69O-203.028. 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) Definition;

(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 subrogation;

(12) Any applicable arbitration provisions which shall state that any arbitration is voluntary and shall be conducted pursuant to Chapter 682, F.S.;

(13) Conversion and extension of benefits privileges;

(14) Subscriber grievance procedures, formal and informal; and

(15) Any applicable co-payments.

Specific Authority 636.067 FS. Law Implemented 636.016, 636.027, 636.028 FS. History–New 11-15-94, Formerly 4-203.028.