Required Benefits
The HMO contract must be delivered within 10 working days after approval. The contract must include the following:
- The rates charged can not be excessive or unfairly discriminatory.
- The contract can not exclude coverage for HIV infection or contain limitations on HIV or AIDS coverage that are different from those that apply to sickness or medical conditions. (Same as health insurance, Chapter 29.)
- It can not exclude or limit benefits because the subscriber has had a fibrocystic condition, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer. (Same as health insurance, Chapter 29.)
- Emergency medical treatment outside the HMO's geographic area must be included.*****
- A grace period of at least 10 days must be included.
- Any restrictions regarding preexisting conditions must be noted.
- Immediate coverage for newborn children.
- Family coverage must cover adopted children.
- Preexisting conditions in children can not be excluded.
- After a period of two years, only fraudulent statements may be used to void a contract or deny payment for a claim.
- An identification card given to the individual must contain the following:
- The name of the organization administering the contract
- The name of the subscriber
- The member identification number
- A contact phone number or e-mail address for authorizations
Extension of benefits
All plans in Florida must be guaranteed renewable anyway, so why would an HMO have to extend benefits? Well, what if the HMO was going out of business? If you are healthy that's no problem because you have the luxury of shopping around. But if you're already uninsurable, maybe due to a disability, the plan must be extended until the earliest of the following happens:
- 12 months;
- you're not disabled anymore;
- another carrier covers you; or
- maximum benefits under the contract have been paid.
Open enrollment****
Group HMOs must have open enrollment at least once every 18 months, and it must be at least 30 days long.
Direct access to dermatologists ****
Florida is the "Sunshine State". HMOs must give direct access (no referral required) to dermatologists for office visits, minor procedures and testing without the need for the subscriber to go through a primary care physician at least five times in a 12 month period.
Newborn child coverage*****
A newborn child of a covered family member (the newborn of a covered daughter or son) must be offered coverage for a period of 18 months, just like health insurance in Chapter 29.
HMO claim payments to providers
If a claim to a doctor was overpaid, then the HMO has 12 months to submit a claim for overpayment to the provider. Likewise, a provider has 12 months after payment of a claim by an HMO to submit a claim for underpayment. HMOs must reimburse all claims made by a contract provider within 20 days after receipt of the claim.
If the HMO requests additional information, the provider must provide it within 35 days of the request. Upon receipt of the additional information requested from the contract provider, the HMO must pay or deny the contested claim or portion of the contested claim within 90 days after receipt of the claim. In any event, an insurer must pay or deny any claim no later than 120 days after receiving the claim.
