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Health Insurance and HMO Header

Health insurance covers you and your family from the devastating financial effects of unexpected medical bills.

Policies can be issued to individuals, employer/employee groups, or to members of associations. Some coverage is provided by self insured funds, not regulated by the State of Florida. Although there are other forms of health insurance, the three main categories of health insurance are:

  1. Policies that provide managed care services, including major medical Preferred Provider Organization (PPO) coverage and Health Maintenance Organization (HMO) contracts;
  2. Policies that offer traditional major medical coverage, and
  3. Policies that provide limited benefits.

 

Common terms

COBRA: “Consolidated Omnibus Budget Reconciliation Act of 1985,” a federal law extending group health coverage to qualified terminated employees and their families for up to 18 or 36 months. It applies to groups with 20 or more employees.

Coinsurance: Principle under which the company insurers only part of the potential loss, the policyowner paying the other part. For instance, in a major medical policy, the company may agree to pay 80 percent of the insured expenses, with the insured to pay the other 20 percent.

Deductible: A deductible is a stated initial dollar amount that the individual insured is required to pay before insurance benefits are paid. For example, if a plan has a flat $250 annual deductible, the insured is responsible for the first $250 of medical expenses every year.

 

Managed Care services

The managed care system combines the delivery and financing of health care services. This limits your choice of doctors and hospitals. In return for this limited choice, you usually pay less for medical care (i.e., doctor visits, prescriptions, surgery and other covered benefits) than you would with traditional health insurance as long as you obtain services from an in-network provider or facility. The managed care network controls health care services.

The types of Managed Care are:

Preferred Provider Organizations (PPOs): PPOs offer a provider network to meet the health care needs of its insureds. An insurer contracts with a group of health care providers to control the cost of providing benefits to its insureds. These providers charge lower-than-usual fees because they require prompt payment and serve a greater number of patients. Insureds usually choose who will provide their health care, but typically pay a lower deductible and less in coinsurance with a preferred provider than with a non-preferred provider. Most group health policies fall under this category of major medical coverage.

Florida Statute References

HMO (Individual and Group): 627.6471
Small Group Health: 627.6471
Large Group Health: 627.6471
Individual Health: 627.6471
Out-of-State: does not apply
Standard & Basic (HMO & Insurance): 627.6471 and 627.6699

 

Health Maintenance Organization (HMO): HMO members pay a monthly fixed dollar amount (similar to an insurance premium), which gives them access to a wide range of health care services. In many cases, members also pay a predetermined amount, or copayment, for each doctor or emergency room visit and for prescription drugs, rather than paying the provider in full and obtaining a portion of the reimbursement later. Members must use the HMO’s network of providers, which may include the doctors, pharmacies and hospitals under contract with that particular HMO. Emergency services are covered regardless of the network status of the medical provider or facility.

Florida Statute References

HMO (Individual and Group): 641.19
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply

 

Point of Service plans (POS): A Point of Service plan is a HMO plan with an out of network option. In a POS plan, insured members may choose, at the point of service, whether to receive care from a physician within the plan’s network or to go out of the network for services. The POS plan provides less coverage for health care expenses provided outside the network than for expenses incurred within the network. Also, the POS plan will usually require you to pay higher deductibles and coinsurance costs for medical care received out of network.

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply

 

Exclusive Provider Organizations (EPOs:) In an EPO arrangement, an insurance company contracts with hospitals or specific providers. Insured members must use the contracted hospitals or providers to receive benefits from these plans. Emergency services are covered regardless of the network status of the medical provider or facility.

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.6472
Individual Health: 627.6472
Large Group Health: 627.6472
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): 627.6472 and 627.6699
Traditional Major medical

Traditional health coverage is provided by major medical policies and is more expensive because it provides more benefits than basic policies. A major medical policy normally pays a percentage of covered expenses (normally 80%), after you pay the deductible. Insurance companies use fee schedules to determine the reasonable and customary cost of a procedure; however, this cost may differ from the actual charge you receive. Maximum out-of-pocket limits restrict the amount of coinsurance you pay. Not all policies include such limits, but those that do pay 100 percent of remaining covered expenses after you pay a stated amount of coinsurance. You are not restricted to a particular network of medical providers under a traditional major medical policy.

Required Benefits

The following “required benefits” may not apply to all policies. The term “required benefits” is broadly interpreted to include any coverage requirement; required benefits may include:

  1. required benefits;
  2. the requirement to offer benefits;
  3. required payment to a class of providers;
  4. required coverage of certain insured individuals; and,
  5. other underwriting restrictions.

Acupuncturists: Acupuncture services are not a required benefit under health insurance contracts. However, any policy of health insurance that provides coverage for acupuncture shall cover the services of an acupuncturist certified under Chapter 457, Florida Statutes, under the same conditions that apply to services of a licensed physician. (This does not apply to HMO’s or Out of State Groups.)

Florida Statute References

HMO (Individual and Group): does not apply
Individual Health: 627.6403
Large Group Health: 627.6618
Small Group Health: 627.6618
Out-of-State: does not apply
Standard & Basic (HMO & Insurance):627.6699 (may limit number of treatments)
 

Adopted or Foster Children with Pre-Existing Illness: A health plan that provides coverage for a family member must provide that benefits applicable to children of the contract holder also apply to an adopted child. Coverage should start from the moment of placement in the residence of the contract holder or the moment of birth, if a written agreement was signed prior to the birth of the child.

The contract may not exclude coverage for any pre-existing condition(s) of the child. An additional premium may be charged to add an adopted child to a group plan, if the plan charges an additional premium for each family member. (This requirement does not apply to out-of-state groups.)

Florida Statute References

HMO (Individual and Group): 641.31 (adopted only)
Small Group Health: 627.6578
Large Group Health: 627.6578
Individual Health: 627.6415
Out-of-State: does not apply
Standard & Basic (HMO & Insurance):627.6699 (adopted only)

Ambulatory Surgical Centers: All health insurance policies providing coverage on an expense-incurred basis shall provide coverage for any service performed in an ambulatory surgical center, as defined in s. 395.002, Florida Statutes, if such service would have been covered under the terms of the policy or contract as an eligible inpatient service. (Does not apply to HMO’s and Out of State Group Plans)

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.6699
Individual Health: 627.6056
Large Group Health: 627.6616
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): 627.6699
 

Autism and Developmental Disabilities: Insurers and HMO’s must provide coverage for individuals with autism spectrum disorder for large group health insurance plans (51 or more employees) and the State of Florida employee plan.

The contracts must cover screening and therapies for autism for children diagnosed before age 8 with autism spectrum disorders - specifically autistic disorder, Asperser’s disorder, and pervasive development disorder not otherwise specified - coverage includes up to $36,000 a year for therapies, up to $200,000 in total lifetime benefits.

Additionally, insurers or HMO’s cannot deny coverage due to diagnosis of a developmental disability, and coverage must continue until the child’s 18th birthday or until the child is no longer enrolled in high school

Florida Statute References

HMO (Large Group and State Plans Only) 641.31098
Individual Health: does not apply
Large Group Health: 627.6686
Small Group Health: does not apply
Out-of-State: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Birth Centers and Midwife Benefits: A policy of health insurance that provides maternity benefits must provide, as an option, coverage for the services rendered by nurse-midwives and midwives licensed under Chapter 467, and the services of birth centers licensed pursuant to Florida Statute 383.30 - 383.335.

Health Maintenance Organizations (HMOs) must also comply with this provision if these services are available within the service area.

Florida Statute References
HMO (Individual and Group): 641.31
Small Group Health: 627.6699 and 627.6574
Large Group Health: 627.6574
Individual Health: 627.6406
Out of State Group: 627.6515 and 627.6574
Standard & Basic (HMO & Insurance): 627.6699
 

Bone Marrow Transplants: An insurer or a HMO may not exclude coverage for bone marrow transplant procedures recommended by the referring physician and the treating physician under a policy exclusion for experimental, clinical investigative, educational, or similar procedures contained in any individual or group health insurance policy or HMO contract issued, amended, delivered, or renewed in this state that covers treatment for cancer, if the particular use of the bone marrow transplant procedure is determined to be accepted within the appropriate oncological specialty and not experimental. Covered bone marrow transplant procedures must include costs associated with the donor-patient to the same extent and limitations as costs associated with the insured, except the reasonable costs of searching for the donor may be limited to immediate family members and the National Bone Marrow Donor Program. (This does not apply to Out of State Group Plans)

Florida Statute References

HMO (Individual and Group): 627.4236
Small Group Health: 627.4236
Large Group Health: 627.4236
Individual: 627.4236
Out-of-State: does not apply
Standard & Basic (HMO & Insurance)627.4236
 

Breast Cancer - Fibrocystic Conditions (Limitations): An insurer may not refuse issuance, renewal or cancel solely because the insured has been diagnosed as having a fibrocystic condition or a non-malignant lesion that demonstrates a predisposition, or solely due to the family history of the insured related to breast cancer, or solely due to any combination of these factors, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer. Also, an insurer may not refuse issuance, renewal, or cancel solely due to breast cancer, if the insured has been free from breast cancer for more than 2 years before the applicant's request for health insurance coverage. (This does not apply to Out of State Group or Standard & Basic Plans)

Florida Statute References

HMO (Individual and Group): 627.6419
Small Group Health: 627.6419
Large Group Health: 627.6419
Individual Health: 627.6419
Out of State: does not apply
Standard & Basic (HMO & Insurance):does not apply
 

Cancer Drugs: If a policy covers the treatment of cancer, an insurer may not exclude coverage for any prescribed drug on the ground it’s not approved by the U.S. Food and Drug Administration (FDA), if the drug is recognized for treatment of that indication in a standard reference compendium or recommended in the medical literature, unless the FDA has determined that the use of the drug is contra-indicated or has not otherwise approved the drug for any indication.

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.4239
Individual Health: 627.4239
Large Group Health: 627.4239
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Child Health Supervision (aka Well Baby Care): All health plans or HMOs issued or delivered in the State of Florida; must provide for child health supervision services delivered or supervised by a physician. Coverage must include periodic visits which shall include a history, a physical examination, a developmental assessment and anticipatory guidance, and appropriate immunizations and lab tests. Visits and periodic visits shall be provided in accordance with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics. Under state law, policy deductibles do not apply but co-insurance can apply. Policy co-payments do apply.

Please note: If the policy is subject to the federal Affordable Care Act (ACA), there should be no out of pocket expense for well visits. Check with the insurer or HMO to confirm policy benefits.

This benefit is commonly referred to as "Well Baby Care." Florida law does not apply to disability income, specified disease, Medicare Supplement, hospital indemnity or self-funded health plans. It does apply to all Individual, Small & Large Group, Out of State Group, and HMOs.

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6579
Large Group Health: 627.6579
Individual Health: 627.6416
Out-of-State Group: 627.6515 and 627.6579
Standard & Basic (HMO & Insurance):627.6699
 

Cleft Lip / Cleft Palate, Children: A health insurance policy that covers a child under the age of 18 must provide coverage for treatment of cleft lip and cleft palate for the child. The coverage must include medical, dental, speech therapy, audiology, and nutrition services only if those services are prescribed by the treating physician or surgeon and such physician or surgeon certifies that the services are medically necessary and consequent to treatment of the cleft lip or cleft palate.

The coverage required by law is subject to terms and conditions applicable to other benefits. The law does not apply to specified-accident, specified-disease, hospital indemnity, limited benefit disability income, or long-term care insurance policies.
(This applies to all individual, groups, out of state group, and HMO contracts.)

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.66911
Large Group Health: 627.66911
Individual Health: 627.64193
Out of State Group: 627.6515 and 627.66911
Standard & Basic (HMO & Insurance):627.6699
 

Continuation of Coverage for Handicapped Children: Coverage for a handicapped child terminates once the dependent child has reached the age specified in the contract. However, the dependent child will not be removed if the child continues to be both:

  1. incapable of self-sustaining employment due to mental retardation or a physical handicap, and
  2. chiefly dependent upon the policyholder or subscriber for support or livelihood.

If a claim is denied under a policy or contract for the stated reason that the child has attained the limiting age for dependent children s specified in the policy or contract, the notice of denial must state that the policyholder has the burden of establishing that the child continues to meet the criteria specified in subsections (1) and (2). (This does not apply to out of state association groups.)

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6515
Large Group Health: 627.6515
Individual Health: 627.6041
Out-of-State: does not apply
Standard & Basic (HMO & Insurance):627.6699
 

Chiropractors: When any health insurance policy, health care services plan, or other contract provides for the payment for medical expense benefits or procedures, such policy, plan, or contract shall be construed to include payment to a chiropractic physician who provides the medical service benefits or procedures which are within the scope of a chiropractic physician's license. Any limitation or condition placed upon payment to, or upon services, diagnosis, or treatment by, any licensed physician shall apply equally to all licensed physicians without unfair discrimination to the usual and customary treatment procedures of any class of physicians. (This does not apply to HMOs.)

Florida Statute References

HMO: does not apply
Small Group Health: 627.6699
Group: 627.419
Individual: 627.419
Out-of-State Group: 627.6515
Standard & Basic (HMO & Insurance):627.6699
 

Continuation of Group Coverage (Mini-COBRA): The Florida Health Insurance Coverage Continuation Act is the state law that provides employees and their dependents the opportunity to extend group health coverage through their employer’s health plan due to certain qualified events if they are not eligible for the federal COBRA program due to the size of the group. Mini-COBRA applies to groups with 2 -19 employees. (This does not apply to a one-life group.)

Continued Care after HMO Provider is Terminated: When a contract between an Health Maintenance Organization (HMO) and a treating provider is terminated for any reason other than for cause, each party shall allow subscribers for whom treatment was active to continue coverage and care when medically necessary, through completion of treatment of a condition for which the subscriber was receiving care at the time of the termination, until the subscriber selects another treating provider, or during the next open enrollment period offered by the HMO, whichever is longer, but not longer than 6 months after termination of the contract. Each party to the terminated contract shall allow a subscriber who has initiated a course of prenatal care, regardless of the trimester in which care was initiated, to continue care and coverage until completion of postpartum care. 

Florida Statute References

HMO (Individual and Group): 641.51
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Conversion on Termination of Eligibility:

Individual Plans:  Florida law allows for an individual that was covered under a Florida-regulated individual health insurance policy providing hospital or medical expense coverage and is no longer eligible for the plan prior to becoming eligible for Medicare or Medicaid the opportunity to obtain a health insurance policy without evidence of insurability.

The application and premium must be paid within 31 days of the termination. The premium shall be at the insurer’s then customary rate applicable to such policies, to the class of risk in which the person belongs, and to his or her age attained on the effective date of the policy.

The converted policy may exclude any condition excluded by the prior policy. The insurer must offer maternity and dental benefits if they were provided in the prior policy.

The conversion policy shall be effectuated in such a way as to result in continuous coverage during the 31-day period for such insured. This section does not apply to HMOs, out of state association groups, disability Income, Medicare Supplement, accident only, hospital indemnity, specified disease, limited benefit, non-conventional, or excess policies.

Large Group, Small Group, Out of State Group Plans:  Written application must be received and the first premium paid not later than 63 days after termination of coverage. Employment can be terminated for any reason including gross misconduct. If termination is for non-payment of premium and is due to acts of the employer or policyholder other than the employee or certificateholder, then the written application and first premium must be paid to the insurer not later than 63 days after notice termination of is mailed by the insurer or employer, whichever is earlier, to the employee or certificateholder.

The converted contract must be issued without evidence of insurability. At the option of the company, a separate converted policy may be issued to any dependents previously covered.

The premium shall be at the insurer’s then customary rate applicable to such policies, to the class of risk in which the person belongs, and to his or her age attained on the effective date of the policy. The converted premium must be approved by the Office of Insurance Regulation and may not exceed 200 percent of the standard risk rate, as established under s. 627.6675.

The effective date of the converted contract will be the day after the termination date.

Please note: Conversion is not required under the Florida Standard & Basic Plan but it is included in the policy.

HMO:The written application and first premium must be received by the company within 63 days of the termination date. The converted contract must be issued without evidence of insurability and the termination can result from any cause including Gross Misconduct.

The converted premium must be approved by the Office of Insurance Regulation and may not exceed 200 percent of the standard risk rate, as established under s. 627.6675. The effective date of the converted contract will be the day after the termination date.

Florida Statute References

HMO (Group): 641.3921 and 641.3922
Small Group Health: 627.6675
Large Group Health: 627.6675
Individual Health: 627.646
Out of State: 627.6515
Standard & Basic (HMO & Insurance):Not required but included in the policy
 

Dental Care (This requirement applies to employers, not insurers.): An employer, group, or organization that pays or contributes to the premium of a group health insurance plan or dental service plan that provides services only through an exclusive list of dentists, must provide an alternative to enable the insured to have a free choice of dentist. The employer, group, or organization shall pay or contribute an equal dollar amount toward either alternative elected by the insured.

It is also the responsibility of the insurer to advise the employer, group, or organization of the requirement to offer the alternative plan.

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.6577
Individual Health: does not apply
Large Group Health: 627.6577
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Dental Procedure, Anesthesia & Hospitalization for Children: Anesthesia or hospitalization for dental procedures must be provided under certain circumstances by health plans, if the policy provides coverage for general anesthesia and hospitalization services to a covered person.

The covered person must be under 8 years of age and the licensed dentist and the child's physician state that anesthesia is necessary or that treatment must be in a hospital setting or ambulatory surgical center due to either of the following conditions:

  1. A significantly complex dental condition or a developmental disability in which management in the dental office has proved ineffective; or
  2. The child has one or more medical conditions that would create significant or undue medical risk for the child if not delivered in the above setting.

This does not require coverage for the diagnosis or treatment of the dental disease. The other terms of the policy will also apply to this service.

Florida Statute References
HMO (Individual and Group): 641.31
Small Group Health: 627.65755
Large Group Health: 627.65755
Individual Health: 627.4295
Out-of-State Group: does not apply
Standard & Basic (HMO & Insurance): Not Required
 

Dentists: The word "physician" or "medical doctor," when used in any health insurance policy, health care services plan, or other contract providing for the payment of surgical procedures which are specified in the policy or contract or are performed in an accredited hospital in consultation with a licensed physician and are within the scope of a dentist's professional license, shall be construed to include a dentist who performs such specified procedures. (This does not apply to HMO’s)

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.419
Individual Health: 627.419
Large Group Health: 627.419
Out of State Group: 627.6515 and 627.419
Standard & Basic (HMO & Insurance):627.6699
 

Dependent Children Maximum Age: Florida based group and individual health insurance policies and HMO contracts that offer coverage for dependent children of the contract holder, must insure a dependent child of the contract holder until the qualifying age if eligibility requirements are met. Contracts issued or renewed on or after October 1, 2008, must comply with the following requirements:

Insure a dependent child until the end of the calendar year in which the child reaches the age of 25, if the child meets the following requirements:

  1. The child is dependent upon the policyholder or certficateholder for support and
  2. The child is living in the household of the policyholder or certificateholder, or the child is a full-time or part-time student.

If a policy is subject to the above requirement, the insurer or HMO must also offer the contract holder the option to insure a dependent at least until the end of the calendar year in which the child reaches the age of 30, if he/she meets the following requirements:

  1. Is unmarried and does not have a dependent of his or her own;
  2. Is a resident of this state or a full-time or part-time student; and
  3. Is not provided coverage through another group or individual health plan, Medicare, or Medicaid.

The contract must also provide in substance that attainment of the limiting age does not terminate the coverage of the child while the child continues to be both:

  1. Incapable of self-staining employment by reason of mental retardation or physical handicap, and
  2. Chiefly dependent upon the employee or member for support and maintenance.

Please note: This Florida law does not apply to Out of State Groups. Florida regulated standalone dental and vision contracts have to comply with only the section that applies to dependents until age 25. This requirement does not apply to any self insured ERISA policies, disability, or specific disease (such as cancer) or life insurance policies.

Policies or contracts that are subject to the Patient Protection and Affordable Care Act (PPACA) that cover dependent children must extend coverage until the child’s 26th birthday. If the adult child is eligible for their own employer sponsored health plan, he/she is not eligible for the parent’s coverage. As of January 1, 2014, the eligibility of an adult dependent child for their own employer sponsored health plan will not render them ineligible for coverage under the parent’s policy. Adult children cannot be charged more than any other dependent.

The adult dependent child can be married and still eligible for coverage. However, a child of an adult dependent covered under a parent’s health insurance policy does not have to be covered.

This applies to all types of plans. This provision is effective for new business on or after September 23, 2010, and on the first policy anniversary on or after September 23, 2010, for existing business other than grandfathered individual policies.

Florida Statute References

HMO (Individual and Group): 641.31
Florida sitused Small Group Health: 627.6562; 627.6615
Florida sitused Large Group Health: 627.6562; 627.6615
Florida sitused Individual Health: 627.602; 627.6562; 627.6041
Out of State: does not apply
Standard & Basic (HMO & Insurance): 627.6562; 627.6615; 641.31
Self-insured ERISA: does not apply

Dermatologists: Insurers must provide coverage for Dermatologists and, without referral or authorization, direct access for up to five office visits annually, including minor procedures and testing, to a dermatologist who is under contract with the insurer or HMO. (This benefit does not apply to small group Standard and Basic plans or Out of State association groups.)

Florida Statute References

HMO (Individual and Group): 627.6472 & 641.31
Small Group Health: 627.662
Large Group Health: 627.662
Individual Health: EPO: 627.6472 PPO: 627.6471
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Diabetes Coverage: Individual and group health insurance policies, as well as HMO contracts, must cover all medically appropriate and necessary equipment, supplies, and diabetes outpatient self-management training and educational services used to treat diabetes, if the patient's physician or a physician who specializes in the treatment of diabetes certifies that such services are necessary. (This provision does not apply to out-of-state group associations.)

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.65745
Large Group Health: 627.65745
Individual Health: 627.6408
Out of State: does not apply
Standard & Basic (HMO & Insurance):627.65745
 

Emergency Care:

EPOs: Insurer’s issuing exclusive provider organization (EPO) contracts must cover non-exclusive providers if the services are for symptoms requiring emergency care and a network provider is not reasonably accessible.

HMOs: Health Maintenance Organizations (HMO’s) must provide coverage, without prior authorization, for emergency care, provided by either a participating or nonparticipating provider. The emergency treatment may have an additional copayment, but may not exceed $100 per claim.

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6472
Individual Health: 627.6472
Large Group Health: 627.6472
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): 627.6699
 

Enrollment Periods (Open, Special & Late): (This does not apply to Out of State Group or Individual Plans)

Open Enrollment: Open Enrollment: Employers must offer an annual 30-day open enrollment period. (HMO plans must offer a 30-day period every 18 months) when eligible employees may enroll in the group health plan regardless of their health history.

Special Enrollment: A person may enroll in the health plan as a special enrollee if they meet the following conditions:

At the time of initial enrollment, the person made a written statement indicating they were declining coverage because they were covered under another plan; and

The coverage was later terminated because:

  • Divorce or legal separation results in the person losing coverage under his/her spouse’s health insurance;
  • A young dependent, because of age, work, or school status, is no longer a covered "dependent" under a parent’s plan; under his or her plan;
  • The spouse’s employment ends, so health coverage under his/her employer’s health plan ends as well;
  • The employer reduces a person’s work hours to the point where he/she is no longer covered by the health plan;
  • The employer or plan decides it will no longer offer coverage to a certain group of individuals (for example, those who work part time);
  • The person no longer lives or works in the HMO’s service area;
  • The person has health claims that would meet or exceed the plan's lifetime limit on all benefits.

In addition to special enrollment due to loss of eligibility, an employee, spouse, and new dependent can have the right to special enrollment in the case of a life event such as marriage, birth, adoption, or placement for adoption.

Late Enrollee: A late enrollee is anyone that enrolls during a period other than the first period in which they are eligible for coverage or special enrollment. Late enrollees are subject to an 18 month pre-existing exclusion clause unless they can provide proof of creditable coverage.

Florida Statute References

HMO (Group): Open Enroll: 641.31 & Special Enroll: 641.31072
Small Group Health: 627.65615
Individual Health: does not apply
Large Group Health: 627.65615
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): 627.6699
 

Enteral Feeding Formula's / Treatment of PKU: Insurers shall make “available” to the policyholder as part of the application, for an appropriate additional premium, coverage for prescription and nonprescription enteral formulas for home use which are physician prescribed as medically necessary for the treatment of inherited diseases of amino acid, organic acid, carbohydrate, or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein, in an amount not to exceed $2,500 annually for any insured individual, through the age of 24. This section applies to any person or family notwithstanding the existence of any preexisting condition. (This does not apply to Out of State Groups or the Standard and Basic Plans)

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.42395
Individual Health: 627.42395
Large Group Health: 627.42395
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Extension of Benefits: Extension of benefits is provided if, at the time of the cancellation, nonrenewal or termination of the group contract, a subscriber has a total disability from a specific accident or illness or is pregnant.

An individual is considered totally disabled if the individual has a condition resulting from an illness or injury that prevents them from engaging in any employment or occupation AND the individual is under the regular care of a physician.

Extension of benefits ends at the earliest occurrence of one of the following:

  1. The expiration of 12 months under "major medical" type of coverage and, under other types of hospital, medical, or surgical coverage, provides an extension of at least 90 days.
  2. The member is no longer totally disabled;
  3. The succeeding carrier chooses to provide replacement without limitations for the disability condition; or
  4. The maximum benefits payable under the contract have been paid.

Insurance Companies: In the case of maternity coverage , a reasonable extension of benefits or accrued liability must be provided and include continuation of the contract benefits in connection with maternity expenses for a pregnancy that commenced while the policy was in effect.

HMO’s: In the case of maternity coverage, when not covered by the succeeding carrier, a reasonable extension of benefits or accrued liability provision is required, which provision provides for continuation of the contract benefits in connection with maternity expenses for a pregnancy that commenced while the policy was in effect. The extension shall be for the period of that pregnancy and shall not be based upon total disability.

(This provision does not apply to individual plans. Also, it does not apply to one life group policies terminated for nonpayment.)

Florida Statute References

HMO (Individual and Group): 641.3111
Small Group Health: 627.667
Large Group Health:627.667
Individual Health: does not apply
Out of State Group Health: 627.6515
Standard & Basic (HMO & Insurance): Not required but included in the policy
 

Guaranteed Availability of Individual Coverage (HIPAA-Eligible): Certain persons who lose their health insurance coverage are entitled to a guaranteed individual policy.

If your last policy is:

  1. A group health plan; or
  2. A guaranteed-issue individual policy;

and you meet ALL of the following requirements:

  1. You have at least 18 months of creditable coverage without a significant break (62 days) in coverage;
  2. Your most recent coverage must have been through an employer-based ERISA group health plan or if an individual policy, it must have been purchased in Florida;
  3. You are not eligible for coverage under any other group health plan;
  4. You are not eligible for Medicare or Medicaid;
  5. You do not have other health insurance;
  6. You did not lose your insurance for non-payment of premium or for committing fraud;
  7. You are not eligible for a qualified individual conversion plan per Florida Statute 627.6675 or 641.3921 and 641.3922; and
  8. You accepted and exhausted your COBRA or State Continuation (mini-COBRA) coverage

If the last coverage was an individual policy purchased in Florida, a person will have guaranteed issue rights under the following circumstances:

  1. The insurer or HMO is liquidated,
  2. The insurer or HMO withdraws from the individual market statewide, or
  3. If a managed care plan, the person no longer lives in the service area of the plan.

If a person meets these requirements, they may be eligible for a guaranteed issue individual policy.

Guaranteed Renewability: All individual and group health insurance policies and HMO contracts must be guaranteed renewable, subject to certain exceptions. Examples of the exceptions are as follows:

  • Nonpayment of premium
  • The discontinuance of the plan
  • Fraud or intentional misrepresentation by an insured.

HIV-Acquired Immune Deficiency: Health insurance policies or HMO contracts may not exclude coverage for HIV-infection or acquired immune deficiency syndrome, except as provided in a preexisting condition exclusion.

Florida Statute References

HMO (Individual and Group): 641.3007
Small Group Health: 627.429
Individual Health: 627.411 and 627.429
Large Group Health: 627.411 and 627.429
Out of State Group: 627.429
Standard & Basic (HMO & Insurance): 627.429
 

Home Health Care Services: A group health insurance policy must provide at least $1,000 per year coverage for home health care by a licensed home health care agency, as prescribed by a licensed physician. In the case of persons insured under a group policy receiving Medicare benefits, this coverage shall be considered supplemental and in addition to Medicare benefits. (This does not apply to Individual or Out of State Group plans)

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.6617
Individual Health: does not apply
Large Group Health: 627.6617
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): Not required but included in the policy
 

Mammograms: A Health Maintenance Organization (HMO) contract, individual health policy, group health plan, or an out-of-state association group or trust certificate must include coverage for a baseline mammogram for a woman age 35-39, a mammogram every two years for a woman age 40-49, every year for a woman age 50 or older, and one or more a year based on a physician's recommendation for a woman who is at risk for breast cancer based on specified criteria.

Mammograms are covered for women ages 40 to 50 with or without a physician's prescription. The coverage is subject to the deductible and coinsurance provisions applicable to outpatient visits, and is also subject to all other terms and conditions applicable to other benefits.

Every insurer shall make “available” to the policyholder as part of the application, for an appropriate additional premium, mammography benefits that will not be subject to policy deductible or coinsurance provisions. If the policy is subject to the federal Affordable Care Act (ACA), a preventive mammogram will not be subject to a co-payment, co-insurance, or deductible.

Florida Statute References

HMO (Individual and Group): 641.31095 and 627.6613
Small Group Health: 627.6613 (Deductibles and Co-payments apply unless waived by the company)
Large Group Health: 627.6613 (Deductibles and Co-payments apply unless waived by the company)
Individual Health: 627.6418 (Deductibles and Co-payments apply unless waived by the company)
Out of State Group: 627.6515 and 627.6613 (Deductibles and Co-payments apply unless waived by the company)
Standard & Basic (HMO & Insurance):627.6699
 

Massage Therapist: Health plans and Health Maintenance Organizations (HMOs) are not required to cover massage therapy expenses. However, if the plan provides coverage for massage, it must pay for services of a person licensed to practice massage under chapter 480 Florida Statutes, if the massage is prescribed as medically necessary by a physician licensed under chapters 458, 459, 460, or 461 Florida Statutes, and the prescription specifies the number of treatments.

There currently are no laws governing massage therapists services under the small group Standard and Basic insurance plans, or out-of-state group association or trust certificates, so massage therapists benefits are not required to be paid under these contracts.

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6619
Large Group Health: 627.6619
Individual Health: 627.6407
Out-of-State: does not apply
Standard & Basic (HMO & Insurance):does not apply
 

Mastectomy, Length of Stay & Out-Patient Benefits: A health insurance policy or HMO contract that provides coverage for breast cancer may not limit in-patient hospital coverage for mastectomies to any period that is less than determined medically necessary by the treating physician.

Florida Statute References

HMO (Individual and Group): 641.31 (Deductibles and Co-Payments Apply)
Small Group Health: 627.6699 and 627.66121
Individual Health: 627.64171
Large Group Health: 627.66121
Out of State Group: 627.6515 and 627.66121
Standard & Basic (HMO & Insurance): 627.6699
 

Mastectomy, Surgical Procedures and Devices: Any health insurance policy or HMO contract 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.

The coverage for prosthetic devices and breast reconstructive surgery shall be subject to any deductible, coinsurance, or copayment requirements 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.

Florida Statute References
HMO (Individual and Group): 641.31
Small Group Health: 627.6699 and 627.6612
Large Group Health: 627.6612
Individual Health: 627.6417
Out of State Group: 627.6515 and 627.6612
Standard & Basic (HMO & Insurance): 627.6699
 

Maternity Care / Length of Stay & Post Delivery Care: Any health insurance policy which provides maternity or newborn coverage may not limit coverage for the length of stay in a hospital or for out-patient follow-up care to any time period less than that determined to be medically necessary by the treating obstetrical care provider or the pediatric care provider. The policy must provide coverage for post-delivery care for the mother and infant, including medically necessary clinical tests and immunizations.

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6699 and 627.6574
Individual Health: 627.6406
Large Group Health: 627.6574
Out of State Group: 627.6515 and 627.6574
Standard & Basic (HMO & Insurance): 627.6699
 

Mental and Nervous Disorder Benefits: Insurers and Health Maintenance Organizations (HMO) must make available to a group policyholder (usually the employer), as part of the application and for an additional premium, coverage for mental and nervous disorders.

The decision to include this benefit under the group health plan is left up to the employer. If mental health benefits are elected, coverage must include at least 30 days of in-patient coverage and at least $1,000 per year for outpatient benefits for consultations with a licensed physician, psychologist, mental health counselor, marriage and family therapist, and clinical social worker. (This does not apply to Individual Plans or Out of State Groups. Also, coverage under the Standard & Basic Small Group plans has different limits.)

Florida Statute References

HMO (Individual and Group): 627.668
Small Group Health: 627.6699
Large Group Health: 627.668
Individual Health: does not apply
Out of State: does not apply
Standard & Basic (HMO & Insurance): 627.6699
 

Newborn Babies: Health insurance policies and HMO contracts providing coverage for members of the contract holder’s family must cover newborns from the moment of birth.

If the newborn is the child of an insured dependent, the plan will cover the newborn for only the first 18 months and coverage will consist of benefits for injury or sickness. (There may not be coverage for a normal healthy baby; consult your particular contract.)

Applicable coverage includes the necessary treatment of medically diagnosed congenital defects, birth abnormalities, or pre-mature births. Transportation cost of the newborn child to the nearest appropriately staffed and equipped facility to treat the newborn's condition is also covered, if the transportation is deemed medically necessary by the attending physician. This benefit is limited to a maximum $1,000 (the limit does not apply to HMO contracts).

A policy or contract may require notification to the insurer or HMO of the birth of the child within a time period stated in the contract, which may not be less than 30 days. An insurer or HMO may require pre-enrollment of a newborn prior to birth. If timely notice is given, the plan cannot charge an additional premium for coverage of the newborn child during the 30 days after birth of the child. If timely notice is not given, the plan may charge an additional premium from the date of birth. If notice is given within 60 days of the birth, the plan may not deny coverage of the child due to failure of the subscriber to timely notify the plan of the birth of the child or to pre-enroll the child.

If the policy or contract does not require notification of the birth of the child within a specified period of time, the plan may not deny coverage of the child nor may it retroactively charge the insured an additional premium for the child. However, the contract may prospectively charge an additional premium for the child if the plan provides at least 45 days’ notice of the additional premium required. (This applies to all insurance and HMO plans.)

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6575
Large Group Health: 627.6575
Individual Health: 627.641
Out of State Group: 627.6515 and 627.6575
Standard & Basic (HMO & Insurance): 627.6699
 

Newborn Hearing Screening: All health insurance and Health Maintenance Organizations (HMO) contracts covering a family member of the insured must provide coverage for a newborn's initial hearing screening and any medically necessary follow-up re-evaluations leading to a diagnosis.

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6579
Large Group Health: 627.6579
Individual Health: 627.6416
Out of State Group: 627.6515 and 627.6579
Standard & Basic (HMO & Insurance): 627.6699
 

Nurse Anesthetist: HMO contracts which provide anesthesia coverage, benefits, or services shall offer to the subscriber, if requested and available, the services of a certified registered nurse anesthetist. (Only applies to HMO contracts.)

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

OB/GYN Annual Visit: Insurers issuing Exclusive Provider Organization (EPO) and Health Maintenance Organization (HMO) contracts must allow, without prior authorization, a female subscriber to visit a contracted OB/GYN for one annual visit and for medically necessary follow-up care detected at that visit.

This requirement does not apply to the Small Group Standard and Basic Plans or to Out-of-State Association Group or Trust certificates.

Florida Statute References

HMO (Individual and Group): 641.51
Small Group Health: 627.662
Large Group Health: 627.662
Individual Health: 627.6472 (Exclusive Provider Policies Only)
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

OB/GYN Primary Care Physician: Each female covered by a Health Maintenance Organization (HMO) may select as her primary physician an obstetrician/gynecologist who has agreed to serve as a primary physician and is in the organization's provider network. (Applies to HMO coverage only.)

Florida Statute References

HMO (Individual and Group): 641.19
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Ophthalmologist: Health maintenance organizations which provide coverage, benefits, or services performed by physicians who are ophthalmologists, licensed pursuant to chapter 458 or chapter 459, Florida Statutes, shall offer the subscriber the services of an ophthalmologist. Ophthalmologists are physicians specializing in the diagnosis and treatment of diseases and injuries of the eye. (Applies to HMO contracts only.)

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Optometrist: When any health insurance policy, health care services plan, or other contract provides for the payment for procedures specified in the policy or contract that are within the scope of an optometrist's professional license, such policy shall be construed to include payment to an optometrist who performs such procedures.

Florida Statute References

HMO (Individual and Group):641.31
Small Group Health:627.6699 and 627.419
Large Group Health: 627.419
Individual Health: 627.419
Out of State Group: 627.6515 and627.419
Standard & Basic (HMO & Insurance): 627.6699
 

Osteopaths: Under a Health Maintenance Organization contract, physicians licensed under chapter 459, Florida Statutes (Osteopaths), may be elected as a primary care physician upon request.

Florida Statute References

HMO (Individual and Group): 641.19
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply, but included in the policy
 

Osteoporosis Coverage: A Health Maintenance Organization (HMO) contract, individual health plan, and group health plan, must provide coverage for the medically necessary diagnosis and treatment of osteoporosis for high risk individuals, including individuals with a family history of osteoporosis and other specified high risk criteria. (This does not apply to a Standard or Basic plan.)

Florida Statute References

HMO (Individual and Group): 641.31
Small Group Health: 627.6691
Large Group Health: 627.6691
Individual Health: 627.6409
Out of State Group: 627.6515 and 627.6691
Standard & Basic (HMO & Insurance): does not apply
 

Outpatient Coverage: Health insurance policies must provide coverage for treatment provided outside a hospital, such as an outpatient ambulatory surgical center, if such treatment would be covered on an inpatient basis and is provided by a health care provider whose services would be covered under the policy if the procedure was being performed in a hospital. (This does not apply to Out of State Association Groups or the Standard & Basic Plans)

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.4232
Large Group Health: 627.4232
Individual Health: 627.4232
Out of State Group Association: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Podiatrist Services: When any health insurance policy, health care services plan, or other contract provides coverage for procedures specified in the policy or contract which are within the scope of a podiatric physician's professional license, the policy shall be construed to include payment to a podiatric physician who performs such procedures. The payments shall be made in accordance with the coverage now provided for medical and surgical benefits. Also, if requested by an HMO subscriber, the plan must allow the member to select a Podiatrist as their Primary Physician.

Florida Statute References

HMO (Individual and Group): 641.19
Small Group Health: 627.6699 and 627.419
Individual Health: 627.419
Large Group Health: 627.419
Out of State Group: 627.6515 and 627.419
Standard & Basic (HMO & Insurance): 627.6699
 

Pre-Existing Condition Clause:
Individual Coverage:
Conditions that, during the 24-month period immediately preceding the effective date of coverage, had manifested themselves in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care, or treatment was recommended or received; or a pregnancy existing on the effective date of coverage.

Large & Small Group Coverage, HMO’s and the Standard and Basic Plans:

An insurer that offers group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:

  1. Such exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;
  2. Such exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date; and
  3. The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of the enrollment date.
  4. HIPAA and state law prohibits plans from applying a pre-existing condition exclusion to pregnancy, genetic information, and certain children.

One person group:
The pre-existing condition definition and allowable time period under a one-person group plan, including HMOs, will be different depending on whether or not the employee to be covered had continuous creditable coverage to a date not more than 63 days, before the effective date of the new coverage.

For a one-person group without continuous prior creditable coverage, a pre-existing condition is defined as a condition that, during the 24-month period immediately preceding the effective date of coverage, had manifested itself in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care or treatment was recommended or received.

One-life group policies may not exclude an individual's pre-existing medical condition from coverage for more than 24 months after an individual's enrollment date. Pregnancy may be excluded as pre-existing if there was not continuous creditable coverage.

For a one-person group with continuous prior creditable coverage, the definition of a pre-existing condition and the allowable time periods are the same as a group with 2 or more eligible employees and pregnancy cannot be considered a pre-existing condition.

Primary Care Physician: Under a Heath Maintenance Contract, a Primary Care Physician is responsible for coordinating the health care of the subscriber and for referring the subscriber to other providers when necessary.

Florida Statute References

HMO (Individual and Group): 641.19
Small Group Health: does not apply
Individual Health: does not apply
Large Group Health: does not apply
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Psychotherapeautic Providers: An insurer issuing coverage through preferred provider organizations (PPO) or through exclusive provider organizations (EPO) that cover psychotherapeutic services, must provide eligibility requirements for all groups of health care providers licensed under chapter 458, 459, 490 or 491, which include psychotherapy in their scope of practice, and certified advanced registered nurse practitioners in psychiatric mental health under s. 464.012. (This does not apply to Out of State Groups or the Standard and Basic Plans.)

Florida Statute References

HMO (Individual and Group): does not apply
Small Group Health: 627.6471 and 627.6472
Individual Health: 627.6471 and 627.6472
Large Group Health: 627.6471 and 627.6472
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

Substance Abuse (optional coverage): Insurers and Health Maintenance Organizations (HMO) must make available to a group policyholder (usually the employer), as part of the application and for an additional premium, specified benefits for substance abuse. The benefits are only applicable if treatment is provided by or under the supervision of, or is prescribed by, a licensed physician or licensed psychologist and if services are provided in a program accredited by the Joint Commission on Accreditation of Hospitals or approved by the State.

The decision to include this benefit under the group health plan is left up to the employer. If substance abuse benefits are elected, the benefits must consist of inpatient or outpatient of the following:

  1. Basic benefit - Intensive treatment program for the treatment of substance abuse impaired persons.
  2. Limitations -
    1. Benefits must be available only to covered individuals in a group health plan;
    2. There must be a minimum lifetime benefit of $2,000;
    3. There must be allowable a maximum of 44 outpatient visits;
    4. The maximum benefit payable for an outpatient visit shall not exceed $35.
    5. Detoxification shall not be considered as a benefit under the outpatient program.

(This does not apply to Individual, Out of State Group or Standard and Basic Plans.)

Florida Statute References

HMO (Individual and Group): 627.669
Small Group Health: 627.669
Individual Health: does not apply
Large Group Health: 627.669
Out of State Group: does not apply
Standard & Basic (HMO & Insurance): does not apply
 

TMJ (Temporomandibular Joint): A health plan, including Health Maintenance Organizations (HMOs), that provides coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton, may not discriminate against coverage for such procedures involving bones or joints of the jaw and facial region, if such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. Regulations do not require coverage for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes.

(The small group Standard and Basic plans are not required by statutes to provide this coverage but benefits are included in the policy.

Florida Statute References

HMO (Individual and Group): 641.31094
Small Group Health: 627.65735
Individual Health: 627.419
Large Group Health: 627.65735
Out of State Group: 627.6515
Standard & Basic (HMO & Insurance): Not required but included in the policy
Other Coverage Options

Limited Benefit Policies

Limited benefit health plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans, not to be an alternative to them. The most common (but not all) policies providing limited benefits are:

Basic Hospital Expense: Basic hospital expense insurance covers the cost of hospital confinement. In Florida, coverage must be provided for at least 31 days during any one period of confinement. (Many policies today also provide coverage for outpatient care if it is provided in lieu of hospitalized care.) Basic hospital policies cover costs associated with daily room and board and other miscellaneous expenses.

  • Daily Room and Board: Basic hospital expense policies cover the daily cost of room and board. There are no set standards these policies follow; they vary by daily amount payable and by the length of time the benefits are payable. For example, some policies will pay an in-hospital benefit for as long as 365 days, while others pay benefits for only 90 days or 30 days. Some policies reimburse the insured for the daily room and board charge up to a specified dollar amount. (Fixed Rate Approach) Others provide a service type of benefit, paying an amount equal to the hospital's daily charge for a semiprivate room. (Reimbursement Approach)
  • Miscellaneous Expenses: In addition to room and board, basic hospital expense policies cover hospital "extras" or miscellaneous charges, up to a specified limit. Covered miscellaneous expenses include drugs, X-rays, anesthesia, lab fees, dressings, use of the operating room and supplies.

Basic Surgical Expense: Basic surgical expense policies provide coverage for the cost of a surgeon's services, whether the surgery is performed in the hospital or out. Generally the surgeon’s fees as well as the fees of the anesthesiologist and any postoperative care are included.

There are three different approaches used by insurers in providing this type of coverage and determining the benefits payable. These are the surgical schedule approach, the reasonable and customary approach and the relative value scale approach.

  • Surgical Schedule: Every surgical procedure is assigned a dollar amount by the insurer. When a claim is submitted to the insurer, the claims examiner reviews the policy to determine what amount is payable; if the surgeon's bill is more than the allowed charge set by the insurer, it is up to the insured to pay the surgeon the difference. If the surgeon's bill is less than the allowed charge, the insurer will pay only the full amount billed; the claim payment will never exceed the amount charged.
  • Reasonable and Customary Approach: Under this approach, the surgical expense is compared to what is deemed "reasonable and customary" for the geographical part of the country where the surgery was performed. If the charge is within the “reasonable and customary” parameters, the expense is paid, usually in full. If the charge is more than what is reasonable and customary, the patient must absorb the difference. If using this approach, the company must provide benefits of at least 75% of the reasonable charges.
  • Relative Value Scale: Under the relative value scale, instead of a flat dollar amount being assigned to every surgical procedure, a set of points is assigned. The policy will carry a stated dollar-per-point amount, known as the conversion factor, to determine the benefit. For example, a plan with a $5-per-point conversion factor would pay $1,000 for a 200-point procedure. Generally the larger the conversion factor, the larger the policy's premium.

Specified Disease Plans: Policies that provide medical expense coverage for specific kinds of illnesses are known as critical illness, dreaded disease, limited risk, or specified disease policies. They are available primarily due to the high costs associated with certain illnesses, such as cancer or heart disease and sold as individual or group policies.

In Florida they cannot have a higher deductible than $250. They must provide a benefit of at least $2,500 and a benefit period of no less than 2 years.

Hospital Indemnity Plans: A hospital indemnity (fixed-rate) policy provides a daily, weekly or monthly payment of a specified amount based on the number of days the insured is hospitalized. For example, a plan may provide the insured $100 a day for every day he or she is confined in a hospital. Benefits are payable directly to the insureds and may be used for any purpose. These policies usually are exempt from state laws that apply to specific kinds of insurance contracts.

However, in Florida they must provide a benefit of at least $10.00 per day and not less than 31 days during any one period of confinement and with no elimination period unless the benefit period is 365 days or more, in which case, a 3 day elimination period is acceptable.

Discount Plans
A discount plan is a type of health-related services that is NOT a health insurance plan.

Medical Discount Plans, Prescription Discount Plans, Dental Discount Plans, and Vision Discount Plans are plans where a consumer pays a fee to join in return for discounts on products and services from participating vendors and providers. Often, members who join these plans are issued a card similar to an insurance card identifying them as a member. However, these plans are NOT insurance. You are responsible for the provider’s discounted charges at the time service is received.

Before joining a discount plan (Medical, Prescription, Dental, Vision, etc.), consider the following:

  1. Terminating health insurance while taking out a discount plan may limit your ability to purchase insurance at a later date.
  2. If you drop your health insurance, you may lose coverage for pre-existing conditions when you reapply.
  3. Providers that are contracted by the plan can change without advance notice to the member.
  4. Some plans contain administrative costs and fees.
  5. Plan cancellation and refund policies may be restrictive, beware of paying all costs up front instead of monthly.
  6. Plans may be of little or no benefit to you if you move or when you travel out of the area.
  7. Advertised discounts may change or may only apply to certain services or prescriptions. For example, many plans claim savings up to a certain percent, however "up to 40 percent" does not guarantee forty percent savings. Discounts are sometimes exaggerated and often times ranged, i.e. 15-60% so that the savings often become hard to understand and see.
  8. When using a discount plan in conjunction with health insurance, most providers are not obligated to reduce fees with a discount card because they have already agreed to reduce their fees with the health insurance plan.
Common Claim Concerns

Grievance Appeal offer Required:

Individual, Large Group, Small Group, Standard & Basic: Under state law, each claimant, or provider acting for a claimant, who has had a claim denied as not medically necessary must be provided an opportunity for an appeal to the insurer's licensed physician who is responsible for the medical necessity reviews under the plan or is a member of the plan's peer review group. The appeal may be by telephone, and the insurer's licensed physician must respond within a reasonable time, not to exceed 15 business days.

HMO: Every subscriber shall receive a description of the method for resolving subscriber grievances, and the method shall be set forth in the contract, certificate, and member handbook. The HMO shall also furnish, at the time of initial enrollment and when necessary due to substantial changes to the grievance process a separate and additional communication notifying the contract holder of their rights and responsibilities under the grievance process.

Non-grandfathered group and individual health insurance and HMO grievances may fall under federal guidelines. For more information on the federal internal and external appeal process, your should review the policy or contract or contact your health plan. If you have additional questions, you can call our toll free Consumer Helpline at 1-877-693-5236 or visit the federal Department of Health and Human Services website at www.healthcare.gov.

Incontestability Clause:

Individual health policies and HMO contracts must contain either a "Time Limit on Certain Defenses" or an "Incontestable" clause. The "Time Limit on Certain Defenses" states that after the policy has been in force for two years, the insurer cannot use material misrepresentation (misstatements) in the application either to void the policy or deny claims unless the misrepresentation was fraudulent.

In place of the "Time Limit on Certain Defenses" the insurer may include a provision called an "Incontestable" clause. This clause states that the insurer cannot contest a statement made in an application after the policy has been in force for 2 years. After 2 years from the inception date of the policy, the insurer cannot deny or reduce claim benefits for a loss or disability that existed before the effective date of coverage. Prior to the 2-year period, if the company determines that facts were omitted or incorrect answers were given during the application process which, if known, would have resulted in the policy not being issued, they can cancel the policy from its inception and refund all premiums paid. This is also known as a "Policy Rescission."

Reasonable & Customary Charges:

The "reasonable and customary" medical charges are based on what is deemed "reasonable and customary" for the geographical part of the country where the services were performed. If the charge is within the “reasonable and customary” parameters, the expense is paid, less any deductible or coinsurance. If the charge is more than what is reasonable and customary, the patient must absorb the difference. Some insurance companies use the term “usual and customary” instead of “reasonable and customary”. Also, you may see insurance policies that pay the “prevailing rate”.

Insurers are required by Florida law to specify the formula or criteria it uses in determining the amount to be paid on a claim, regardless of which term a company uses to calculate the eligible expense. Also, if the insurance company uses a specific methodology for paying claims, at the written request of the insured, they must provide an estimate of the amount they will pay for a particular medical procedure or service.

The estimate may be in the form of a range of payments or an average payment. The insurance company can require the insured to provide detailed information about the procedure or service, including the code number provided by the health care provider and the amount the provider is charging. The insurance company is not bound by the estimate. However, a pattern of providing estimates that vary significantly from the ultimate insurance payment constitutes a violation of the insurance code.

Time limit for Payment of Claims:

Health insurers shall reimburse all claims or any portion of any claim, from their insured or the insured’s assignee within 45 days after receipt of the claim by the health insurer. If a claim is contested by the insurer, the insured will be notified, in writing, that the claim is being contested or denied within the 45 day period.

Contested claims or contested portions of claims that require additional information by the insurer must be paid or denied within 60 days upon receipt of the additional information. An insurer shall pay or deny any claim no later than 120 days after receiving the claim. All overdue payments shall bear simple interest at the rate of 10 percent per year.

An insurer must investigate any claim of improper billing by a provider upon receipt of written notice from the insured. If the insurer determines the billing was improper it must reduce the payment to the provider and pay the insured 20 percent of the reduction, up to $500. (Please note, there are other requirements for payment to a contracted provider of the insurer. )

Health Insurance Tips

Verify before you buy!!!! Contact us to verify the license of the agent and the insurance company before you sign an application for a policy.

Health Insurance & HMO Guide: The guide is an excellent tool if you are shopping for a specific type of insurance or HMO and would like to gain a better understanding of all the aspects of the product prior to making your purchase.

Small Group Carrier List: A list of companies that are offering health insurance to Small Business Owners in Florida.

Individual Carrier List: A list of companies that are marketing guaranteed issue health insurance policies for eligible individuals.

Review your policy carefully!!!! Understand your deductible and coinsurance provisions. Understand your responsibility if you need a referral to see a specialist. Also, understand your rights to file an appeal or grievance if a claim is denied that you feel should be paid.

Individual health insurance plans (not HMO’s) regulated by the State of Florida have a 10-day free-look provision. This allows you to return the policy and receive a full refund if you are not happy with the policy.

An individual policy must include a grace period provision. The grace period is from 7 to 31 days, depending on how the premium is paid. Individual HMO’s must provide at least a 10 day grace period. 7

Contact us or file a complaint

Should you need additional information, you may speak with an insurance specialist between the hours of 8am–5:00pm at one of the telephone numbers listed below:

1-877-MY-FL-CFO (1-877-693-5236)

Out of State Callers: (850) 413-3089

You can also contact us for assistance anytime by email at Consumer.Services@MyFloridaCFO.com. or file a complaint through our “Consumer Help Online” website.