Chapter 29 - Laws & Rules Pertinent to Health Insurance

Important stuff from Health Laws 11 under question *What are the key requirements of the Florida Employee Health Care Access Act?

*Preexisting exclusions are limited to 12 months for conditions manifested during the previous 6 months for small employers with two (2) to 50 workers. Florida law provides that no preexisting condition exclusion may apply to pregnancy for groups of two or more. Exclusions are limited to 24 months for conditions manifested during the previous 24 months for employers with one worker. *Under the act's "portability" provision, a worker or dependent will have to meet the waiting period for an existing condition only once, even if the individual changes employers and insurers. Eligibility for this "portability" provision is limited to workers or dependents that have had qualifying previous coverage continually to a date not more than 63 days before the effective date of the new coverage

Health Care: *Preexisting Conditions (applies to groups of two or more and HMO group policies only)

1) Policies may not exclude coverage for preexisting conditions for longer than 12 months (18 months for late enrollees), with a six-month look back. 2) Genetic information is not a preexisting condition in the absence of a diagnosis. 3) No preexisting condition period may be applied to newborns, adopted children, or pregnancy. 4) Credit must be given for time served under other creditable coverage.

What is a "contributory" group health insurance plan?

A contributory plan is one that requires that each participating employee pay some specified part of the cost of the plan. This payment is usually made through a payroll deduction.

What is a health maintenance organization (HMO)?

A health maintenance organization is a health care delivery system which provides comprehensive health care services for its members. The members are typically enrolled on a group basis by their employer. The employer pays a fixed periodic contribution in advance for the services of participating physicians and cooperating hospitals. The employee may also contribute to the prepayment in some groups.

*How do HMOs differ from traditional health insurance plans?

A major difference is that the HMO provides medical service while emphasizing preventive medicine and early treatment through routine physical examinations and diagnostic screening techniques. At the same time, the HMOs also provide complete hospital and medical care for sickness and injury. Traditional health insurance plans are designed to provide reimbursement for medical costs in the treatment of sickness or injury. These plans emphasize curative rather than preventive medicine and contribute toward the cost of medical services rather than delivering the service.

For what reason may an insurance company, within two years after the date of issue of the policy, return all premiums instead of paying a claim when the application is attached to, and made part of, the policy?

A misrepresentation, omission, concealment of fact, or incorrect statement may prevent recovery under the contract or policy only if any of the following apply: 1) A misrepresentation, omission, concealment, or statement is fraudulent or is material either to the acceptance of the risk or to the hazard assumed by the insurer 2) If the true facts had been known to the insurer pursuant to a policy requirement or other requirement, the insurer in good faith would not have issued the policy or contract, would not have issued it at the same premium rate, would not have issued a policy or contract in as large amount, or would not have provided coverage with respect to the hazard resulting in the loss.

*What is a "non-cancelable" policy?

A non-cancelable policy is continuable at the option of the policyowner at the premium stated in the policy. The insured thus may continue it until its stated date by timely payment of the fixed premium. No change in benefits or premiums may be made by the insurer.

What is a "noncontributory" group health insurance plan?

A noncontributory plan is one in which the employer pays the total cost. Employees are not required to contribute to the plan through payroll deduction.

What is meant by the lapse of a policy?

A policy lapses and insurance ceases when the premium is not paid when due nor within the grace period.

*What is meant by the term "preexisting condition"?

A preexisting illness or preexisting condition is defined as any disease or sickness that was diagnosed by a physician or treated within a stated period prior to health insurance taking effect, or any disease or sickness that was diagnosed by a physician not treated prior to the effective date of coverage; or any disease or sickness exhibited within a period before coverage symptoms that a physician could have diagnosed and for which a prudent person would have sought treatment.

*What is the definition of a "small employer"?

A small employer is an employer who employs not more than 50 employees, and the majority of whom are employed in Florida. The law applies to employers with 1-50 employees. (This includes sole proprietors, independent contractors and self-employed individuals.)

*What should insurance agents know about unauthorized insurance entities?

Agents must take the time to be sure they are dealing with a licensed insurance entity. Agents should check with the Department of Financial Services to be sure they are dealing with a Florida-licensed insurance company before representing any company. Recently, there has been an alarming increase in the marketing of insurance, predominantly group health plans, in which the insurer is not authorized to conduct the business of insurance in Florida. These plans are usually represented as being as an Employee Retirement Income Security Act (ERISA) plan, which is claimed to be exempt from the state Office of insurance Regulation. A true ERISA Plan must be single employer-based and the employer controls the plan. Any plan involving more than one employer is a Multiple Employer Welfare Arrangement (MEWA) and is subject to licensure and regulation by the Office of Insurance Regulation. Agents frequently agree to market these plans without exercising due diligence and then must face clients whose medical bills remain unpaid and are without any insurance.

Health Care: *Guaranteed Renewability

All policies are renewable except for the following reasons: 1) failure to pay premiums; 2) fraud or intentional misrepresentation; or 3) the insurer ceases offering coverage, in which case the insurer is prohibited from selling coverage for a specified period of time.

**What is an Exclusive Provider Organizaton?

An EPO, or exclusive provider organization, is a new type of entity authorized by the 1992 Legislature. It is a provider that has entered into a written agreement with a health insurance company to provide health care services for certain insureds. It can offer these services through its own facilities or a network of health care professionals, or it may use another facility, such as an HMO.

What is the Florida law regarding an "outline of coverage" for health insurance policies?

An Outline of Coverage must accompany every individual or family accident and health insurance policy when: 1) it is delivered or issued for delivery. Or the Outline of Coverage can be delivered to the applicant at the 2) time the application is taken and an acknowledgment of receipt or certificate of delivery of such outline is provided to the insurer with the application.

*What information must be contained in the "Outline of Coverage"?

An Outline of Coverage must contain the following information: 1) A statement that identifies the applicable category of coverage afforded by the policy based on minimum basic standards. 2)A brief description of the principal benefits and coverages provided in the policy. 3) A summary statement of the principal exclusions and limitations or reductions contained in the policy, including, but not limited to, preexisting conditions, probationary periods, elimination periods, deductibles, coinsurance and any age limitations or reductions. 4) A summary statement of the renewal and cancellation provisions, including any reservation by the insurer of a right to change premiums. 5) A statement that the outline contains a summary only of the details of the policy as issued (or of the policy as applied for) and that the issued policy should be referred to for the actual contractual governing provisions. 6) When home health care coverage is provided, a statement that such benefits are provided in the policy.

*Are limitations imposed on the benefits payable under Part B of Medicare?

An annual deductible is applied to all benefits, and there is a stipulated participation (co-insurance) requirement for costs above the deductible

Health Care: *Maternity Coverage

An insurer may not: 1) deny the mother or her newborn eligibility, or continued eligibility, to enroll or renew coverage, for the purpose of avoiding the requirements of the bill 2) penalize, reduce or limit payment to a provider who complies with the bill 3) offer incentives to a provider to render care inconsistent with the law; or 4) restrict benefits for hospital length of stay which are less favorable than the benefits provided.

Who is eligible for benefits under Part A of the Medicare program?

Basically, coverage under Part A is available to all persons age 65 or over drawing Social Security benefits. In addition, all persons who are eligible for Social Security disability income benefits are eligible.

How are benefits financed under the Supplementary Part B of Medicare?

Benefits under Part B of Medicare are optional. If elected, they are financed by monthly premiums paid by the insured and supplemented by the federal government.

*Does Florida law provide for the continuation of coverage for handicapped children?

Both individual and group health insurance policies must continue to provide coverage for a handicapped child, covered under a family policy, when that child becomes an adult. This requirement applies when the child is, and continues to be, both (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap and (2) chiefly dependent upon the policyholder for support and maintenance. This rule applies even though the family policy would normally terminate coverage for a child who reaches a specified age.

*What are the requirements for newborn child coverage under Florida law?

Both individual and group health insurance policies that provide coverage for a family member of the insured must also provide that the health insurance benefits for children will be payable for a newborn child of the insured from the moment of birth. The law also requires that coverage be provided for a newborn child of a covered family member (e.g., the newborn of a covered daughter or son) for a period of 18 months.

*What are some of the common causes of loss that are not covered by typical health insurance contracts?

Common causes of loss not covered by typical health insurance contracts are: 1) intentional self-inflicted injury 2) act of war 3) military service 4) injuries in private aviation as pilot or crew member 5) losses due to preexisting conditions 6) *cosmetic surgery 7) expenses not associated with treatment of injury or sickness 8) mental disorders

*What is the minimum number of employees specified by Florida law that must be included before a group health insurance policy can be issued?

Florida law does not specify any minimum number for employee group health insurance.

*In a family basic policy, when do maternity benefits go into effect?

Florida law provides that no preexisting condition exclusion may apply to pregnancy for groups of two or more. Consequently, maternity benefits go into effect when a family basic policy is issued.

Health Care: *Guaranteed Availability of Individual Coverage

Florida law requires eligibility for guaranteed-issuance of an individual health insurance policy to include persons with 18 months of prior coverage under a group health plan; or under an individual plan, if the prior insurance coverage is terminated due to the insurer or HMO becoming insolvent or discontinuing all policies in the state, or due to the individual no longer living in the service area of the insurer or HMO.

*What is the Florida Employee Health Care Access Act?

Florida's small group health insurance law passed in the 1992 legislative was amended in the 1993 legislative session. (Amendments were part of the Health Care and Insurance Reform Act of 1993.) The act governs group health insurance provisions provided by insurers or HMOs to small employers.

*What is a preferred provider organization (PPO)?

Following the passage of legislation in 1983, insurance companies were authorized to enter into "alternative rates of payment" agreements with licensed health providers. Those entering into the agreements are called preferred provider organizations (PPOs). The concept is that if one provider or a group of providers has a large volume of business from a group of insureds, it can afford to give them health care at lower guaranteed costs. This savings in health care costs can then be used to prevent health insurance premiums from increasing for that particular group of insureds.

What is group accident and health insurance?

Group accident and health insurance is that form of health insurance covering groups of persons under a master group policy as limited by law.

Health Care: *What has Florida done to make sure the Florida Insurance Code conforms to the provisions of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA)?

HIPAA requires that any person with 18 months of creditable coverage, who does not have access to other health insurance, must be given access to an insurance policy. Creditable coverage includes a group health plan, individual health insurance delivered in Florida, Medicare and Medicaid as well as coverage by the Florida Comprehensive Health Association and others. However, the last period of creditable coverage must have been under a group health plan.

How are health insurance claims paid within a PPO network? What happens if a patient uses an out-of-network provider?

If a patient uses a provider within the network, the provider will get paid for the services directly from the insurer. The PPO provider is prohibited from charging any additional amount to the patient above what the provider is paid from the insurer, except for the coinsurance amount that is based on the network discounted fee that the provider agreed to accept. If the patient uses an out-of-network provider, the insurer must also pay the provider directly for the services, but in this case, the provider can charge the patient any difference between what is paid by the insurer and the amount the provider charges for services.

*When were health insurance benefits added to the Social Security program?

In 1965, the Social Security Act was amended to add a health insurance program for the aged and disabled.

Mr. "A" lapsed his disability policy March 2. He reinstated it on March 22. He claimed coverage for an illness that occurred March 26. Is the claim valid? Why? If the same circumstances occurred except that the claim was for an accident rather than a sickness, would it be paid?

In the first situation the claim would not be valid. An illness would have had to occur more than ten days after reinstatement for a claim to be valid. In the case of the accident, the insurance company would be liable for the claim because the insured would be entitled to full benefits as soon as the policy was re-instated.

Are maternity benefits required in health insurance policies?

Maternity benefits may or may not be offered under individual health insurance policies. There is no requirement provision under Florida law. However, group medical expense plans must provide maternity benefits

*What Is Medicare supplemental insurance and what is its purpose?

Medicare supplemental insurance is a form of private insurance designed to pay some or all of the deductible and co-payment amounts that Medicare recipients are required to pay. The coverage applies to both the hospital and medical insurance plans administered by the federal government for the elderly and permanently disabled. The purpose of the Medicare supplemental insurance is to relieve the insured of the significant total costs not paid by Medicare due to its deductible and co-payment provisions. Medicare supplement insurance is available to individuals who enroll within the six months prior to their 65th birthday, those who are under 65 and have End Stage Renal Disease (ESRD), or those who have SSI eligibility.

What benefits are available for maternity in basic policies?

Most family basic policies cover maternity claims. Usually the hospital expenses are covered up to ten times the room and board benefit. The insured would receive $10,000 if the room and board were $1000. This item ($1,000) would be paid if the hospital charges were equal to (or greater than) this amount regardless of the length of time the patient was in the hospital.

Can an insurer exclude coverage for bone marrow transplants?

No, provided the particular use of the bone marrow procedure is determined to be acceptable and not experimental under rules adopted by the Department of Health.

If an error is found in the application, may the agent recopy the application and sign the applicant's name?

No. In this case the agent should return it to the applicant and have a new application completed.

On a master group policy issued to an association, may employees of members of the association be covered?

No. Such policies may insure the spouses and dependent children of members, but not individuals who are not members of the association or dependents thereof.

*May a health insurance company refuse coverage or require a higher premium because the person to be insured has the sickle-cell trait or solely because of their sex or marital status?

No. That would violate the Florida rules on discrimination.

If an application for insurance is not attached to the policy, may the insurance company claim the application contains false answers and void the policy?

No. The application only becomes a part of the policy and subject to legal contest by the insurance company when it is attached to the policy.

If the insured is engaged in a more hazardous occupation at the time of claim than was originally contemplated in the policy, can the insurance company deny the claim?

No. The claim will be paid in full unless the policy contains a provision setting forth that in such cases there will be a reduction in benefits.

May an agent make a change in any application without the written consent of the policy owner?

No. The insurance company home office can make certain changes for administrative purposes. This must be done in such a manner that they are clearly not to be ascribed to the applicant.

Can an insurer refuse coverage solely because the proposed insured has been diagnosed as having a fibrocystic condition?

No. The law prohibits this unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer.

*Is Part A of Medicare optional coverage?

No. This coverage is provided at no premium cost for the eligible persons.

What are the advantages of a contributory group health Insurance plan?

One advantage of a contributory plan is that greater benefits can be provided than if only the employer portion was used for funding. Another advantage is that employees take a greater interest in the plan, since they share in its cost.

*What types of benefits are provided under Part A of Medicare?

Part A of Medicare provides benefits for the following: 1) inpatient hospital services, including all those ordinary services furnished by a hospital to its inpatients; 2) post-hospital skilled nursing care in a facility having an arrangement with a hospital for the timely transfer of patients; 3) post-hospital home health services if the recipient must be in the care of a physician and under a plan established by a physician for such services after being discharged as a hospital inpatient; and 4) hospice care for the terminally ill (in lieu of other benefits).

What is the basis for reimbursement for services provided under Part A?

Payment of bills under Part A is made to the providers of the service on the basis of "reasonable costs" incurred in providing care for the patient.

What would be a reason to exclude the payment of benefits under a health insurance policy for costs associated with the treatment of an occupational Illness or injury?

Since most states' workers' compensation laws provide for payment of medical costs for work-related injury or illness, the exclusion in private insurance of these costs would be an effort to avoid duplication of payments.

What Is the Florida Health Insurance Plan?

The Florida Health Insurance Plan is a mechanism designed by the legislature to guarantee health insurance to any Florida resident who, for health reasons, is unable to secure coverage from the voluntary health insurance market. The benefits provided by the plan are the same as the standard and basic plans for small employers

*What information regarding the agent is required on the application?

The application must contain the name of the insurance company, the name of the soliciting agent and the agent's identification number as it appears on his or license. This information may be printed, typed, stamped or handwritten, if legible.

What is the purpose of the insurance application form?

The application provides the insurance company with necessary information regarding the insured's age, address, health history and other factors. This information is important so that the insurance company can properly determine if the applicant meets their underwriting rules and can determine the proper premium.

What is the basic character of the benefits provided under Part A?

The benefits are for hospital expense and related expenses.

What types of benefits are provided under Part B of Medicare?

The benefits provided under Part B are basically the following: 1) physicians' and surgeons' services whether furnished in a hospital, clinic, office home or elsewhere; 2) medical and health services, including X-rays and lab tests, ambulance services, rental of medical equipment, prosthetic devices,

*What is the purpose of the "entire contract clause" in health insurance?

The clause states that the policy, its endorsements and any attached materials, including the application, constitute the entire contract of insurance. This assures that no other documents that are not actually a part of the contract can be used to deny claims or coverage

*What extensions of benefits are required in group health insurance policies?

The following extensions of benefits are required: 1) Every group, blanket or franchise policy or contract renewed, delivered or issued for delivery in the state of Florida shall contain a reasonable provision for extension of benefits in the event of total disability at the date of discontinuance of the policy of contract. The extension shall be required whether the group policyholder or other entity secures replacement coverage from a new insurer or forgoes the provision of coverage. 2) Discontinuance of the policy during a disability shall have not effect on benefits payable for that disability or confinement under a group plan providing benefits for loss of time from work or specific indemnity during hospital confinement. 3) In the case of hospital or medical expense coverage other than for dental and maternity expense, a reasonable extension-of-benefits or accrued"liability provision is required, which provides for continuation of policy benefits in connection with the treatment of a specific accident or illness incurred while the policy was in effect. 4) An extension of benefits is required in a group, blanket or franchise policy or contract that provides coverage for dental procedures either in the form of reimbursed expenses or services performed. 5) In the case of maternity expense coverage, a reasonable extension of benefits or accrued liability provision is required. The required provision must provide for continuation of policy benefits in connection with maternity expenses for a pregnancy that began while the policy was in effect. The extension shall be for the period of that pregnancy and may not be based upon total disability. 6) Any applicable extension of benefits or accrued liability shall be described in any policy or contract involved as well as in group insurance certificates. The benefits payable during any period of extension or accrued liability may be subject to the regular benefit limits of the policy or contract. 7) This section also applies to holders of group certificates which are renewed, delivered or issued for delivery to residents of this state under group policies effectuated or delivered outside this state, unless a succeeding carrier under a group policy has agreed to assume liability for such benefits

What are the special rules designed to protect the insureds against the unintentional lapse of a long-term care policy?

The following rules, designed to provide ample notice to insureds and owners, require that: 1) !!A long-term care policy must have a grace period of not less than 30 days!!, during which a premium may be paid after it is due and before the policy lapses; 2) A long-term care policy must not be canceled for nonpayment unless, after the grace period, and at least 30 days prior to the cancellation, a notice has been mailed to the policy owner and to a secondary addressee, if one has been designated ( the insurer must notify the owner of the right to designate a secondary addressee at least annually ); and If a long-term care policy is canceled due to nonpayment, the policy owner may reinstate the policy for a period of at least 5 months if the owner or secondary addressee demonstrates that the lapse was unintentional and due to cognitive impairment, loss of functional capacity or confinement in a care facility for a period exceeding 60 days.

*How does the grace period apply in a health insurance policy?

The grace period is a stated period of time after the premium due date during which the policy remains in force even though the premium has not been paid. The grace period applies to premiums other than the initial premium.

*What must the insurance company do when it receives notice of claim?

The insurance company must furnish the claimant with proof-of-loss forms within 15 days. If it does not furnish the claimant with its forms, the claimant may present proof in any reasonably written manner showing the nature of loss, extent of loss and other information.

What is the purpose of a medical examination during the pendency of a claim?

The insurance company uses the medical examination to determine the extent of the disability of the insured.

In connection with the issuance of a master group health insurance policy, may health questions be asked to permit the insurance company to select risks?

The law provides that all employees or all members, as the case may be, must be eligible regardless of individual health history. The insurer may decline the entire group, but not individual employees.

How are health insurance rates governed?

The law provides that the benefits must be reasonable for the premium charged. The Office of Insurance Regulation has established various criteria that insurance companies must meet before rates can be approved. These are based on loss ratios and expense ratios and are designed to prevent the insured from being overcharged by the insurance company. Prior rate approval does not apply to group health insurance policies, effectuated and delivered in this state, insuring groups of 51 or more persons, except for Medicare supplement insurance, long-term care insurance, and any coverage under which the increase in claim costs over the lifetime of the contract due to advancing age or duration is pre-funded in the premium.

*What is the length of the grace period in a health insurance policy?

The law provides that there must be a grace period of not less than seven days on weekly premium policies, ten days for monthly premium policies and 31 days for all others.

How is the original Medicare program structured?

The original Medicare program has two parts. Part A covers eligible persons over age 65 and those under age 65 who are eligible for Social Security Disability benefits. Part B is optional for the same groups covered by Part A. It provides a program of surgical and doctor care plus certain other benefits. A premium is withheld from the participants' Social Security check to cover Part B.

*An agent accepts a premium for a lapsed disability policy. When does the reinstatement become effective?

The policy becomes effective for accident coverage immediately, but does not become effective for any illness coverage until after ten days from the date of acceptance.

Why is it important that the agent carefully ask the applicant each question on the application and see that the answers are correctly stated?

The policy is issued based on the statements and agreements contained in the application. The insured or a beneficiary may not have a valid claim unless the questions have been answered truthfully and correctly on the application.

*What are the requirements for dependent coverage under a group, blanket, or franchise health insurance policy?

The policy must insure a dependent child of the policyholder or certificate holder at least until the end of the calendar year in which the child reaches the age of 26, if the child meets all of the following. 1) The child is dependent upon the policyholder or certificate holder for support. 2) The child is living in the household of the policyholder or certificate holder, or the child is a full-time or part-time student. The policy must also offer the policyholder or certificate holder the option to insure a child of the policyholder or certificate holder at least until the end of the calendar year in which the child reaches the age of 30, if the child: 1) is unmarried and does not have a dependent of her own: 2) is a resident of this state or a full-time student; and 3) is not provided coverage as a named subscriber, insured, enrollee,or covered person under any other group, blanket, or franchise health insurance policy or individual health benefits plan, or is not entitled to benefits under Title XVIII of the Social Security Act.

*What is the usual provision in a policy with respect to misstatement of age or sex of the insured?

The policy will provide, in substance, "If the age or sex of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age or sex."

What provision does the usual disability insurance policy contain with reference to a change of beneficiary?

The policyowner has the right to change the beneficiary upon proper notification to the insurance company and without consent of the beneficiary.

What are the primary advantages of a noncontributory group Insurance plan?

The primary advantages of a noncontributory plan are employer control and total participation by all eligible employees, since no contribution is required of them.

What is meant by "reinstatement"?

The term means placing a policy in force again after it has lapsed.

*Four different types of groups are eligible for group health insurance.

The types of groups eligible for group health coverage are: 1) employer/employee groups; 2) labor unions and association groups; 3) debtor groups; and 5) any other group that is eligible for group life insurance.

*What Is the Florida Health Insurance Coverage Continuation Act?

This legislation (627.6691) requires insurers that sell health plans to small employers (less than 20 employees) to offer in those plans a right to elect continued coverage, without providing evidence of insurability, to the covered employee or their dependents who will lose employer-sponsored group coverage for various reasons and who may not be able to obtain replacement insurance. Coverage may be continued in most circumstances for up to 18 months beyond the time when it would have otherwise ended. This Florida law extends essential provisions similar to the federal COBRA to employers in Florida with less than 20 employees and is referred to as "Mini-COBRA"

Small Employers Access Program which includes the creation of the Small Business Health Plan

This plan is intended to provide small employers the option and the ability to provide health care benefits to their employees through the creation of purchasing pools. These pools may be comprised not only of employers with up to 25 employees, but any municipality, county, school district or hospital employer located in rural areas as defined in statute s.288.0656(2)(b), as well as any nursing home employer regardless of the number of employees

What is the purpose of the "other insurance" provision?

This provision operates when there is other insurance coverage in force which the insured has failed to give written notice about to the insurance company prior to the time that a claim begins. This clause gives the insurance company the right to prorate benefits and make appropriate premium refunds. The purpose of this clause is to prevent over-insurance through multiple policies.

*What is the "time limit on certain defenses" provision?

This provision states in general that after two years, no misstatements except fraudulent ones, made by the applicant on the application, shall be used to void the policy or to deny a claim for loss incurred commencing after the end of such two year period. It also provides that no claim for loss incurred after two years from the date of issue shall be denied on the grounds that a disease or physical condition, not specifically excluded by name, had existed prior to that date.

What information is contained within the "time of payment of claims" provision?

This provision stipulates the time after proof of loss is received by the insurance company within which the claim payment must be made.

*What is meant by the term "coordination of benefits"?

This term refers to insurance companies coordinating the payment of benefits when an insured is covered by two or more group health insurance policies. Its purpose is to limit benefits from multiple plans to no more than 100 percent of expenses incurred and to designate the order in which insurers are to pay benefits. As a cost containment measure, this section was amended to require or allow a greater degree of coordination so as to avoid duplication of benefits.

What is meant by the term "required provisions" in health insurance contracts?

This term refers to those provisions that must be included in health insurance contracts as a matter of law.

*What minimum percentage participation is required by Florida law under employee group health insurance before a policy can be issued?

Under Florida law there is no specific minimum percentage participation of employees under employee group health insurance.

Under what types of health insurance policies are the provisions for naming and changing beneficiaries most important?

Under those policies that provide benefits in the event of the insured's death.

*What is generally the law regarding change of occupation by the insured after the policy is issued?

When an insurance company charges a different rate for persons in different occupations, the policy may provide for a reduction in benefits if the insured changes to a more hazardous occupation, unless the insured has previously notified the insurance company and has paid an increased premium. However, if the insurance company wrote all risks at the same rate, then the change of occupation would not affect the benefits.

*What is the time limit for giving notice of claim?

Written notice must be given within 20 days, giving the name of the policyowner, nature of the loss and other information to identify the claimant to the insurance company. In the event it is not reasonably possible to give notice within this time, notice must be given as soon as reasonably possible.

*Does the free look also apply to Medicare supplement policies?

Yes, but in the case of Medicare supplements and long-term care policies the period is 30 days.

*May a policyowner sue the insurance company to recover under a policy?

Yes, provided: 1) *the suit is filed at least 60 days after proof of loss has been given; 2) the loss is not paid within 120 days from the date of filing proof of loss as required by the policy if the claim is contested; and 3) the suit is brought within five years after proof of loss is furnished to the company.

Are there limitations imposed on the post-hospital skilled nursing care benefits?

Yes. A maximum limit of 100 days is imposed on each benefit period, and a co-payment is applicable from the 21st to the 100th day of care.

*Are there special marketing provisions in Florida for Medicare Supplements?

Yes. All Medicare Supplements marketed in Florida must meet or exceed the requirements of the NAIC Medicare Supplements Insurance Minimum Standards Model Act. Additionally they must: - Contain a definition of Medicare-eligible expense that is not more restrictive than that used by Medicare - Provide that benefits designed to cover the deductibles, daily copays and coinsurance of Medicare will be changed automatically to keep up with the changes instituted in these cost of Medicare, - Be written in simple language, and -Contain a prominently displayed coordination of benefits clause

*Are there any special requirements imposed on an agent who solicits Medicare supplements?

Yes. Florida law requires an agent to ask every person solicited whether he or she is currently covered under another contract. The agent must explain the extent to which the proposed coverage will overlap or duplicate the existing coverage. Before an application is taken, the Department of Financial Services requires that an agent obtain a signed form from the prospect acknowledging that this information has been provided.

Is health insurance coverage for alcoholism or drug dependency required by Florida law?

Yes. Group health insurance policies are required to offer coverage for alcoholism and drug dependency to the policyholder (i.e. the employer, not the employee). Although certain minimum benefits must be offered, the statute allows the policy owner to select "any alternative benefits or level of benefits as may be offered by the insurer.

Can an insurance company demand an independent medical examination during the pendency of the claim?

Yes. It may request such an examination as often as it reasonably requires.

*Does Florida law require a free look for Medicare Supplement policies?

Yes. It states a Medicare Supplement policy must, "Contain a prominently displayed no-loss cancellation clause enabling the insured to return the policy within 30 days of the date of receipt of the policy, or the certificate issued there under, with return in full of any premium paid."

Are there limitations placed on the inpatient hospital service benefits?

Yes. Medicare Part A pays for allowable medically necessary inpatient hospital costs above a "benefit period" deductible amount for up to 150 days of hospitalization.

*Are there policy standards under Florida law that must be met to be considered long-term care policies?

Yes. The Financial Services Commission is tasked with adopting rules regarding required disclosures, term of renewability, eligibility for benefits, non-duplication of benefits, continuing or conversion, probation and elimination periods, requirements for replacement, disclosure of tax consequences, standards of marketing, and more. Some of these include that a long -term care policy sold in Florida must: 1) !!Provide a free look of at least 30 days!! after delivery during which the owner may return the policy to the insurer for a full refund; 2) !!Be prominently stamped on the first page!! that the policy is an approved long-term care policy and that it may not meet all the long-term car cost incurred by the buyer; 3) !!Be accompanied by the Buyer's Guide and Outlined of Coverage!! which describes the principal benefits, exclusions, and limitations of the policy, include renewal and conditions for premium increases; 4) !!Include a disclosure statement!! indicating whether or not the policy is intended to be tax qualified long-term care policy and also whether it is intended to be limited benefit policy as defined the International Revenue Code; 5) Offer an !!inflation protection rider!! designed to account for reasonably anticipated increases in the coast of long-term care services; and 6( Include nonforfeiture benefit in the event of the policy lapse which provides for reduced paid-up, extended term, reduced benefit, or other approved benefits that account for premiums paid.

*Must a free privilege be disclosed to an applicant?

Yes. The existence of a free look must be disclosed. It provides that after the policyholder has received and read the policy, if the decision is made that it is not the coverage desired, the policy may be returned and a full refund of premiums received. 1) Health and disability policies require a 10 day period, 2) life and annuity policies require a 14 day period, and 3) long term care and Medicare policies require a 30 day period. This would not apply to short-term single premium policies (aviation accident policies).

*Are persons insured under a master group health policy entitled to a certificate of insurance?

Yes. The law provides that each member of the insured group must receive a certificate that sets forth the essential features of the master insurance contract. In health insurance, this certificate is usually in the form of a booklet describing the benefits

Do the words "physician" or "medical doctor" when used in a health insurance policy include dentists?

Yes. The law requires that the words physician or medical doctor, when used in such policies, include a dentist when the policy covers surgical procedures that are specified in the coverage or are performed in an accredited hospital in consultation with a licensed physician and are within the scope of a dentist's professional license.

Are there other provisions that can be included in the policy but are not required?

Yes. These are known as the "optional provisions" and are found in some health insurance policies.

What is the Medicaid program?

at is the Medicaid program? This is a federal program, under the Social Security Act amendments of 1965. It is a program under which the federal government makes grants to the states to help fund health care benefits under public assistance programs. It is basically a welfare program for persons with insufficient income or resources to pay for health care. Each state manages it's own Medicaid program .

Agents who sell unauthorized plans are subject to

having their licenses suspended or revoked and/or monetary penalties assessed against the agent. Under Florida law, if an unlicensed insurer fails to pay claims, agents who sold the unlicensed coverage are liable for unpaid claims. It is also possible that civil and criminal action can be taken against them. As of October 1, 2002 any agent licensed in this state, who, in this state, represents or aids an unauthorized insurer commits a third-degree felony.