627.6498 Minimum benefits coverage; exclusions; premiums; deductibles.
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627.6498 Minimum benefits coverage; exclusions; premiums; deductibles.
(1) COVERAGE OFFERED.
(a) The plan shall offer in a semiannually renewable policy the coverage specified in this section for each eligible person. For applications accepted on or after June 7, 1991, but before July 1, 1991, coverage shall be effective on July 1, 1991, and shall be renewable on January 1, 1992, and every 6 months thereafter. Policies in existence on June 7, 1991, shall, upon renewal, be for a term of less than 6 months that terminates and becomes subject to subsequent renewal on the next succeeding January 1 or July 1, whichever is sooner.
(b) If an eligible person is also eligible for Medicare coverage, the plan shall not pay or reimburse any person for expenses paid by Medicare.
(c) Any person whose health insurance coverage is involuntarily terminated for any reason other than nonpayment of premium may apply for coverage under the plan. If such coverage is applied for within 60 days after the involuntary termination and if premiums are paid for the entire period of coverage, the effective date of the coverage shall be the date of termination of the previous coverage.
(d) The plan shall provide that, upon the death or divorce of the individual in whose name the contract was issued, every other person then covered in the contract may elect within 60 days to continue under the same or a different contract.
(e) No coverage provided to a person who is eligible for Medicare benefits shall be issued as a Medicare supplement policy as defined in s. 627.672.
(2) BENEFITS.
(a) The plan shall offer major medical expense coverage similar to that provided by the state group health insurance program as defined in s. 110.123 except as specified in subsection (3) to every eligible person who is not eligible for Medicare. Major medical expense coverage offered under the plan shall pay an eligible person’s covered expenses, subject to limits on the deductible and coinsurance payments authorized under subsection (4), up to a lifetime limit of $500,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.
(b) The plan shall provide that any policy issued to a person eligible for Medicare shall be separately rated to reflect differences in experience reasonably expected to occur as a result of Medicare payments.
(3) COVERED EXPENSES. The coverage to be issued by the association shall be patterned after the state group health insurance program as defined in s. 110.123, including its benefits, exclusions, and other limitations, except as otherwise provided in this act. The plan may cover the cost of experimental drugs which have been approved for use by the Food and Drug Administration on an experimental basis if the cost is less than the usual and customary treatment. Such coverage shall only apply to those insureds who are in the case management system upon the approval of the insured, the case manager, and the board.
(4) PREMIUMS, DEDUCTIBLES, AND COINSURANCE.
(a) The plan shall provide for annual deductibles for major medical expense coverage in the amount of $1,000 or any higher amounts proposed by the board and approved by the office, plus the benefits payable under any other type of insurance coverage or workers’ compensation. The schedule of premiums and deductibles shall be established by the association. With regard to any preferred provider arrangement utilized by the association, the deductibles provided in this paragraph shall be the minimum deductibles applicable to the preferred providers and higher deductibles, as approved by the office, may be applied to providers who are not preferred providers.
1. Separate schedules of premium rates based on age may apply for individual risks.
2. Rates are subject to approval by the office.
3. Standard risk rates for coverages issued by the association shall be established by the office, pursuant to s. 627.6675(3).
4. The board shall establish separate premium schedules for low-risk individuals, medium-risk individuals, and high-risk individuals and shall revise premium schedules annually beginning January 1999. No rate shall exceed 200 percent of the standard risk rate for low-risk individuals, 225 percent of the standard risk rate for medium-risk individuals, or 250 percent of the standard risk rate for high-risk individuals. For the purpose of determining what constitutes a low-risk individual, medium-risk individual, or high-risk individual, the board shall consider the anticipated claims payment for individuals based upon an individual’s health condition.
(b) If the covered costs incurred by the eligible person exceed the deductible for major medical expense coverage selected by the person in a policy year, the plan shall pay in the following manner:
1. For individuals placed under case management, the plan shall pay 90 percent of the additional covered costs incurred by the person during the policy year for the first $10,000, after which the plan shall pay 100 percent of the covered costs incurred by the person during the policy year.
2. For individuals utilizing the preferred provider network, the plan shall pay 80 percent of the additional covered costs incurred by the person during the policy year for the first $10,000, after which the plan shall pay 90 percent of covered costs incurred by the person during the policy year.
3. If the person does not utilize either the case management system or the preferred provider network, the plan shall pay 60 percent of the additional covered costs incurred by the person for the first $10,000, after which the plan shall pay 70 percent of the additional covered costs incurred by the person during the policy year.
(5) PREEXISTING CONDITIONS. An association policy may contain provisions under which coverage is excluded during a period of 12 months following the effective date of coverage with respect to a given covered individual for any preexisting condition, as long as:
(a) The condition manifested itself within a period of 6 months before the effective date of coverage; or
(b) Medical advice or treatment was recommended or received within a period of 6 months before the effective date of coverage.
(6) OTHER SOURCES PRIMARY.
(a) No amounts paid or payable by Medicare or any other governmental program or any other insurance, or self-insurance maintained in lieu of otherwise statutorily required insurance, may be made or recognized as claims under such policy or be recognized as or towards satisfaction of applicable deductibles or out-of-pocket maximums or to reduce the limits of benefits available.
(b) The association has a cause of action against a participant for any benefits paid to the participant which should not have been claimed or recognized as claims because of the provisions of this subsection or because otherwise not covered.
History. ss. 496(2nd), 809(2nd), ch. 82-243; ss. 61, 79, ch. 82-386; s. 8, ch. 83-28; s. 109, ch. 83-216; s. 2, ch. 87-345; s. 20, ch. 89-167; ss. 10, 13, 14, ch. 90-334; s. 8, ch. 91-304; s. 4, ch. 91-429; s. 6, ch. 98-159; s. 1162, ch. 2003-261; s. 22, ch. 2004-297.
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Note. A. Section 12, ch. 90-334, provides that “[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated.”
B. As amended by s. 8, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:
“(2) In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.
“(3) The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict.”
C. Section 22, ch. 2004-297, provides that “[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed.”