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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-203. Prepaid Limited Health Service Organizations And Discount Medical Plan Organizations |
1Upon 45 days notice, a PLHSO may cancel or terminate the coverage of a subscriber for the following reasons:
20(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 the subscriber’s continuing participation in the PLHSO seriously impairs the PLHSO’s ability to provide services to either the subscriber or other subscribers. The PLHSO may also cancel or terminate the coverage of a subscriber for the other reasons enumerated in Section 86636.028, F.S. 88Prior to disenrolling a member, the following are required:
97(a) An effort to resolve the problem. The PLHSO shall make a reasonable effort to resolve the problem presented by the subscriber, including the use or attempted use of subscriber grievance procedures.
129(b) Consideration of extenuating circumstances. The PLHSO should ascertain that the subscriber’s behavior is not related to the use of medical services or mental illness to the extent possible.
158(c) Documentation. The PLHSO shall document the problems, efforts, and medical conditions as described in this rule chapter;
176(2) The PLHSO may provide that termination of eligibility will result if:
188(a) The subscriber leaves the geographical service area of the PLHSO with the intent to relocate or establish a new residence on a permanent basis outside of the PLHSO’s geographic service area;
220(b) A dependent of the subscriber reaches the limiting age under the PLHSO contract, provided that the termination shall only apply to coverage of the dependent.
246Specific Authority 248636.067 FS. 250Law Implemented 252636.028 FS. 254History–New 11-15-94, Formerly 4-203.035.
