Health Insurance Benefit Coverage Law Summaries

Florida's mandated health care coverage law is codified in the Florida Statutes at Title XXXVII, Chapter 627.

DEFINITIONS

"Small employer" means, in connection with a health benefit plan with respect to a calendar year and a plan year, any person, sole proprietor, self-employed individual, independent contractor, firm, corporation, partnership or association that is actively engaged in business, has its principal place of business in Florida, employed an average of at least one but not more than 50 eligible employees on business days during the preceding calendar year, and employs at least one employee on the first day of the plan year (Sec. 627.6699, as amended by S. 228, L. 1997, effective October 1, 1998).

WHAT THE EMPLOYER MUST DO

Florida does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.

Mental health coverage. --Every insurer, health maintenance organization, and nonprofit hospital and medical service plan corporation transacting group health insurance or providing prepaid health care in Florida must make available to the policyholder as part of the application, for an appropriate additional premium under a group hospital and medical expense-incurred insurance policy, under a group prepaid health care contract, and under a group hospital and medical service plan contract, the benefits or level of benefits specified below for the necessary care and treatment of mental and nervous disorders, subject to the right of the applicant for a group policy or contract to select any alternative benefits or level of benefits as may be offered by the insurer, health maintenance organization, or service plan corporation. If alternate inpatient, outpatient, or partial hospitalization benefits are selected, such benefits must not be less than the level of benefits required below for mental and nervous disorders (Sec. 627.668).

Under group policies or contracts, inpatient hospital benefits, partial hospitalization benefits, and outpatient benefits consisting of durational limits, dollar amounts, deductibles, and coinsurance factors must not be less favorable than for physical illness generally, except that (Sec. 627.668):

(1) Inpatient benefits may be limited to not less than 30 days per benefit year as defined in the policy or contract. If inpatient hospital benefits are provided beyond 30 days per benefit year, the durational limits, dollar amounts, and coinsurance factors thereto need not be the same as applicable to physical illness generally.

(2) Outpatient benefits may be limited to $1,000 for consultations with a licensed physician, psychologist, mental health counselor, marriage and family therapist, or clinical social worker. If benefits are provided beyond the $1,000 per benefit year, the durational limits, dollar amounts, and coinsurance factors thereof need not be the same as applicable to physical illness generally.

(3) Partial hospitalization benefits must be provided under the direction of a licensed physician. In any benefit year, if partial hospitalization services or a combination of inpatient and partial hospitalization are utilized, the total benefits paid for all such services may not exceed the cost of 30 days of inpatient hospitalization for psychiatric services, including physician fees, which prevail in the community in which the partial hospitalization services are rendered. If partial hospitalization services benefits are provided beyond the limits set forth in this paragraph, the durational limits, dollar amounts, and coinsurance factors thereof need not be the same as those applicable to physical illness generally.

Dependent care coverage. --A health insurance policy, other than a disability income or hospital indemnity policy, and a health care services plan contract issued by a nonprofit corporation, that provides coverage on an expense-incurred basis for a member of the family of the insured, certificateholder or subscriber must, as to the family member's coverage, also provide that the health insurance benefits applicable for children will be payable with respect to a newborn child of the insured, certificateholder, subscriber, or covered family member from the moment of birth. However, with respect to a newborn child of a covered family member of the insured, certificateholder or subscriber, the coverage for the newborn child terminates 18 months after the birth of the newborn child (Secs. 627.641 and 627.6575).

The required coverage for newborn children consists of coverage for injury or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and transportation costs of the newborn to and from the nearest available facility appropriately staffed and equipped to treat the newborn's condition, when such transportation is certified by the attending physician as necessary to protect the health and safety of the newborn child. The coverage of such transportation costs may not exceed the usual and customary charges, up to $1,000 (Secs. 627.641 and 627.6575).

If an insurer offers coverage that insures dependent children of the policyholder or certificateholder, the policy must insure a dependent child of the policyholder or certificateholder at least until the end of the calendar year in which the child reaches the age of 25, if the child meets all of the following (Sec. 627.6562):

(1) The child is dependent upon the policyholder or certificateholder for support.

(2) The child is living in the household of the policyholder or certificateholder, or the child is a full-time or part-time student.

Adoption. --A health insurance policy that provides coverage for a member of the family of the insured, certificateholder or subscriber must, as to the family member's coverage, provide that the health insurance benefits applicable to children of the insured, certificateholder or subscriber also apply to an adopted child or a foster child from the moment of placement in the residence of the insured, certificateholder or subscriber. Except in the case of a foster child, the policy may not exclude coverage for any preexisting condition of the child. In the case of a newborn child, coverage begins at the moment of birth if a written agreement to adopt the child has been entered into by the insured, certificateholder or subscriber prior to the birth of the child, whether or not the agreement is enforceable. Coverage for an adopted child who is not ultimately placed in the residence of the insured, certificateholder or subscriber is not required (Secs. 627.6415 and 627.6578).

In order to increase access to postnatal, infant, and pediatric health care for all children placed in court-ordered custody, including foster children, all health insurance policies that provide coverage for a member of the family of the insured, certificateholder or subscriber must, as to such family member's coverage, also provide that the health insurance benefits applicable for children are payable with respect to a foster child or other child in court-ordered temporary or other custody of the insured, certificateholder or subscriber (Secs. 627.6415 and 627.6578).

Disabilities. --A hospital or medical expense insurance policy, group health insurance policy or health care services plan contract that is delivered or issued for delivery in Florida and that provides that coverage of a dependent child will terminate upon attainment of the limiting age for dependent children specified in the policy or contract must also provide in substance that attainment of the limiting age does not terminate the coverage of the child while the child continues to be both incapable of self-sustaining employment by reason of mental retardation or physical disability and chiefly dependent upon the policyholder or subscriber for support and maintenance (Secs. 627.6041 and 627.6615).

Child health supervision services. --All health insurance policies providing coverage on an expense-incurred basis (other than disability income, specified disease, Medicare supplement and hospital indemnity policies) that provide coverage for a member of a family of the insured, certificateholder or subscriber must, as to such family member's coverage, also provide that the health insurance benefits applicable for children include coverage for child health supervision services from the moment of birth to age 16 years. Deductibles do not apply (Secs. 627.6416 and 627.6579, as amended by H. 1785, L. 1997, effective July 1, 1997).

Child health supervision services must include periodic visits that include a history, a physical examination, a developmental assessment and anticipatory guidance, and appropriate immunizations and laboratory tests (Secs. 627.6416 and 627.6579, as amended by H. 1785, L. 1997, effective July 1, 1997).

Cleft lip and cleft palate. --Effective October 1, 1998, a health insurance policy or health maintenance contract that covers a child under 18 must provide coverage for treatment of cleft lip and cleft palate for the child. The coverage must include medical, dental, speech therapy, audiology and nutrition services only if such services are prescribed by the treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary and consequent to treatment of the cleft lip or cleft palate (Secs. 627.64193, 627.66911 and 641.31(34), as added by S. 228, L. 1997, effective October 1, 1998).

Hearing. --Effective July 1, 2000, all health insurance policies and HMOs, except for supplemental policies that only provide coverage for specific diseases, hospital indemnity or Medicare supplement, or to the supplemental policies, must compensate providers for newborn hearing screenings at the contracted rate (Sec. 1, H. 399, L. 2000, effective July 1, 2000).

Substance abuse coverage. --Insurers, health maintenance organizations, and nonprofit health care services plans transacting group health insurance or providing prepaid health care in Florida must make available to the policyholder as part of the application for any such policy of insurance issued or delivered in Florida or contract executed or operative in Florida the level of benefits specified below for the necessary care and treatment of substance abuse-impaired persons, subject to the right of the applicant for a group policy or contract to select any alternative benefits or level of benefits as may be offered by the insurer, health maintenance organization, or plan (Sec. 627.669).

Inpatient benefits or outpatient benefits must consist of an intensive treatment program for the treatment of substance-abuse-impaired persons. Benefits are available only to covered individuals in a group health plan, and there is a minimum lifetime benefit of $2,000. A maximum of 44 outpatient visits is allowed, with the maximum benefit payable for an outpatient visit not to exceed $35. Detoxification is not considered as a benefit under the outpatient program (Sec. 627.669).

Benefits for treatment of substance-abuse-impaired persons are applicable only if treatment is provided by, or under the supervision of, or is prescribed by, a licensed physician or licensed psychologist, and if services are provided in a program accredited by the Joint Commission on Accreditation of Hospitals or approved by the state (Sec. 627.669).

Coordination of benefits. --An employer or the insurer, managed care plan, or third-party administrator that manages a health benefit plan for an employer may share the payment of expenses with another benefit plan sponsored by another employer, with the government thro ugh Medicare benefits, or with another type of insurance company through automobile or homeowners' insurance (subrogation). To determine which plan has primary responsibility for payment, coordination of benefits (COB) language specifies the order of bene fit payments. Preserving cost management initiatives, such as deductibles and coinsurance, is known as maintenance of benefits. The National Association of Insurance Commissioners (NAIC) has established model guidelines for COB which many states apply to insurance companies, health maintenance organizations, or other health care benefit providers. Self-insured employee benefit plans are not required to adopt coordination of benefits language; however, most self-insured health plans do specify how they wil l coordinate benefit payments with other plans.

The following types of plans must specify how benefits will be coordinated: group hospital, medical, or surgical expense policy, group health care services plan, or group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses delivered. A hospital, medical, or surgical expense policy, health care services plan, or self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses may permit the ins urer to reduce or refuse to pay benefits otherwise payable thereunder solely on account of the existence of similar benefits provided under insurance policies issued by the same or another insurer, health care services plan, or self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses only if, as a condition of coordinating benefits with another insurer, the insurers together pay 100 percent of the total reasonable expenses actually incurred of the type of expense within the benefits described in the policies and presented to the insurer for payment. These standards apply to coordination of benefits payable under Medicare, Title XVIII of the Social Security Act. Coordination of benefits is not permitted against an indemnity-type policy, an excess insurance policy, a policy with coverage limited to specified illnesses or accidents, or a Medicare supplement policy (Sec. 627.4235).

Order of benefits. --The following priority applies when coordinating health benefit payments (Sec. 627.4235):

(1) Employee/Dependent: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee, subscriber, or member before a plan or policy that cov ers the individual as a dependent;

(2) Dependent Child/Birthday Rule: For a dependent child covered by two health benefit plans, health maintenance organizations, or health insurance policies whose parents are not separated or divorced, benefits will be paid first by the plan that covers the parent whose birthday month and day is earlier in the calendar year. If both parents have the same birthday, benefits will be paid first by the plan that covered a parent for a longer period of time. If only one plan specifies the birthday rule and the other plan determines benefits for dependents of a male before benefits for dependents of a female, benefits will be paid first according to the gender rule;

(3) Dependent Child/Divorced or Separated Parents: For a dependent child covered by two health benefit plans, health maintenance organizations, or health insurance policies whose parents are separated or divorced, benefits will be paid first by the plan that covers the custodial parent, second by the plan of the spouse of the custodial parent, and third by the plan of the noncustodial parent. If a court decree states that one of the parents is responsible for health care expenses of the child, benefits will be paid first by the plan of that parent;

(4) Active/Inactive Employee: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that covers the individual as an employee who is neither laid off or retired or as that person's dependent before a plan or policy that covers the individual as a laid-off or retired employee or dependent. If only one of the two plans specifies this rule, this standard is ignored;

(5) Longer/Shorter Length of Coverage: Benefits will be paid first by a health benefit plan, health maintenance organization, or health insurance policy that has covered the individual as an employee, subscriber, or member for a longe r period of time before a plan or policy that covered the individual for a shorter period of time;

(6) Continuation Coverage: For an individual covered by two health benefit plans, health maintenance organizations, or health insurance policies one of which is a COBRA continuation plan, benefits will be paid first by the plan that covers the individual as an employee, member, or subscriber or as the employee's dependent and second as a former employee or as the former employee's dependent.

Medicare coordination. --If the person is also a Medicare beneficiary, and if the rule established under the Social Security Act of 1965 makes Medicare secondary to the plan covering the person as a dependent of an active employee , the order of benefit determination is as follows: first, benefits of a plan covering a person as an employee, member, or subscriber; second, benefits of a plan of an active worker covering a person as a dependent; and third, Medicare benefits (Sec. 627.4235).

Providers. --Any policy of health insurance that provides coverage for massage must also cover the services of persons licensed to practice massage under Florida law, where the massage has been prescribed by a physician licensed under Florida law as being medically necessary and the prescription specifies the number of treatments (Secs. 627.6407 and 627.6619).

All health maintenance contracts that provide coverage for massage must also cover the services of persons licensed to practice massage under Florida law if the massage is prescribed by a contracted physician licensed under Florida law as medically necessary and the prescription specifies the number of treatments (Sec. 641.31(37), as added by Ch. 275 (S. 2554), L. 1999, effective July 1, 1999).

Nurse midwives. --Any policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives otherwise licensed pursuant to Florida law (Secs. 627.6406 and 627.6574, as amended by S. 1682, L. 1997).

Health maintenance organizations must also cover the services of nurse-midwives (Sec. 641.31(18), as amended by S. 1682, L. 1997).

Acupuncturists. --Any policy of group or individual health insurance that provides coverage for acupuncture must cover the services of an acupuncturist certified pursuant to Florida law under the same conditions that apply to services of a licensed physician (Secs. 627.6403 and 627.6618).

Preexisting conditions. --An insurer or HMO that offers group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if (Sec. 627.6561, as amended by S. 1682, L. 1997; Sec. 641.31071, as added by S. 1 682, L. 1997):

(1) the exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the six-month period ending on the enrollment date;

(2) the exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date; and

(3) the period of any such preexisting condition exclusion is reduced by the aggregate periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.

Genetic information may not be treated as a preexisting condition in the absence of a diagnosis of the condition related to such information (Sec. 627.6561, as amended by S. 1682, L. 1997; Sec. 641.31071, as added by S. 1682, L. 1997).

An insurer or HMO that offers group health insurance coverage may not impose any preexisting condition exclusion in the case of (Sec. 627.6561, as amended by S. 1682, L. 1997; Sec. 641.31071, as added by S. 1682, L. 1997):

(1) an individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage;

(2) a child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage;

(3) pregnancy.

Items (1) and (2) immediately preceding do not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage (Sec. 627.6561, as amended by S. 1682, L. 1997; Se c. 627.31071, as added by S. 1682, L. 1997).

Breast cancer. --Routine followup care to determine whether a breast cancer has recurred in a person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment f or purposes of determining preexisting conditions, unless evidence of breast cancer is found during or as a result of the followup care. This applies to policies and contracts issued or renewed after October 1, 1997 (Secs. 627.64172, 627.66122 and 641.310 96, as added by S. 530, L. 1997).

Small employers. --Health benefit plans issued to a small employer who has two or more eligible employees, and health benefit plans issued to a small employer who has fewer than two eligible employees that cover an employee who has had creditable coverage continually to a date not more than 63 days before the effective date of the new coverage, must comply with the preexisting condition provisions specified in Sec. 627.6561 or, for HMOs, in Sec. 641.31071 (see above) (Sec. 627.6699, as amended by S. 228, L. 1997, effective October 1, 1998).

For health benefit plans that are issued to a small employer who has fewer than two employees and that cover an employee who has not been continually covered by creditable coverage within 63 days before the effective date of the new coverage, preexisting condition provisions must not exclude coverage for a period beyond 24 months following the employee's effective date of coverage and may relate only to (Sec. 627.6699, as amended by S. 228, L. 1997, effective October 1, 1998):

(1) conditions that, during the 24-month period immediately preceding the effective date of coverage, had manifested themselves in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care or treatment or for which medical advice, diagnosis, care or treatment was recommended or received; or

(2) a pregnancy existing on the effective date of coverage.

Associations. --Association health insurance plans may deny health benefit coverage because of preexisting conditions if the condition that would cause a prudent person to seek diagnosis, care, treatment, or medical advice first ma nifested itself within six months immediately before the effective date of coverage or medical advice or treatment was recommended or received within six months immediately before the effective date of coverage. Coverage will not be excluded due to preexi sting conditions for longer than 12 months after the effective date (Sec. 627.6498).

Mammograms. --An accident or health insurance policy issued, amended, delivered, or renewed in Florida, and every health maintenance contract issued or renewed on or after January 1, 1996, must provide coverage for at least the following (Secs. 627.6418, 627.6613 and 641.3109, as amended by Ch. 95-188, L. 1995):

(1) a baseline mammogram for any woman who is 35 years of age or older, but younger than 40 years of age;

(2) a mammogram every two years for any woman who is 40 years of age or older, but younger than 50 years of age, or more frequently based on the patient's physician's recommendation;

(3) a mammogram every year for any woman who is 50 years of age or older;

(4) one or more mammograms a year, based upon a physician's recommendation, for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of a biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has or has had breast cancer, or because a woman has not given birth before the age of 30.

Except as provided in item (2) above, for mammograms done more frequently than every two years for women 40 years of age or older but younger than 50 years of age, the coverage required by items (1) through (4) applies, with or without a physician prescription, if the insured obtains a mammogram in an office, facility, or health testing service that uses radiological equipment registered with the Department of Health and Rehabilitative Services for breast-cancer screening (Secs. 627.6418 and 627.6613, as amended by Ch. 95-188, L. 1995).

Insurers and health maintenance organizations subject to the above requirements regarding mammograms must make available to the policyholder as part of the application, for an appropriate additional premium, the coverage described above without such coverage being subject to deductibles or coinsurance (Secs. 627.6418, 627.6613 and 641.3109, as amended by Ch. 95-188, L. 1995).

Mastectomies. --Any health insurance policy issued or renewed after October 1, 1997, that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy (Secs. 627.6417 and 627.6612, as amended by S. 530, L. 1997).

Length of stay/outpatient postsurgical care. --Effective after October 1, 1997, any health insurance policy that is issued, amended, delivered, or renewed in Florida that provides coverage for breast cancer treatment may not limit inpatient hospital coverage for mastectomies to any period that is less than that determined by the treating physician to be medically necessary in accordance with prevailing medical standards and after consultation with the insured patient (Secs. 627.64171 and 627.66121, as added by S. 530, L. 1997).

Any health insurance policy that provides coverage for mastectomies as described above must also provide coverage for outpatient postsurgical followup care in keeping with prevailing medical standards by a licensed health care professional q ualified to provide postsurgical mastectomy care (Secs. 627.64171 and 627.66121, as added by S. 530, L. 1997).

The provisions described above relating to length of hospital stay and outpatient postsurgical care also apply to HMOs (Sec. 641.31(29) and (30), as added by S. 530 and H. 1785, L. 1997).

Breast cancer/Fibrocystic conditions. --An insurer may not deny the issuance or renewal of, or cancel, a policy of accident insurance or health insurance, nor include any exception or exclusion of benefits in a policy solely because the insured has been diagnosed as having a fibrocystic condition or a nonmalignant lesion that demonstrates a predisposition, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer. With respect to policies and contracts issued or renewed after October 1, 1997, an insurer may not deny the issuance or renewal of, or cancel, a policy of accident or health insurance, nor include any ex ception or exclusion of benefits in a policy solely due to breast cancer, if the insured has been free from breast cancer for more than two years before the applicant's request for health insurance coverage. These provisions also apply to a policy of gro up, blanket, or franchise accident or health insurance and to a contract or evidence of coverage issued by a health maintenance organization (Sec. 627.6419, as amended by S. 530, L. 1997).

Bone marrow transplants. --Effective January 1, 2000, insurers and HMOs may not exclude coverage for bone marrow transplant procedures recommended by the referring physician and the treating physician under a policy exclusion for experimental, clinical investigative, educational or similar procedures contained in any group health insurance policy or HMO contract issued, amended, delivered or renewed in Florida that covers treatment for cancer, if the particular use of the procedure is determined to be accepted within the appropriate oncological specialty and not experimental. Covered bone marrow transplant procedures must include costs associated with the donor-patient to the same extent and limitations as costs associated with the insured, except the reasonable costs of searching for the donor may be limited to immediate family members and the National Bone Marrow Donor Program (Sec. 627.4236(2), as amended by H. 377, L. 1999).

Maternity benefits. --A health insurance policy that provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that de termined to be medically necessary by the treating obstetrical care or pediatric care provider (Secs. 627.6406 and 627.6574, as amended by S. 1682, L. 1997).

Also, any policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant, including medically necessary clinical tests and immunizations (Secs. 627.6406 and 627.6574, as amended by S. 1682, L. 1997).

These provisions also apply to health maintenance organizations (Sec. 641.31(18), as amended by S. 1682, L. 1997).

AIDS. --An insurer of a group policy may not exclude coverage of an eligible individual because of a positive test result for exposure to the HIV infection or a specific sickness or medical condition derived from such exposure, either as a condition for or subsequent to the issuance of the policy. This provision does not apply to individuals applying for coverage where individual underwriting is otherwise allowed by law (Sec. 627.429).

Subject to the total benefits limits in a health insurance policy, no health insurance policy may contain an exclusion or limitation with respect to coverage for exposure to the HIV infection or a specific sickness or medical condition derived from such infection, except as provided in a preexisting condition clause. This provision does not prohibit the issuance of accident-only or specified disease health policies (Sec. 627.429).

Any major medical or comprehensive accident and health policy for which individual underwriting is authorized by law may contain a provision excluding coverage for expenses related to AIDS or ARC if, in the opinion of a legally qualified physician, the insured, prior to the first anniversary of the insured's coverage under the policy, first exhibited objective manifestations of AIDS or ARC, which objective manifestations are attributable to no other cause, or was diagnosed as having AIDS or ARC if all of the following apply (Sec. 627.429):

(1) The applicant for the policy is not required to submit to any medical test for HIV infection.

(2) The policy provision (a) is set forth separately from the other exclusion and limitation provisions of the policy; (b) has an appropriate caption or heading; (c) is disclosed and referenced in a conspicuous manner on the policy data page; and (d) contains a statement that the exclusion will not apply to any person if the insurer does not assert the defense before the person has been insured under the policy for two years.

(3) The insurer must notify the insured in writing of a determination that the insured would be subject to the effect of the exclusion within 90 days after the insurer first determines that an insured would be subject to the effect of the exclusion, even if there are no claims for AIDS or ARC.

(4) Objective manifestations of AIDS or ARC first exhibited after the 12-month manifestation period must be covered the same as any other illness.

Diabetes. --A group health insurance policy sold in Florida must provide coverage for all medically appropriate and necessary equipment, supplies and diabetes outpatient self-management training and educational services used to treat diabetes, if the pa tient's treating physician or a physician who specializes in the treatment of diabetes certifies that such services are necessary (Secs. 627.6408 and 627.65745, as amended by H.B. 1239, L. 1996).

Additionally, each HMO and prepaid health plan must provide coverage for all medically appropriate and necessary equipment, supplies and services used to treat diabetes, including outpatient self-management training and educational services, if the patient's primary care physician, or the physician to whom the patient has been referred who specializes in treating diabetes, certifies that the equipment, supplies or services are necessary (Sec. 641.31(26), as added by H.B. 1239, L. 1996).