69O-191.039. Certificate and Member Handbook Standards

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 receiving services and any other limitations;

(3) Health care services to be provided;

(4) Renewal, re-enrollment, termination, cancellation, and disenrollment conditions;

(5) Provisions for adding new family members;

(6) Benefits for newborn and adopted children;

(7) Grace period;

(8) Limitations, exceptions, or exclusions, such as waiting periods, specific conditions not covered and limitations on length of stay and all other qualifying or limiting features;

(9) Provisions relating to pre-existing conditions, if applicable;

NOTE: Pre-existing conditions cannot be excluded for longer than two years;

(10) Provisions relating to coordination of benefits;

(11) Provisions relating to the right of subrogation shall be allowed, providing it is not in conflict with any applicable Florida Statute or the decisions of courts of competent jurisdiction which eliminate or restrict such rights;

(12) Provisions relating to the right of reimbursement pursuant to Section 641.31(8), F.S., shall be allowed, providing it is not in conflict with any applicable Florida Statute or the decisions of courts of competent jurisdiction which eliminate or restrict such rights;

(13) Arbitration provisions, if any, shall include a statement that arbitration shall not preclude review pursuant to Rule 69O-191.081, F.A.C., and shall be conducted pursuant to Chapter 682, F.S.;

(14) Conversion and extension of benefit privileges;

(15) Subscriber grievance procedures, formal and informal;

(16) Any applicable co-payments;

(17) The names, addresses, and telephone numbers of any primary care physicians licensed under Chapter 458 or 459, F.S., Chapters 460 and 461, F.S., clinics, hospitals, and other providers to be used by the subscribers. This specific list may be added as a supplement to the certificate or member handbook; and

(18) The term of coverage shall be no less than for a period of twelve months for non-group and group plans unless otherwise requested by the subscriber in writing. HMOs shall not offer or initiate this request during initial solicitation or prior to renewal.

Specific Authority 641.36 FS. Law Implemented 641.21(1)(e), 641.22(9), 641.31(3)(b)5., (4), (5), 641.3111 FS. History–New 2-22-88, Amended 10-25-89, Formerly 4-31.039, Amended 5-28-92, Formerly 4-191.039.