FL statutes rules and regulations pertinent to Health insurance

Active and Inactive Employees

A plan that covers a person as an active employee pays benefits before those of a plan that covers the person as a laid off or retired employee.

Time Limit for Notice of Claim

A claimant must give written notice of a claim to the insurer within 20 days after a loss or as soon thereafter as reasonably possible.

Prohibited Practices

A discount medical plan organization may not use the term "insurance" in its advertisements and marketing materials; use the terms "health plan," "co-pay," "pre-existing conditions," "premium," "PPO," or similar terms in its advertisements and marketing materials if it would mislead a person into believing the discount medical plan is health insurance; have restrictions on access to plan providers (e.g., waiting periods and notification periods); or pay providers any fees for medical services.

Group Plan Issued Outside Florida

A group health insurance policy approved in its home state and issued to a group in Florida must contain the following statement: "The benefits of the policy providing your coverage are governed by the law of a state other than Florida."

Benefits Required in Group Plans

A group health insurance policy or HMO contract is not required to provide benefits for maternity services. However, if a group policy or contract covers such care, certain minimum requirements must be met. For example, a policy must provide coverage for birth centers and midwives, and cannot limit the length of stay in a hospital following childbirth to less than is medically necessary. In addition, post-delivery care must be provided to the mother and newborn, including immunization.

Occupational Illness or Injury

A health insurance policy can also exclude coverage for services for which state or federal workers' compensation, employer's liability, occupational disease, or a motor vehicle no-fault law provides benefits.

Treatment in Government Hospital

A health insurance policy can exclude treatment in a federal government facility (unless coverage is required by law).

Insurer and Agent Responsibilities Insurance Application

A health insurance policy must specify that the policy, any endorsements, and any attached documents constitutes the entire insurance contract. Changes to an application for a health insurance policy are invalid unless they are approved by the applicant. An insurer or agent cannot change the application. A policy must contain a provision that all statements made by the insured are considered representations and not warranties. Such statements may not void the contract, unless they are fraudulent or material to accepting the risk. The insurer's name must be displayed on the first page of the application form along with the agent's name and license identification number.

Entire Contract

A health insurance policy must specify that the policy, any endorsements, and any attached documents, constitutes the entire insurance contract. Changes to the contract are invalid unless they are approved and endorsed by an officer of the insurance company. A producer cannot change the terms of the policy.

Treatment for Cleft Lip and Cleft Palate

A health insurance policy that covers children under the age of 18 must provide coverage for the treatment of cleft lip and cleft palate. Coverage must be provided for medical, dental, speech therapy, audiology, and nutrition services, if prescribed by a physician.

Treatment for Breast Cancer and Mastectomies

A health insurance policy that covers mastectomies must also provide coverage for prosthetic devices and reconstructive surgery. A health insurance policy that covers treatment for breast cancer may not limit inpatient hospital coverage for mastectomies, if a physician determines that such care is medically necessary. Policies must also cover outpatient postsurgical follow-up care. Routine follow-up care to determine whether breast cancer has recurred does not constitute medical advice, diagnosis, care, or treatment for purposes of determining pre-existing conditions, unless evidence of breast cancer is found during the follow-up care.

Dependent Children Handicapped Children

A health insurance policy that ends coverage for a dependent child upon reaching the limiting age specified in the policy must provide that if the child reaches the limiting age, coverage will not end while the child is both incapable of self-sustaining employment due to mental or physical handicap, and chiefly dependent upon the policyholder or subscriber for support.

Use of Genetic Information Prohibited

A health insurer may not cancel, limit, deny coverage, or charge different premium rates based on a person's genetic information, in the absence of a diagnosis of a medical condition. An insurer may not require genetic information, use genetic test results, or consider a person's actions relating to genetic testing for any insurance purpose.

Regulation of Health Insurance Plans, Part 1 Types of Health Plans, Part 1 Health Maintenance Organization (HMO)

A health maintenance organization (HMO) is a type of health-care delivery system that provides comprehensive health care for its subscribers in exchange for a prepaid fixed contribution. Subscribers may enroll on an individual or group basis. HMOs are designed to control health-care costs through the use of managed care and case management. They also emphasize preventive care and cost and quality controls in delivering care.

Grace Period

A policyholder is entitled to the following grace periods following the premium due date, during which the policy remains in force at least seven days for policies with premiums that are due weekly; at least ten days for policies with premiums that are due monthly; and at least 31 days for all other policies.

Duties of Agent

A policyowner can report a claim either to the insurer or to the insurer's agent. If an agent is notified, he or she must immediately report the claim to the insurance company.

Prohibited Prepaid Health Clinic Names

A prepaid health clinic is prohibited from using the words "HMO," "insurance," "casualty," "surety," or "mutual" in its name, or any words that are descriptive of an HMO, insurance company, or surety corporation. However, insurers that are operating as prepaid health clinics are not subject to this prohibition. It is also unlawful for an entity that has not received a certificate of authority as a prepaid health clinic to use the phrase "prepaid health clinic" or the initials "PHC" in its name.

Annual Report

A prepaid health clinic must file an annual report with the Office on or before March 1 each year (or within three months after the end of its reporting period). The report must include a copy of the clinic's financial statement for the preceding year, the number of prepaid health clinic contracts issued and terminated, the names of individuals responsible for conducting the clinic's business, the clinic's basic rates for services, and the number of claims brought against the clinic. A clinic that fails to file an annual report on time will be fined up to $100 for each day that the report is late. The Office may also notify the clinic that it cannot operate in the state while the default continues.

Prepaid Health Clinic

A prepaid health clinic provides basic health-care services to enrollees on a prepaid per capita or prepaid aggregated fixed-sum basis. It also covers basic services that are required to maintain good health, such as physical exams. Clinics that provide inpatient hospital services, hospital inpatient physician services, or indemnity against the cost of such care are not considered prepaid health clinics. Prepaid health clinics must obtain a certificate of authority from the Office before they can provide services. To obtain a certificate, an applicant must submit an application and hold a Health Care Provider Certificate issued by the Agency for Health Care Administration.

Prepaid Limited Health Service Organization (PLHSO)

A prepaid limited health service organization (PLHSO) is a person or entity which, in return for a prepayment, provides or arranges access to limited health services for enrollees through an exclusive panel of providers. A PLHSO must be incorporated and may operate on a nonprofit or for profit basis. A PLHSO must also receive a certificate of authority before it can act as a PLHSO in Florida, and must maintain a complaint system for resolving written complaints from enrollees and providers. Each year, a PHLSO must report to the Department and Office the total number of grievances, the types of complaints, and a summary of how the complaints were resolved. To sell PLHSO contracts, a person must be licensed as a health insurance agent. Each PLHSO contract must provide benefits for at least 12 months, unless the enrollee requests a shorter period of time.

Small Employer Defined

A small employer in Florida is, for purposes of group health insurance, defined as any person or entity engaged in business that employed between one and 50 employees during the preceding year, the majority of whom worked in Florida. A small employer must also maintain its principal place of business in the state.

Optional Policy Provisions

Accident and health insurance policies issued in Florida may contain certain optional provisions, which provide additional protection for the insurer as well as the insured. Though they are not required by law, they must follow approved standards in content and form.

Time Limit on Certain Defenses

After a health insurance policy has been in effect for two years, the insurer can void the policy or deny a claim only on the basis of a fraudulent misstatement the insured made in the application. An insurer cannot deny or limit a claim for loss or disability beginning after two years from the policy's issue date on the basis of a pre-existing condition that was not specifically excluded when the policy was issued.

Minimum Number of Employees

All employees (or class of employees) must be eligible for coverage under a group policy. Spouses and dependent children are also eligible for benefits. However, Florida does not require a minimum number of employees for group health insurance

Inpatient and Outpatient Services

All health insurance policies are required to cover treatment performed outside of a hospital if the treatment would be covered on an inpatient basis and is provided by a health care provider whose services would be covered in a hospital. Such outpatient care must also be medically necessary.

Exclusive Provider Organization (EPO)

An exclusive provider organization (EPO) is a provider or group of health-care providers who have entered into a written agreement with an insurer to provide health-care services to subscribers. An insurer may not issue a policy that is subject to an exclusive provider provision until the EPO's plan of operation has been approved by the agency. An EPO's proposed plan of operation must include: a description of the service area a description of the grievance procedure and quality assurance program a list of all providers, by specialty access to 24-hour, 7-day-a-week emergency care services any limitations or restrictions on providers An EPO must also file an updated list of exclusive providers with the Agency at least semiannually. An insurer must disclose all restrictions and limitations when selling policies that are subject to an exclusive provider organization. The insurer must also obtain a signed form stating that the policyholder has received information about the policy's restricted nature and understands the limitations.

Guaranteed Renewability

An individual health insurance policy will be renewed at the insured's request. However, an insurer may nonrenew or discontinue individual health coverage because the insured failed to pay the premiums within the grace period; the insured has committed fraud or made an intentional misrepresentation of material fact; the insurer is no longer writing or renewing policies and has discontinued all coverage in the individual market; the insured no longer lives in the service area (in the case of network plans); or the insured is no longer a member of an association through which coverage was provided. An insurer can stop offering a particular type of health insurance coverage in the individual market if the insurer first notifies every person insured under the policy form at least 90 days before discontinuing the policy form; and the insurer offers to every insured the option to buy any other individual health insurance coverage that the insured offers in that market, without regard to the health status of these insureds. An insurer can stop offering all health insurance coverage in Florida if the insurer first notifies the Office and every insured individual at least 180 days before the coverage will expire; and the insurer does not renew any of the health insurance policies it issued or delivered in Florida. The insurer cannot issue any new individual health insurance policies in Florida for five years. A health insurer that offers group health insurance must renew or continue coverage for all eligible employees and dependents of employees for as long as the plan sponsor (the employer) desires. However, the insurer can refuse to renew or cancel a group health plan only on the following conditions: The employer fails to pay the premiums or delays payment. The employer committed fraud or intentionally misrepresented material facts. The employer fails to fulfill its obligations for participation in the plan. The insurer is no longer offering new coverage and is not renewing its group health plans as they come up for renewal.

Cancellation

An individual health insurance policy will be renewed at the insured's request. However, an insurer may nonrenew or discontinue individual health coverage because the insured failed to pay the premiums within the grace period; the insured has committed fraud or made an intentional misrepresentation of material fact; the insurer is no longer writing or renewing policies and has discontinued all coverage in the individual market; the insured no longer lives within the service area of the insurer's network of providers; or the insured is no longer a member of an association through which coverage was provided. An insurer can stop offering a particular type of health insurance coverage in the individual market if the insurer first notifies every person insured under the policy form at least 90 days before discontinuing the policy form; and the insurer offers to every insured the option to buy any other individual health insurance coverage that the insured offers in that market, without regard to the health status of these insureds. An insurer can stop offering all health insurance coverage in Florida if the insurer first notifies the Office and every insured individual at least 180 days before the coverage will expire; and the insurer does not renew any of the health insurance policies it issued or delivered in Florida. The insurer cannot issue any new individual health insurance policies in Florida for five years.

Outline of Coverage

An individual or family accident and health insurance policy cannot be issued or delivered in Florida unless an outline of coverage is delivered with it. An insurer or agent may instead deliver an outline of coverage at the time of application and must obtain a signed receipt from the applicant. The outline of coverage contains the following information about the policy for the new policyholder: the type of coverage provided a description of the benefits a description of the exceptions and limitations the conditions for renewal, including any reservation by the insurer of its right to change the premium a statement that the outline summarizes the policy and that the policyholder should refer to the policy for the governing provisions a statement that home health care coverage is provided, if applicable to the policy

Legal Actions

An insured cannot sue the insurer on a claim before 60 days have passed since filing written proof of loss. However, an insured cannot bring suit after five years has passed since filing proof of loss.

Bone Marrow Transplants

An insurer cannot exclude coverage for bone marrow transplants recommended by a physician, if the procedure is not considered experimental.

Fibrocystic Condition

An insurer may not refuse coverage or cancel a policy because an insured has a fibrocystic condition, unless the condition is diagnosed through a breast biopsy that demonstrates an increased likelihood of developing breast cancer.

Sex or Marital Status of Applicants

An insurer may not refuse to issue a policy or charge a higher premium based on a person's sex or marital status. For example, it is unlawful for an insurer to deny coverage to females employed at home or part-time or who work for relatives when coverage is offered to men who are similarly employed; deny policy riders to females when the riders are available to males; deny maternity benefits to insureds purchasing an individual contract when comparable family coverage contracts offer maternity benefits; deny dependent coverage to husbands of female employees under group contracts, when dependent coverage is available to wives of male employees; deny disability income contracts to employed women when coverage is offered to men similarly employed; treat complications of pregnancy differently from other illness or sickness; restrict, reduce, or exclude benefits relating to coverage involving the genital organs of only one sex; offer lower maximum monthly benefits to women than to men; offer more restrictive benefit periods and definitions of disability to women than to men; establish different conditions by sex under which the policyholder may exercise benefit options contained in the contract; or limit the amount of coverage an insured may purchase based upon marital status unless such a limitation is used to determine individuals eligible for dependents' benefits.

Applicant Considerations Applicants with Sickle Cell Trait

An insurer may not refuse to issue a policy or charge a higher premium solely because a person has sickle-cell trait.

Certificate of Insurance

An insurer must deliver certificates to the group policyholder (for delivery to each insured person) that state the following: the group number the principal features of the coverage whether dependents are covered the party to whom benefits are payable

Special Enrollment Periods

An insurer that issues group, small group, or HMO group policies must allow employees and their dependents to enroll under the group policy if they previously declined enrollment because they had other health insurance coverage. Individuals who become dependents through birth, marriage, or adoption must be allowed to enroll in a group policy within 30 days of the birth, marriage, or adoption.

Requirements of Act

As a condition of transacting insurance in Florida, a small employer insurer must offer at least two health benefit plans: a basic and a standard health benefit plan. The standard policy is a major medical policy and the basic policy is a more affordable, lower benefit option. Plans must be offered on a guaranteed issue basis, which means that a policy must be offered to a small employer, regardless of employees' health status, pre-existing conditions, or claims history. If an employer has one employee, an insurer must offer a basic, standard, and high-deductible health benefit plan on a guaranteed issue basis. The insurer must make these plans available during an open enrollment period each year from August 1 to August 31. In addition, one-employee groups may not be established solely to obtain insurance (i.e., they must have a noninsurance purpose). Small employer plans must allow eligible employees or dependents to enroll during a 30-day open enrollment period each year. Insurers must use a modified community rating methodology to determine premiums for each small employer. Premiums must be based on eligible employees' gender, age, family composition, tobacco use, and geographic area. An approved premium rate may be adjusted no more than 15 percent, based on the group's claims experience, health status, or duration of coverage. Any adjustments are applied to the group as a whole rather than to an individual employee. An adjustment based on these factors cannot exceed 10 percent each year. Small group carriers are allowed to provide small employer groups a credit to reflect administrative and acquisition expense savings resulting from the size of the group. Insurers may not use a composite rating methodology to rate a small employer with fewer than 10 employees. A composite rating methodology averages the impact of the rating factors for age and gender in the premiums charged to all employees, rather than separately listing the applicable rate for each employee. Small employer health benefits plans may not deny or exclude benefits for losses incurred due to pre-existing conditions more than 12 months after an individual's enrollment date, for conditions that began during the previous six months. However, plans covering two or more employees may not impose a pre-existing condition exclusion relating to pregnancy. For employers with one worker, pre-existing conditions may be excluded for 24 months if the condition began during the previous 24-month period. If an insurer offers coverage to a small employer, the insurer must offer coverage to all eligible employees and their dependents. A small employer insurer may not restrict coverage only to certain individuals in the group. Insurers may nonrenew small employer policies only for the following reasons: nonpayment of premium fraud or intentional misrepresentation failure to comply with a plan's contractual provisions An insurer may also nonrenew a policy if it stops offering coverage in the market and certain notice requirements are met.

Health Insurance Rates

Before an insurer can issue a health insurance policy in Florida, it must file its rating manual and rating schedule (or premium rates) with the Office for approval. However, prior approval is not required for group health insurance policies insuring 51 or more individuals (except for Medicare supplement insurance), long-term care insurance, and policies where the increase in claim costs over the lifetime of the contract due to age or duration is prefunded in the premium. An insurer must also submit a filing each year to show the reasonableness of benefits in relation to premium rates. The Office will consider past and prospective loss experience, expenses, risk and contingency margins, and acquisition costs in determining whether benefits are reasonable in relation to the premium charged. The Office may disapprove a policy form or withdraw its previous approval if the form provides benefits that are not reasonable in relation to the premium charged; contains provisions that are unfair, inequitable, or against public policy; applies rating practices that result in unfair discrimination; or excludes coverage for human immunodeficiency virus (HIV) infection or acquired immune deficiency syndrome (AIDS).

Cover Florida

Cover Florida Health Care was designed to guarantee affordable health-care coverage to Florida residents who have been uninsured for at least six months. The program is administered by the state of Florida along with private health insurers. Individuals between the ages of 19 and 64 who have been without health insurance for the past six months are eligible for a Cover Florida policy, even if they have pre-existing conditions. Florida residents may also be eligible to purchase Cover Florida plans if they lost employer-sponsored health insurance due to job loss, death, divorce, or exhaustion of COBRA or state continuation coverage. Insurers offer two types of policies: catastrophic and noncatastrophic plans. All Cover Florida policies, however, must offer some coverage for preventive care, physicians' visits, outpatient surgery, mental health benefits, and diabetes supplies. Policies must also provide coverage for prescription drugs or a prescription drug discount plan. "Catastrophic" Cover Florida plans must include limited coverage for inpatient hospital services, hospital emergency care services, urgent care services, and outpatient facility services. Due to new federal requirements enacted in 2010, providers can no longer offer new policies under the Cover Florida program.

Newborn Children

Dependent children are covered by their parents' health insurance from the moment of birth. For coverage to continue, the policyholder must notify the insurer of a child's birth. The policyholder may also need to pay the premium for the child's coverage within 30 days after the child's birth to continue coverage beyond the 30-day period. However, if notice is given within 60 days after a child's birth, the insurer may not deny coverage because the insured failed to timely notify the insured. A policy must also cover the newborn child of a covered family member (e.g., the child of a covered daughter) for 18 months. A policy must cover injury and sickness, including medically diagnosed congenital defects, birth abnormalities, and prematurity. A policy must also cover up to $1,000 in transportation costs if a newborn child needs to be transported to another health care facility.

Health Insurance Marketing Practices

Each state has its own laws, rules, and regulations that apply to insurance business transacted in the state or affecting risks located in the state. While many principles and concepts of insurance are common to all states, it is through these insurance laws that states regulate insurance within their state lines for the protection and welfare of their own citizens, businesses, and interests. The following lessons will examine those laws and regulations that apply specifically to health insurance transactions in Florida.

Group Accident and Health Insurance

Group accident and health insurance is a type of health insurance covering groups of persons under a master group health insurance policy. It may be issued to employer groups, labor unions, associations, debtor groups, and other groups that are eligible for insurance.

Coordination of Benefits

Group health insurance plans may include a coordination of benefits (COB) provision to establish the priority in which they pay their claims. This avoids the duplication of benefits by allowing a plan to reduce its benefits when it is not the insured's primary insurance plan. The benefits payable from a primary plan are determined without regard to the existence of any other coverage that may apply. The COB provision seeks to cover the insured for the losses caused by the injury or illness, while avoiding duplication of benefits and the chance that the insured may profit from the loss. Group health plans in Florida are required to coordinate benefits among group plans that contain similar benefits.

Required Extensions of Benefits

Group health insurance policies must extend benefits for an insured who is totally disabled when the contract is discontinued. Benefits must be continued for at least 12 months under major medical type policies; or 90 days for other types of hospital, medical, or surgical coverage.

Access to Dermatologists

HMOs and exclusive provider organizations that offer dermatological services must cover office visits, procedures, and testing by dermatologists. Subscribers and enrollees can visit a dermatologist up to five times each year without having to receive a referral or prior authorization.

Common Exclusions from Coverage

Health insurance policies issued in Florida can exclude the following from coverage: pre-existing conditions or diseases alcoholism and drug addiction illness, treatment, or medical conditions arising from war or act of war; participation in a felony, riot, or insurrection; service in the armed forces or auxiliaries; suicide, attempted suicide, or intentionally self-inflicted injury; or aviation as a crewmember or non-fare paying passenger mental or emotional disorders services for which Medicare pays benefits routine physical exams pregnancy eyeglasses and hearing aids cosmetic surgery services for which no charge is usually made in the absence of insurance

Mental Health Parity

If a group policy provides mental health benefits, the policy must offer the same lifetime and annual dollar limitations on benefits as for other medical and surgical benefits under the policy. However, small group policies are exempt from this requirement.

Other Insurance

If a person has other insurance that provides benefits on an expense-incurred (or for-service) basis, the total amount of coverage the person can have from a single insurer will be limited to a specific maximum amount, no matter how many health insurance policies have been issued to the person. The benefits that an insurer will pay for expenses incurred will be prorated if the insurer was not notified of other existing coverage for the same risk. This prevents overinsurance of the person. Any premiums paid for excess coverage will be returned to the insured

Policy Reinstatement

If a policyholder fails to pay the renewal premium within the grace period and the policy lapses, the policy will nevertheless be reinstated if the insurer accepts payment at a later date. However, if the insured must also apply for reinstatement, the insurer will issue a conditional receipt to the insured until the application for reinstatement is approved. If the insurer fails to approve the application within 45 days, the policy will be automatically reinstated unless the insurer has given written notice to the insured that it will not reinstate the policy. The reinstated policy will cover losses resulting from accidental injury after the date of reinstatement and losses resulting from sickness that began more than ten days after reinstatement. In all other respects, the reinstated policy restores the same rights that the insurer and insured had before the policy lapsed.

Misstatement of Age or Sex

If the insured misstated his or her age or sex in the application, benefits payable will be what the premiums would have purchased at the correct age or sex.

Length of Coverage

If the order of benefit payment cannot be determined by other rules, the benefits of the plan that has covered the employee or subscriber longer pay before those of a plan that has covered the insured for a shorter time.

Proof of Loss

If the policy provides benefits for a continuing loss (such as an ongoing disability), the claimant is required to give written proof of loss to the insurer within 90 days after the end of each period for which the insurer is obligated to pay benefits. For all other losses, the claimant has up to 90 days after the loss to file written proof of loss. If it is not reasonably possible for the claimant to give this written proof within the time allowed, the claimant must provide it as soon as reasonably possible. However, the claimant cannot submit this proof more than one year after it is required, unless the claimant was legally incapacitated.

Small Employers Access Program

In 2004, the Florida legislature added the Small Employers Access Program, which created the Small Business Health Plan. The purpose of the plan is to expand affordable health insurance coverage options for small employers. Notably, small employers can provide health-care benefits to their employees through purchasing pools, which may be comprised of: employers with up to 25 employees a municipality, county, school district, or hospital employer located in rural areas nursing home employers Specially selected insurers approved by the Office can offer coverage, while licensed and appointed health insurance agents can solicit policies.

Maternity Care

In Florida, if an individual, group, or HMO health insurance policy provides coverage for maternity care, it must also cover the services of certified nurse-midwives, midwives, and birth centers. A health insurance policy that provides maternity benefits may not limit the length of a hospital stay to less than what is medically necessary. Policies must also cover post-delivery follow-up care, including a postpartum assessment and newborn assessment, and tests and immunizations.

Eligible Groups

In Florida, the following groups may obtain group accident and health insurance coverage: employer and employee groups labor unions, associations, and small employer health alliances debtor groups credit union groups any group that is eligible for group life insurance

Selection of Risks

Insurers may not establish eligibility rules for group health insurance based on the following health-status related factors: health status medical condition, including physical and mental illnesses claims experience receipt of health care medical history genetic information evidence of insurability, including conditions related to domestic violence disability

Medicare Supplement Policies

In a Medicare supplement policy, a pre-existing condition cannot be defined more restrictively than a condition for which medical advice was given or treatment was recommended by or received from a medical doctor within six months before the effective date of coverage. In general, an insurer can exclude benefits during the first six months of coverage on the basis of a pre-existing condition for which the insured received treatment or was diagnosed during the six months before the effective date of coverage

Health Insurance Policy Regulations Required Policy Provisions

Individual accident and health insurance policies issued in Florida must contain certain provisions, as required by law.

Treatment of Facial Bones and Joints

Individual and group health insurance policies must provide coverage for diagnostic and surgical procedures involving the bones or joints of the jaw and facial region, if medically necessary to treat congenital or developmental deformity, disease, or injury.

Treatment of Diabetes

Individual and group health insurance policies must provide coverage for equipment, supplies, and outpatient self-management training and educational services that are medically necessary to treat diabetes.

Treatment of Osteoporosis

Individual and group health insurance policies must provide coverage for the diagnosis and treatment of osteoporosis for high-risk individuals.

Emergency Care

Individual and group policies are required to cover treatment provided in an ambulatory surgical center, if the treatment would have been covered on an inpatient basis.

Health Insurance Coverage Required Health Coverages Pre-existing Conditions

Individual health insurance policies may not exclude coverage for pre-existing conditions for more than 24 months following the effective date of coverage. A pre-existing condition exclusion may only relate to a condition for which medical advice was given or treatment was recommended by or received from a medical doctor within 24 months before the effective date of coverage; or a pregnancy existing on the effective date of coverage. An insurer is required to credit any pre-existing condition exclusionary period that a person satisfied under a previous plan to the pre-existing condition exclusionary period of the new plan, if the previous coverage was continuous during the 63 days before the effective date of the new coverage.

Maternity Benefits Optional in Individual Policies

Individual health insurance policies may or may not provide maternity benefits. If an individual policy covers maternity services, the policy must meet minimum standards prescribed by law, discussed next.

Guaranteed Availability of Coverage

Individuals are eligible for guaranteed issuance of an individual policy if they had 18 months of creditable coverage under a group plan. If covered by an individual policy, guaranteed issuance applies if coverage terminated because the insurer discontinued offering all policies in the state or the insured no longer lives in the insurer's service area.

Replacement

Insurers and producers are required to determine from an applicant whether he or she already has a Medicare supplement policy, Medicare Advantage, Medicaid coverage, or another health insurance policy in force. They must also determine whether a Medicare supplement policy is intended to replace an existing health insurance policy. They are to inform the applicant that more than one Medicare supplement policy is not necessary and that the policy may not cover all of the applicant's expenses. If a Medicare supplement policy replaces another Medicare supplement policy, the agent or insurer must give the applicant a Notice Regarding Replacement of Medicare Supplement Coverage. The applicant and agent must both sign the notice and retain a copy. If a Medicare supplement policy replaces another Medicare supplement policy, the replacing insurer must waive any pre-existing condition periods, waiting periods, elimination periods, and probationary periods in the replacement policy to the extent these periods were satisfied under the original policy.

Alcoholism and Drug Dependency

Insurers must offer group policyholders the option of adding coverage for the treatment of alcoholism and substance abuse. The following minimum benefits must be offered: a minimum lifetime benefit of $2,000 a maximum of 44 outpatient visits a maximum benefit of $35 per outpatient visit

Mental and Nervous Disorders

Insurers must offer group policyholders the option of including coverage for mental and nervous disorders. If coverage is elected, a group policy must provide at least 30 days per year for inpatient benefits outpatient benefits (which may be limited to $1,000 per year) benefits for partial hospitalization

Prohibited Discrimination

Insurers that offer group, small group, or HMO group policies may not condition eligibility or continued eligibility for health insurance coverage based on an individual's: health status medical condition, including physical and mental illnesses claims experience receipt of health care medical history genetic information evidence of insurability, including conditions arising out of acts of domestic violence disability Florida also permits insurers to sell federally qualified long-term care insurance policies. These policies may not be canceled or not renewed because of the insured's age or deterioration of mental or physical health; establish a new waiting period if existing coverage is converted to or replaced by a new policy within the same company (except if benefits are voluntarily increased by the insured individual or group policyholder); provide coverage for skilled nursing care only or provide more coverage for such care; or contain an elimination period that is more than 180 days.

Medicare Supplement Insurance Regulation of Medicare Supplement Insurance Purpose of Medicare Supplement Insurance MEDIGAP

Medicare supplement plans, also known as Medigap plans, are designed to fill the gaps and pick up coverage where Medicare leaves off. Sold by private insurance companies, Medicare supplement policies cover most, if not all, of the coinsurance and deductible amounts and also pay for various health services not covered by Medicare. Consequently, Medicare supplement policies can help retirees lower their out-of-pocket health-care expenses.

Medicare Supplement Policies

Medicare supplement policyholders have the right to return the policy within 30 days of delivery and receive a full refund of premium if, after examining the policy, they are not satisfied for any reason. The insurer must refund the premium paid in a timely manner.

Time of Payment of Claims

Once the insurer receives proof of loss, it will pay the benefits due to the insured, the beneficiary, or the insured's estate. If benefits are to be paid over a period of time, they cannot be paid any less often than monthly. Health insurers must reimburse claims within 45 days after receiving the claim. If a claim is contested, the insurer must pay or deny the claim within 60 days after receiving additional information requested regarding the claim.

Policy Lapse

Policies that cover persons age 64 or older and that have been in force for at least one year have an additional 21-day grace period before a policy will lapse due to nonpayment of premium. This means that a policyowner has a minimum grace period of 52 days for ordinary life insurance policies. However, this provision does not apply in cases where the premium is payable monthly or more often, or if the premium is automatically deducted from the policyowner's checking account, billed to a credit card, or regularly collected by an agent. Insurers must send a lapse notice to these policyowners at the end of the regular grace period and allow an additional 21 days for payment of the past-due premium. In cases where the policy already includes an extended grace period (52 or more days), the lapse notice must be sent 21 days before the expiration of policy's grace period. Insurers must notify policyowners age 64 or older that they have the right to name a secondary addressee—that is, a person who will also be notified in the event of an impending lapse.

Maternity Coverage

Policies that provide coverage for maternity care must cover: the services of midwives and birthing centers post-delivery care Policies may not shorten hospital stays to less than what is considered medically necessary or offer incentives to providers to offer care or benefits that are inconsistent with the law.

Pre-Existing Conditions

Pre-existing conditions are those for which medical advice or treatment was received or recommended up to six months before the effective date of coverage. Though an insurer of a group, small group, and HMO policy may exclude pre-existing conditions, it must cover them no later than 12 months after the effective date of coverage (18 months for late enrollees). An insurer is required to credit any pre-existing condition exclusionary period that a person satisfied under a previous plan to the pre-existing condition exclusionary period of the new plan. Genetic information may not be treated as a pre-existing condition unless an actual condition or illness has been diagnosed. A pre-existing condition exclusion may not be applied to newborns, adopted children, or pregnancy.

Florida Legislation for Individual and Employee Health Care State Health Care Legislation Florida Employee Health Care Access Act

The Florida Employee Health Care Access Act regulates the provisions that must be included in health insurance contracts offered to small employers.

Small Employer Health Alliances

Small Employer Health Alliances are voluntary association group plans that negotiate with various insurers for insurance in the private market. The purpose is to encourage small employers in Florida to join together and purchase health insurance collectively for their employees at a reduced premium rate. If a small employer eventually employs more than 50 but fewer than 75 employees, it may continue coverage under the Alliance for one year only. Small employers who participate in an Alliance must be formed for a purpose other than to obtain insurance and must certify that employees have not been hired solely to obtain insurance coverage.

Florida Health Insurance Plan

The Florida Health Insurance Plan makes health insurance available to Florida residents who are denied coverage in the regular insurance market because of prior medical conditions. The plan offers: a standard health insurance plan a basic health insurance plan catastrophic coverage (which includes a minimum level of primary care coverage) a high deductible plan that meets the federal requirements of a health savings account A Florida resident is eligible for a plan policy if he or she has been rejected or refused insurance coverage for health reasons from at least two health insurers or HMOs; or the person is enrolled in the Florida Comprehensive Health Association (a program designed to help residents who are uninsurable that has stopped accepting new enrollments). Dependents of Florida residents who are eligible for coverage are also entitled to benefits under the plan. A person is not eligible for coverage under the plan if he or she obtains similar health insurance or is eligible to obtain such coverage; is eligible for Medicaid, Medicare, the state's children's health insurance program, or another federal, state, or local government program that provides health benefits; voluntarily terminates plan coverage (unless 12 months have elapsed since the termination); is an inmate or resident of a public institution; or has premiums paid for or reimbursed by a government-sponsored program, agency, or health-care provider.

Florida Healthy Kids

The Florida Healthy Kids Corporation is a public-private initiative designed to improve access to comprehensive insurance and health care for uninsured children ages 5 through 18 in the state. Coverage is provided for doctor visits, immunizations, dental care, emergency care, and hospital stays, among other benefits. Healthy Kids uses local, state, federal, and family funds to pay premiums to commercial health insurers, who agree to provide insurance. Families pay a nominal premium amount per month, along with co-payments for certain services. To qualify for coverage, a child must be a Florida resident and must be uninsured; be age 5 through 18; not be eligible for Medicaid; and not be a child of a state employee.

Health Insurance Portability and Accountability Act (HIPAA) Florida Conformity with HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) requires insurers to comply with certain requirements when offering health coverage.

Investigatory Power of Department

The Office can examine and investigate a prepaid health clinic's books and records to ensure that it is operating lawfully and that it is not engaged in any unfair methods of competition or unfair or deceptive acts or practices.

Small Employer Rating, Renewability, and Portability Act

The Small Employer Rating, Renewability, and Portability Act requires insurers to set the premiums for an employer's group policy on the sex, age, family composition, use of tobacco products, or geographical location of the employees and their dependents. Rates cannot depend on the health status or claims experience of any member of the group or of the group as a whole. Once the rates have been set, insurers cannot change them for 12 months after the coverage takes effect or is renewed unless the composition of the group changes or the benefits change.

Medical Examination

The insurer has the right to conduct a physical examination of the insured whenever and as often as reasonably necessary to investigate a claim. The insurer may also conduct an autopsy of the insured in Florida during the contestability period unless the law forbids it.

Change of Occupation

The insurer is allowed to reduce the benefits payable under the policy if the insured changes his or her occupation to one that is more hazardous than the one for which the premiums were set. Conversely, if the insured changes his or her occupation to one that is less hazardous than the one for which the premiums were set, the insurer may reduce the premium. Any excess unearned premium will be returned to the insured.

Order of Benefit Payment

The order in which benefits are paid under a COB provision are generally as follows: The primary plan pays its benefits as if the secondary plan did not exist. However, if coverage is intended to supplement other insurance, that supplementary coverage will be excess to any other coverage. A secondary plan can take benefits paid under another plan into consideration only when it is secondary to that other plan. A plan that covers the insured as an employee or subscriber (but not as a dependent) pays benefits before those of a plan that covers the insured as a dependent.

Dependent Children of Married Parents, or of Parents with Joint Custody

The order of benefits for dependent children is as follows when they are covered by two or more health insurance plans: The benefits of the plan of the parent whose birthday (month and day) is earlier in the year pays benefits before those of the plan of the parent whose birthday is later in the year. If both parents have the same birthday, the plan that has covered the parent longer pays benefits before the plan that covers the other parent pays benefits.

Dependent Children of Separated or Divorced Parents

The order of benefits for dependent children is as follows when they are covered by two or more health insurance plans: The plan of the parent with custody of the child pays benefits first. The plan of the spouse of the parent with custody of the child pays next. The plan of the parent who does not have custody of the child pays last. However, if a court orders one of the parents to be responsible for the health care expenses of a child, that parent's plan will be the primary coverage. The other parent's plan will be the secondary coverage.

Right to Examine (Free Look)

The policyholder is entitled to review the policy for at least ten days after it is delivered. If unsatisfied with it for any reason, the policyholder can return it to the insurer for a full refund of the premium paid.

Exclusions from Health Insurance Coverage Policy Exclusions Purpose

The purpose of an exclusions provision in a health insurance policy is to specify the types and causes of loss that are not covered by the policy.

Purpose and Definition

The purpose of the Florida Employee Health Care Access Act is to promote the availability of health insurance for small employers, regardless of claims experience or employees' health status; establish rules regarding renewability of coverage; limit the use of exclusions for pre-existing conditions; develop a standard and basic health benefit plan for small employers; establish a reinsurance program for small employer coverage; and improve the fairness and efficiency of the small group health insurance market.

Florida Health Insurance Coverage Continuation Act

The purpose of the Florida Health Insurance Coverage Continuation Act is to ensure continued access to affordable health insurance coverage for employees of small employers and their dependents who are not currently protected by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Group health plans issued to small employers must provide that each person who would lose coverage under the group plan (due to job loss, death, divorce, or ceasing to be a dependent) is entitled to continue coverage under the group plan. Evidence of insurability is not required. A person must notify the insurer that he or she elects to continue coverage and must pay the first premium within 30 days after receiving an election and premium notice form from the insurer. Coverage under the group plan must be extended until the earliest of: 18 months after the date group coverage would have ended the date the person fails to pay premiums the date the person is covered by another group plan the date the person becomes eligible for Medicare the date group coverage is terminated for all employees

Forms of Group Health Insurance

The types of health insurance that can be written on a group basis include: basic hospital expense insurance basic medical expense insurance basic surgical expense insurance hospital confinement indemnity insurance major medical expense insurance disability income insurance accident only insurance limited benefit insurance supplemental insurance home service health coverage

Protection Against Unintentional Lapse

To protect a long-term care insurance policy from unintentionally lapsing, long-term care applicants may designate a person to receive notice of lapse or termination of the policy due to nonpayment of premium. The applicant may sign a written waiver electing not to designate another person to receive such notice. The waiver states as follows: "Protection against unintended lapse.—I understand that I have the right to designate at least one person other than myself to receive notice of lapse or termination of this long-term care or limited benefit insurance policy for nonpayment of premium. I understand that notice will not be given until 30 days after a premium is due and unpaid. I elect NOT to designate any person to receive such notice." Insurers must regularly notify insureds of the right to change their written designation, at least every year. An insurer may terminate an individual long-term care policy for nonpayment of premium only after giving the insured and his or her designee at least 30 days' notice. If a policy is cancelled due to a failure to pay the premium, the insured can have the policy reinstated if, within five months after the cancellation, the insured (or the other designated person) shows that the failure to pay the premium was unintentional and due to the insured's cognitive impairment, loss of functional capacity, or continuous confinement in a hospital, nursing or assisted living facility for more than 60 days.

Creditable Coverage

Under HIPAA, a person with 18 months of creditable coverage must be given access to an insurance policy. Creditable coverage includes a group health plan (insurance or HMO), individual policy, Medicare, Medicaid, or other government plan. A certificate of creditable coverage provided by a health insurer is its written confirmation that the insurer insured an individual for the period stated. Another health insurer must accept this certificate in determining the eligibility of an individual for coverage. If applicable, the certificate will show that the individual has at least 18 months of creditable coverage, the date on which creditable coverage began, and the date it ended. An insurer will not count a period of creditable coverage if, after the most recent period of creditable coverage and before enrollment in its plan, 63 consecutive days have passed during which the individual did not have any creditable coverage. In Florida, the required access to an individual policy is made available through the issuance of a conversion policy when the insured is no longer eligible for group coverage (e.g., because the group policy is canceled, the insured leaves the group, or a spouse or dependent no longer qualifies as a family member). Insurers are required to mail an election and premium notice form to eligible individuals within 14 days after receiving notice that an individual is eligible for a conversion policy. However, if a person is HIPAA-eligible but does not qualify for a conversion policy, the person must be given access to an individual health insurance policy by an insurer selling individual policies in Florida.

Discount Medical Plan

Under a discount medical plan, an entity, in exchange for a fee, provides access for plan members to medical service providers and the right to receive medical services from those providers at a discount. Medical discount plans do not pay for a person's health-care costs. Before an organization can transact business in Florida as a discount medical plan, it must submit an application and receive a license from the Office. A license expires one year after it is issued. The Office will renew a license if the organization pays the annual license fee and has complied with the law. Before receiving a license, a discount medical plan organization must also establish an Internet Web site where it maintains a current list of providers with which it has contracted.

Regulation of Health Insurance Plans, Part 2 Types of Health Plans, Part 2 Preferred Provider Organization (PPO)

Under a preferred provider organization (PPO) health plan, a group of doctors and health-care providers contracts with a commercial insurer to provide services at an agreed-upon, reduced rate. PPO members are free to receive services from any providers in the PPO's network. They can also visit out-of-network doctors but will be reimbursed at a lower rate for such care. Unlike an HMO, PPO members need not select a primary care physician and are not required to obtain a referral before seeing a specialist. Insurers must give each PPO member a current list of preferred providers and must maintain a copy of the list at their home office. The amount of annual deductibles and coinsurance that PPOs can charge for in-network versus out-of-network services are limited by law.

Change of Beneficiary

Unless the insured makes an irrevocable beneficiary designation, the insured retains the right to change the beneficiary by giving written notice to the insurer. Consent of any beneficiary is not required for the insured to surrender or assign the policy or to change any beneficiary, or for other changes in the policy.

Claim Procedures Notice of Claim

Upon receiving the claimant's notice of claim, the insurer has 15 days in which to send the claimant the forms for filing proof of loss. If the insurer fails to do so, the claimant can instead provide proof of loss by giving a written statement describing the loss

Agent Duties when Soliciting Medicare Supplement Insurance

When marketing Medicare supplement plans in Florida, an insurer must develop marketing procedures to ensure that any comparison of its policies by producers is fair and accurate; develop marketing procedures to prevent the sale or issuance of excessive insurance; display a notice on the first page of every policy that says "Notice to buyer: This policy may not cover all of your medical expenses"; reasonably try to determine whether a prospective applicant or enrollee for Medicare supplement insurance already has accident and sickness insurance and the types and amounts of that insurance; and develop a means by which examiners can audit the insurer's marketing procedures. In addition to the usual prohibitions in marketing life and health insurance policies, insurers and producers selling Medicare supplement policies cannot engage in twisting, or making misleading statements or comparisons of policies to induce a person to lapse, surrender, terminate, or convert a policy or to take out a policy with another insurer; high pressure tactics, or inducing a person to buy insurance through force, fear, threat, or undue pressure; or cold lead advertising, or failing to disclose that the intent of the advertising is to sell insurance and that a producer or insurance company will contact the prospect.

Physician and Medical Doctor Defined

When used in health insurance policies, the word "physician" or "medical doctor" also includes a dentist when the policy covers surgical procedures that are specified in the coverage or that are provided in a hospital in consultation with a licensed physician and are within the scope of the dentist's license.