthorized billing by providers to the subscribers of the PLHSO, the PLHSO shall pay promptly all valid claims from subscribers or providers. The following standards shall apply, and failure to meet th…

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

PLHSOs may obtain reinsurance (excess loss insurance) in order to limit the PLHSO's financial risk. All excess loss or reinsurance contracts shall be filed with and approved by the Office. In addition to the regular insurance filing of any reinsurance (excess loss insurance) cont…

(1) Each PLHSO shall file with the Office a full and true report of its financial condition, transactions, and affairs. (a) An Annual Report covering the preceding fiscal year shall be filed on or before April 1 or within 3 months of the end of the reporting period of the PHLSO. …

Every PLHSO shall have a subscriber grievance procedure, which is outlined in all master group and individual contracts as well as any certificate or member handbook provided to subscribers. Standards for the subscriber grievance procedure are as follows: (1) Both informal and fo…

Payment for any fees collected pursuant to these rules or Chapter 636, F.S., including fees for the filing of each annual report, shall be rendered by check made payable to the Florida Office of Insurance Regulation; or, by eCheck or credit card through the secure online portal s…

Funds borrowed by PLHSOs will be considered surplus notes if such borrowed funds result from a written instrument which includes the following: (1) The effective date, amount, interest, and parties involved are clearly set forth, (2) The principal sum and/or any interest accrued …

No company name other than that certified by the Office shall be used by the PLHSO. The name of the PLHSO shall not be changed without prior approval of the Office. The approval process is as follows: (1) The PLHSO shall file a request with the Office to change the PLHSO's name. …

Rulemaking Authority 636.067 FS. Law Implemented 636.065, 628.4615 FS. History-New 11-15-94, Formerly 4-203.093, Repealed 9-29-22.

Rulemaking Authority 636.067 FS. Law Implemented 624.321(1)(a), 624.424, 636.005, 636.008, 636.009, 636.012, 636.043 FS. History-New 11-15-94, Formerly 4-203.100, Amended 7-30-17, Repealed 9-29-22.

(1) Charges as referred to in these rules mean both the periodic charges, defined herein and any one-time processing fee as provided in Section 636.208, F.S. (2) Contract or Form means the document, by whatever name called; such as agreement, certificate or handbook which describ…

(1) Contracts for all Plans shall include all elements contained in this section: (a) Name and address of the DPO; (b) Telephone number for member assistance and Plan information; (c) Contracts shall include the name of the group, if applicable, and the name of the member; (d) Ef…

(1) Such materials must comply with the standards of Sections 636.210 and 212, F.S., and must be truthful and not misleading in fact or implication. Words or phrases shall be clear and understandable. (2) Deceptive Words, Phrases, or Illustrations Prohibited. (a) Words, phrases, …

Rulemaking Authority 636.232 FS. Law Implemented 624.424(1)(c), 636.208, 636.216 FS. History-New 4-7-05, Amended 5-4-06, 11-1-07, Repealed 4-11-19.

Rulemaking Authority 636.232 FS. Law Implemented 636.230 FS. History-New 5-4-06, Amended 11-1-07, Repealed 4-11-19.

Rulemaking Authority 624.424(1)(c), 636.232 FS. Law Implemented 624.424, 636.204, 636.220, 636.226, 636.228, 636.234, 636.236 FS. History-New 5-22-05, Amended 10-29-08, 7-30-17, 4-11-19, 9-29-22, 1-4-24, Transferred to 69O-136.047.

Annual Reports are to be filed with the Office within three months after the end of each fiscal year on Form OIR-A1-1671, "Annual Report - Discount Plan Organizations," effective 07/23, hereby incorporated by reference and available at http://www.flrules.org/Gateway/reference.asp…

Rulemaking Authority 626.9925 FS. Law Implemented 626.991 FS. History-New 3-4-09, Repealed 4-27-26.

In addition to the definitions in Section 626.9911, F.S., the following definitions apply to this regulation: (1) "Control" or "effective control" as used in the Viatical Settlement Act and this rule chapter means the possession, directly or indirectly, of the power to direct or …

Every licensed viatical settlement provider shall establish and maintain in accordance with the provisions of Section 626.9922, F.S.: (1) Documentation of compliance with its anti-fraud plan and procedures filed in accordance with Section 626.99278, F.S. (2) All documentation per…

(1) Definitions. "Person performing life expectancies" as used in Section 626.99175(4)(d), F.S., and "individuals who determine life expectancies" as used in Section 626.99175(4)(g)2., F.S., means a person or individual with the decisionmaking authority to sign or authorize the i…

(1) The following schedule of fines is hereby adopted by the Commission as a guideline in assessing fines against the referenced entities for the late filing of annual reports or statements as required by law: Entity Per Day Fine Maximum Fine (a) Continuing Care (Sections 651.015…

Financial reports, associated filings and related correspondence for the following specialty insurers shall be submitted electronically to http://www.floir.com/iportal: (1) Legal Expense Insurance Corporations; (2) Insurance Administrators; (3) Viatical Settlement Providers; (4) …

Rulemaking Authority 624.308 FS. Law Implemented 624.307(1), 626.752, 626.793, 626.837 FS. History-New 10-12-93, Formerly 4-215.050, Repealed 2-19-20.

Rulemaking Authority 624.308 FS. Law Implemented 624.307(1), 626.342, 626.752, 627.4085 FS. History-New 10-12-93, Formerly 4-215.060, Repealed 2-19-20.

Rulemaking Authority 624.308 FS. Law Implemented 624.307(1), 626.561(1), 626.611, 626.621, 626.752, 626.9541, 627.4085, 627.420 FS. History-New 10-12-93, Formerly 4-215.070, Repealed 2-19-20.

Specific Authority 624.308(1) FS. Law Implemented 624.307(1), 626.8732, 626.8734 FS. History-New 2-25-93, Amended 8-18-94, 1-7-97, 10-20-97, 1-9-03, Formerly 4-220.001, Repealed 10-1-08.