Fla. Admin. Code R. 60P-1.003

Current through Reg. 50, No. 235-239, December 10, 2024

Section 60P-1.003 - Definitions

For the purpose of administering the State Group Insurance Program, the following words and terms shall have the meaning indicated:

(1) "Administrator" means the Department of Management Services, hereinafter referred to as "Administrator" or "Department."

(2) "Appeal" means the filing of a petition pursuant to Rule 60P-1.004, F.A.C, and the proceeding that results from such filing.

(3) "Cancellation" means the loss of coverage, with a right of reinstatement, caused by a failure to pay the required premiums for two consecutive months.

(4) "Continuation coverage" means coverage that is identical to the coverage provided under the Health Program to active employees which must be offered to qualifying employees and dependents in accordance with the Consolidated Omnibus Budget Reconciliation Act (COBRA).

(5) "Conversion plan" means a standard policy as is issued by the servicing agent to direct payment subscribers at applicable rates then in effect. An insured shall have the right to apply directly to the servicing agent in writing within thirty-one (31) days of the termination date of coverage under the Program.

(6) "Coverage" means the provision of plan benefits to a subscriber and eligible dependents.

(7) "Eligible children" shall mean the subscriber's own children, legally adopted children or children placed in the subscriber's home for the purpose of adoption in accordance with Chapter 63, F.S., stepchildren for whom the employee or retiree is financially responsible, or any other children for whom the subscriber has established legal guardianship in accordance with Chapter 744, F.S., foster children, or any other unmarried children for whom the subscriber has been granted court-ordered temporary or other custody. Such children are eligible for coverage as follows:

(a) From their date of birth to the end of the month in which their nineteenth (19th) birthday occurs;

(b) From their nineteenth (19th) birthday to the end of the calendar year in which their twenty-fifth (25th) birthday occurs, if they are dependent upon the subscriber for support and are either living with the subscriber or enrolled in any school, college or university which provides training or educational activities, and which is certified or licensed by a state or foreign country.

(c) Such children who are mentally or physically disabled shall be eligible to continue coverage after attainment of the above age limits and while the subscriber's family coverage is in effect provided such children are incapable of self-sustaining employment by reason of such mental or physical disability and chiefly dependent upon the subscriber for support and maintenance.

(d) Such children who are over the above age limits at the time of the subscriber's enrollment in the Program, and who are mentally or physically disabled, shall be eligible for coverage if they are incapable of self-sustaining employment by reason of such mental or physical disability and chiefly dependent upon the employee or retiree for support and maintenance.

(8) "Eligible dependents" shall mean the following:

(a) The wife or husband of the employee or retiree and any eligible children.

(b) The eligible children of a surviving spouse.

(c) The newborn child of an eligible child from the date of birth until the end of the month the child attains eighteen (18) months of age.

(d) Children of law enforcement, probation, or correctional officers who were killed in the line of duty and who are attending a college or university beyond their eighteenth (18th) birthday.

(9) "Employee contribution" means that portion of the total premium required by the subscriber to keep the insurance in force.

(10) "Family coverage" means the provision of Plan benefits under a single plan for a subscriber and one or more of his or her eligible dependents.

(11) "Financially responsible" shall mean the degree of financial support sufficient to claim the eligible dependent as an exemption on the subscriber's Federal income tax return.

(12) "Health maintenance organization (HMO) Region" is a county or designated geographical area composed of a county or contiguous counties within which an HMO is authorized by contract with the Department to provide covered services to Subscribers. The Department has established the designated geographical areas for use in procurements of HMO services as set forth below:

(a) Region 1 consists of Bay, Calhoun, Escambia, Gulf, Holmes, Jackson, Okaloosa, Santa Rosa, Walton, and Washington Counties.

(b) Region 2 consists of Franklin, Gadsden, Jefferson, Leon, Liberty, Madison, Taylor, and Wakulla Counties.

(c) Region 3 consists of Alachua, Bradford, Columbia, Dixie, Gilchrist, Hamilton, Lafayette, Levy, Marion, Suwannee, and Union Counties.

(d) Region 4 consists of Baker, Clay, Duval, Flagler, Nassau, Putnam, St. Johns, and Volusia Counties.

(e) Region 5 consists of Brevard, Indian River, Lake, Orange, Osceola, and Seminole Counties.

(f) Region 6 consists of Citrus, DeSoto, Hardee, Hernando, Highlands, Hillsborough, Manatee, Pasco, Pinellas, Polk, Sarasota, and Sumter Counties.

(g) Region 7 consists of Martin, Okeechobee, Palm Beach, and St. Lucie Counties.

(h) Region 8 consists of Charlotte, Collier, Glades, Hendry, and Lee Counties.

(i) Region 9 consists of Broward, Miami-Dade, and Monroe Counties.

(13) "Health Program" means the insurance plans offered to eligible subscribers.

(14) "Individual coverage" means the provision of plan benefits for the subscriber only.

(15) "Initial eligibility period" means the sixty (60) day period beginning on the date a person first becomes employed by the state.

(16) "Open enrollment period" means a period designated by the Department during which time eligible persons may enroll or make changes in the Health Program.

(17) "Qualifying status change (QSC) event" or "QSC event" means the change in employment status, for subscriber or spouse, family status or significant change in health coverage of the employee or spouse attributable to the spouse's employment.

(18) "Servicing agent" means an insurance carrier or professional administrator selected by competitive bid, or request for proposal process and contracted by the Department to process and pay health insurance claims for subscribers and eligible dependents insured under the Health Program and to provide other specific services required by the Department.

(19) "State contribution" means that portion of the total premium appropriated by law.

(20) "Subscriber" means the employee, retiree, surviving spouse, terminated employee or individual with continuation coverage participating in the State Group Insurance Program.

(21) "Suspension" means the temporary loss of coverage caused by a failure to pay the required premiums for one month.

(22) "Termination" means the loss of coverage, without a right for reinstatement, caused by a failure to pay the required premiums for three or more consecutive months.

(23) "Total disability" means disability of an employee resulting from disease or injury which completely and continuously prevents the employee from engaging in any and every occupation or business and from performing any and all work for compensation or profit.

(24) "Total premium or full premium" means the total amount equal to the State contribution plus an amount equal to the employee contribution as determined by the Legislature in the General Appropriations Act.

Fla. Admin. Code Ann. R. 60P-1.003

Rulemaking Authority 110.123(3)(h)2.d., 110.123(5) FS. Law Implemented 110.123 FS.

New 11-2-76, Amended 2-3-77, 6-30-77, 7-1-80, Formerly 22K-1.03, Amended 7-16-86, 9-25-86, 4-11-88, Formerly 22K-1.103, Amended 8-22-96, Repromulgated as Amended 1-31-02, Amended by Florida Register Volume 45, Number 221, November 13, 2019 effective 11/13/2019, Amended by Florida Register Volume 47, Number 240, December 14, 2021 effective 12/14/2021.