Chapter 17/6: Florida Health Regulations

Health insurance policies sold in Florida must cover which of the following for the treatment of diabetes?

A health insurance policy or group health insurance policy sold in this state 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 patient's treating physician or a physician who specializes in the treatment of diabetes certifies that such services are necessary. The correct answer is: All of the above

The time limit on certain defenses for health insurance policies in Florida is:

After 2 years from the issue date, only fraudulent misstatements in the application may be used to void the policy or deny any claim for loss incurred or disability starting after the 2-year period. The correct answer is: 2 years from the date of policy issue

Which of the following is NOT a true statement about breast cancer coverage in a health insurance policy?

An insurer may not deny issuance or renewal of a health insurance policy based on the insured having been diagnosed with a fibrocystic condition due to breast cancer, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer. The correct answer is: Coverage for breast cancer can be cancelled after symptoms are discovered.

Which of the following is NOT a reason for an insured's contract to be cancelled?

An insurer that provides individual health insurance coverage to an individual will renew coverage at the option of the individual. Coverage for individual and group, including HMO contracts, may be non-renewed for any of the following reasons: Failure to pay premiums or the insurer has not received timely premium payments. Performing an act or practice that constitutes fraud or made an intentional misrepresentation of material fact. Failure to comply with premium contribution requirements or group participation. The insurer is ceasing to offer a particular type of coverage in a market. For a network plan or bona fide association plan, there is no longer any enrollee who lives, resides, or works in the service area of the insurer. An insurer may not deny the issuance or renewal of, or cancel, a policy of accident insurance or health insurance, solely due to the family history of the insured related to breast cancer. The correct answer is: The insured having a family history of breast cancer

In Florida, osteoporosis coverage must be in included in every health insurance policy, EXCEPT:

Any health insurance policy that covers a Florida resident and that is issued, amended, delivered, or renewed, must provide coverage for the medically necessary diagnosis and treatment of osteoporosis for high-risk individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis. The following policies are not required to provide coverage for osteoporosis: specified-accident, specified-disease, hospital-indemnity, Medicare supplement, or long-term-care health insurance policies or to the state employee health insurance program. The correct answer is: All of the above

Which of the following would not be covered by a health insurance policy providing coverage for mastectomies and breast cancer treatment?

Any health insurance policy that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy. The insurer may charge an appropriate additional premium for the coverage required by this subsection. The coverage for prosthetic devices and breast reconstructive surgery shall be subject to any deductible and coinsurance conditions and all other terms and conditions applicable to other benefits. Breast reconstructive surgery must be in a manner chosen by the treating physician, consistent with prevailing medical standards, and in consultation with the patient. Any health insurance policy that is issued, amended, delivered, or renewed in this state which 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. The correct answer is: None of the above

What is the information considered that is shown during the negotiations for an insurance contract?

Any statement or description made by or on behalf of an insured or annuitant in an application for an insurance policy or annuity contract, or in negotiations for a policy or contract, is a representation and is not a warranty. The correct answer is: A representation

All of the following are unfair trade practices, EXCEPT:

Coverage continuation is not an unfair trade practice. The correct answer is: Coverage continuation

In Florida, how much time does an insured have to return a health insurance policy for a full refund?

Health insurance policies have a 10-day free look period. During this period, the policy owner may return the policy for any reason and receive a full refund of premium. The correct answer is: 10 days

Individual and group health policies must provide coverage for newborn children from the moment of birth for at least:

Individual and group health insurance policies that provide coverage for a family member of the insured must also provide coverage for the insured's newborn children from the moment of birth. Coverage must be also be provided for the newborn child of a covered family member (such as the newborn of a daughter) for 18 months after the birth of the newborn child. Coverage includes injury and sickness including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities or prematurity. The correct answer is: 18 months

Which of the following does not have to be included in the outline of coverage?

The following must be contained in the outline of coverage:" A statement identifying the applicable category of coverage afforded by the policy based on the minimum basic standards." A brief description of the principal benefits and coverage provided in the policy." A summary statement of the principal exclusions and limitations or reductions contained in the policy including preexisting conditions, probationary periods, elimination periods, deductibles, coinsurance, and any age limitations or reductions." A summary statement of the renewal and cancellation provisions, including any reservation of the insurer of a right to change premiums. The correct answer is: The fees and costs of the policy

When would the Buyer's Guide normally be provided to an applicant?

The insurer must provide each prospective purchaser a buyer's guide and a policy summary prior to accepting the applicant's initial premium, unless the policy for which application is made provides an unconditional refund for a period of at least 14 days. The correct answer is: Prior to accepting the applicant's initial premium

Who is allowed to receive a Buyer's Guide?

The insurer will provide a buyer's guide and a policy summary to any prospective purchaser upon request. (Someone who met with an agent was originally a prospective buyer.) The correct answer is: Any of the above

What is the latest that the outline of coverage can be delivered?

The outline of coverage describes the benefits and features of health insurance policies, and must be provided at the time of application, but no later than at the time of policy delivery. The correct answer is: When the policy is delivered

What is the maximum fine for committing an unfair trade practice when selling health insurance?

The penalty may include the following: a cease and desist order; denial, suspension, or revocation of a certificate of authority or license; imprisonment for criminal penalties; or a fine of up to $200,000. The correct answer is: $200,000

Which of the following is an unfair trade practice?

Unfair trade practices include the following: Misrepresentation and false advertising of HMO contracts, False information and advertising, Defamation, False statements and entries, Unfair claim settlement practices, Failure to maintain complaint handling procedures, Operation without a certificate of authority, Misrepresentation in health maintenance organization applications, Twisting, Illegal dealings in premiums, excess or reduced charges for health insurance coverage, False claims, obtaining or retaining money dishonestly, Unfair discrimination, Misrepresentation of the availability of health care providers, Adverse action against a provider. The correct answer is: All of the above