69O-203.202: Standards for Discount Medical Plans
69O-203.204: Filing, Approval of DMPO Plans, Rates and Related Forms
69O-203.205: Bundled Products.
PURPOSE AND EFFECT: To establish methods by which Discount Medical Plan Organizations may comply with s. 636.216(1), F.S.
SUMMARY: The DMPO must establish reasonableness of the excess charges.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: No Statement of Estimated Regulatory Cost was prepared.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 636.232, FS.
LAW IMPLEMENTED: 636.216, FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE HELD AT THE DATE,TIME AND PLACE SHOWN BELOW(IF NOT REQUESTED, THIS HEARING WILL NOT BE HELD):
DATE AND TIME: May 30, 2007 at 9:30 AM
PLACE: 116 Larson Building, 200 East Gaines Street, Tallahassee, Florida.
Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 5 days before the workshop/meeting by contacting: Tracie Lambright, Life & Health Product Review, Office of Insurance Regulation, E-mail: Tracie.Lambright@fldfs.com. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Tracie Lambright, Life & Health Product Review, Office of Insurance Regulation, E-mail: Tracie.Lambright@fldfs.com.
THE FULL TEXT OF THE PROPOSED RULE IS:
69O-203.202 Standards for Discount Medical Plans.
(1) through (2) No change.
(3)(a) All charges to members must be filed with the Office, and the Office must approve any periodic charge exceeding $30.00 per month, or $50.00 per month as provided by rule 69O-203.204(1)(b), F.A.C., for the contract issued and not per member covered on the contract, before the periodic charges can be used. Periodic charges approved pursuant to this paragraph must remain in compliance with this paragraph. Consequently, subsequent to the initial approval, the periodic charges remain subject to review by the Office to ensure continued compliance.
(b) In a filing made pursuant to paragraph (a) above, the discount medical plan organization has the burden of proof that the periodic charges bear a reasonable relationship to the benefits received by the member. If the plan uses member savings as the basis of demonstrating the benefits received by the member, the benefits shall be benefits and savings that can be reasonably anticipated by an average Floridian who may purchase such contract.
(c) A discount medical plan may, at its option, make a filing that meets one of the following standards that have been determined to meet the requirement of paragraph (b) above:
1. The discount medical plan provides financial information to demonstrate that at least sixty percent (60%) of the periodic charge is used to pay the costs associated with providing access to discount medical services, excluding any administrative costs, commissions and profits; or
2. The discount medical plan provides financial information to demonstrate that the plan’s periodic charge does not exceed sixty percent (60%) of the actual benefit of the discounted services to members, measured as the actual savings realized by members, i.e., provider billed charges without the discount less the discounted provider charges paid by the member. These values shall be measured in the aggregate for all members and all actual services utilized over a period of twelve months with experience from at least 2,000 members; or
3. The discount medical plan provides specific financial information to demonstrate that at least seventy-five percent (75%) of the periodic charge is used to pay the costs associated with providing access to discount medical services, member support services and administrative costs excluding commissions and profits.
Specific Authority 636.232 FS. Law Implemented 636.216 FS. History–New 4-7-05, Amended_________________.
69O-203.204 Filing, Approval of DMPO Plans, Rates and Related Forms.
(1) The DMPO shall file all charges with the Office and shall file for approval by the Office each of the following before use:
(a) No change.
(b) 1. Any periodic charge for any Plan that is in excess of $50.00 $30.00 per month, if the plan includes at least the following services: physician services licensed under chapter 458 or 459, dental services, vision services, chiropractic services, and podiatric services, but does not include hospital services.
2. Any periodic charge for any other Plan, whether the Plan includes one or more services, that is in excess of $30.00 per month.
(2) Free Plans. The Plan contracts and charges of a Plan that is purchased from a DMPO and subsequently provided at no charge to individuals by an insurer, bank, credit union, or employer are exempt from Rule 69O-203.202 (1) (e) & (f).
(3) (2) All filings shall be submitted to the Office electronically to https://iportal.fldfs.com.
(4) (3) A filing shall consist of the following items:
(a) through (e) No change.
Specific Authority 636.232 FS. Law Implemented 624.424(1)(c), 636.208, 636.216 FS. History–New 4-7-05, Amended 5-4-06, Amended_________________.
69O-203.205 Bundled Products.
(1) The provisions of Section 636.230, F.S., recognize that the discount medical plan may be combined together with other products. When a bundled product is sold, the DMPO must provide the charges attributable to the discount medical plan component in writing to the member if the total monthly charges for the bundled product exceed the limits of $30.00 or $50.00 as provided in Rule 69O-203.204(1)(b), F.A.C. Any filing of a bundled product made pursuant to Rule 69O-203.204, F.A.C., shall clearly identify the discount medical plan component separately from each other component.
(2) No change.
(3) When the bundled product contains insurance or other products subject to regulation and approval by the Office, a DMPO may submit for approval a unified application and contract. The provisions of the unified contract, and the charges, relating to each component of the bundled product will be reviewed against and must comply with the laws and regulations applicable to each component.
Specific Authority 636.232 FS. Law Implemented 636.230 FS. History–New 5-4-06, Amended_________________.