Florida HMO Contract Requirements
By law an HMO contract must contain all of the following provisions and disclosures.
- The rates charged shall not be excessive, inadequate or unfairly discriminatory, as determined by the Office of Insurance Regulation.
- Contracts may not exclude coverage for HIV infection or limit HIV or AIDS coverage that is different from those applying to any other sickness or medical condition.
- Contracts must not exclude or limit benefits because the subscriber has been diagnosed as having a fibrocystic condition, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer.
- It must clearly state all services covered by the contract and any limitations placed on these services.
- The rate of payment must be clearly stated.
- A statement outlining procedures to be followed for emergency treatment outside the HMO's geographic area must be included.
- Special provisions pertaining to disenrollment and re-enrollment in Medicare, if applicable, must be noted.
- A grace period of not less than ten days must be expressly included.
- Any restrictions regarding preexisting conditions must be noted.
- A statement delineating immediate coverage for newborn children must be included.
- Each contract providing family coverage must cover adopted children.
- Preexisting conditions in children may not be excluded.
- If maternity services are included, they must allow the options of nurse-midwives, midwives, or birth centers, if located within the service area.
- Ocular services, if provided, may be furnished by an ophthalmologist, or optometrist, if within the scope of his or her license.
- Anesthesia may be performed by a medical doctor or by a nurse-anesthetist.
- A statement of time limit on certain defense clause must be included. It must provide that after a period of two years, only fraudulent statements may be used to void a contract or deny payment for a claim.
HMOs and PPOs are required under Florida law to provide members/subscribers direct access* to dermatologists, chiropractors, optometrists, OB gynecologists, and podiatrists.
*Direct access means that the member does NOT have to get a referral from the PCP.
If a member is covered under a plan that provides for optional family coverage, any newborn of the member must be covered at birth until 18 months of age.
HMOs are required by law to hold an open enrollment period of not less than 30 days every 18-month period. New dependents are eligible to enroll within 30 days of marriage, birth, or adoption (applies to group, small group, and HMO group policies only).
