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Florida Administrative Code (Last Updated: April 18, 2024) |
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69. Department of Financial Services |
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69O. OIR – Insurance Regulation |
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69O-194. Prepaid Health Clinics |
1(1)(a) “Prepaid health clinic” or “PHC contract” means the certificate or contract provided to the subscriber which describes the health care services provided and the amount to be charged. Every subscriber shall be given a PHC contract unless subsection (2) of this rule applies.
45(b) Both individual and family prepaid health clinic contracts must contain the entire agreement between the PHC and the subscriber, including: date of contract; rate to be charged; mode of payment, which shall be monthly; grace period for late payment; copayment features, if any; renewal conditions; services to be furnished; names and addresses of the clinics or other facilities at which services are available; provisions pertaining to pre-existing conditions; limitations; exclusions and exceptions, such as waiting periods, specific conditions not covered and limitations on length of stay, enrollment and disenrollment procedures, and all other qualifying or limiting features; provisions pertaining to amount and kind of reimbursement made if the illness or accident happens outside of the PHC’s geographic area and an explanation of this coverage; provisions for adding new family members; and any other information necessary for a complete understanding of what is covered and what is excluded by the contract.
196(2) Group master prepaid health clinic contracts must also contain complete information as described above, but a certificate may be issued to the subscriber showing the salient features of the plan along with a descriptive pamphlet or brochure to explain the coverage fully.
239(3) Provisions relating to grievances must be included in all prepaid health clinic contracts and certificates.
255(4) All prepaid health clinic contracts must be clear and legible. All limitations, exclusions and exceptions must be grouped together with captions in bold-faced type and shall be printed with at least the same prominence as provisions which describe the benefits.
296Rulemaking Authority 298641.403 FS. 300Law Implemented 302641.42, 303641.405, 304641.406, 305641.408, 306641.421 FS. 308History–New 5-9-85, Formerly 4-69.05, 4-69.005, 4-194.005, Amended 9-28-22.
