Fla. Admin. Code Ann. R. 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.
Notes
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 6-2-22, Ratified by Laws of Florida Ch. 2022-160.
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