12.3.5 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).
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Section 12.3 ReviewAn HMO can offer only HMO contracts approved by the Office of Insurance Regulation and cannot engage in any other type of activity, including insurance. |
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3 |
HMOs must hold an open enrollment period of not less than ______ every 18-month period. |
4 |
HMOs operate almost exclusively through group enrollment plans. |
5 |
HMOs are required to file a report of its activities within three months of the end of each fiscal year. A complete examination of an HMO's affairs is conducted at least once every: |
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HMOs and agents are prohibited from using the HMO Consumer Assistance Plan (CAP) in any of its sales advertisements or marketing procedures. |
7 |
Penalties in Florida for violating the Unfair Trade Practices Act are probation, suspension, or revocation of licensure or HMO Certificate of Authority and a fine up to: |
8 |
Under an HMO group policy, new dependents are eligible to enroll within _____ of marriage, birth, or adoption. |
