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Florida Administrative Code (Last Updated: October 28, 2024) |
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69. Department of Financial Services |
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69O. OIR – Insurance Regulation |
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69O-191. Health Maintenance Organizations |
1(1) Paragraph 3641.31(26)(a), F.S., 5prohibits 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 whom the patient has been referred certifies that the equipment, supplies, or services are necessary.
54(2) The term “appropriate” as used in this rule excludes unproven technology, such as experimental treatment or non-FDA approved treatment.
74(3) Coverage for equipment meeting the standard in paragraph 83641.31(26)(a), F.S., 85shall not be limited by monetary limitations for 93durable medical equipment or other limitations in a health maintenance organization or prepaid health plan contract.
109(4) Paragraph 111641.31(26)(a), F.S., 113does not prohibit the application of deductibles or 121copayments to equipment, supplies, and services meeting the criteria in that paragraph.
133(5) Payments for equipment meeting the standard in paragraph 142641.31(26)(a), F.S., 144can be used by an HMO to apply toward limits for durable medical equipment which does not meet that standard.
164(6) Nothing in this rule shall prohibit a health maintenance organization or prepaid health plan from utilizing contract providers for equipment, supplies, and services certified as necessary by the patient’s primary care physician or the physician to whom the patient has been referred who specializes in treating diabetes, if such equipment, supplies and services are available from the contract provider.
224Specific Authority 226624.308, 227641.36 FS. 229Law Implemented 231624.307(1), 232641.31(26)(a) FS. 234History–New 7-31-02, Formerly 4-191.037.
