Charts
The following charts shows how the out-of-pocket expenses and types of coverage differ between the standard and basic plans for individuals and families.
Brackets around language found in the Schedules of Benefits are used to identify options that insurance carriers may exercise when developing their policies. When the brackets are placed around figures, such as the maximum out-of-pocket maximums, the carrier can choose which of the optional maximum amounts it will use in its contract. When the brackets are around an entire statement, such as the description of services requiring prior authorization from the carrier, it means that the carrier can decide whether or not to use this requirement in its contract. When deciding on a small-group plan, be aware of what options carriers have.
Standard Benefit Plan: Mandated Option One
Standard Benefit Plan: Mandated Option Two
Basic Benefit Plan: Mandated Option One
Basic Benefit Plan: Mandated Option Two
Other Health Options
Modified Community Rating
All small-group health plan premiums are determined using a modified community rating. The modified community rating allows five main factors to be considered in determining an individual’s health plan rate: geographic area, gender, age, tobacco usage and family composition.
For small-business owners seeking coverage, the rate can be increased if the employer does not have workers’ compensation insurance. Also, the base rate can be raised or lowered based on the employees’ health status, past claims or length of time insured. However, the base rates can be raised or lowered by no more than 15 percent in the first year of coverage and no more than 10 percent in any renewal year due to claims or health status. Base rates can also increase due to health care cost increases.
Group size will generally not affect the rate charged. However, rates for one-life groups may be up to 50 percent higher.
COBRA Benefits
The federal Consolidated Omnibus Budget Reconciliation Act (COBRA) requires insurance companies that cover employee groups of 20 or more to provide health coverage to employees who lose eligibility to participate in the company's health plan. Employees typically lose their eligibility when they retire, resign, lose their jobs or have their work hours reduced below the minimum amount required to participate in the company’s health plan.
COBRA allows employees enrolled in small-group plans to receive coverage for themselves and their insured dependents for an additional 18 months following the termination of regular health plan coverage. An employee or insured dependent who is disabled at the time of job termination can receive a total of 29 months of continued coverage. Dependents losing coverage (spouse or dependent children) can receive up to 36 months of coverage under certain conditions. Under this law, the employer or its designee (usually its insurance company) is required to inform the employees of their COBRA rights when they lose their eligibility.
Mini COBRA
Florida’s Mini-COBRA law provides similar continuation of coverage protection for employees who work for employers with fewer than 20 employees.
Note: Under this law, the employee must notify the insurer within 63 days of losing group eligibility that he or she is eligible to continue coverage. If you have specific questions, call the Consumer Helpline toll-free at 1-800-342-2762.
Conversion
After you exhaust COBRA, you may qualify for a conversion plan, which is guaranteed-issue, individual coverage that the group plan insurer must offer you. You should receive two conversion plan options with different levels of comprehensive, major medical benefits. However, these benefits may differ from those offered by your previous group plan. If a conversion plan is not available, please call the Consumer Helpline toll-free at 1-800-342-2762, since you may have other options.
Disability Income Insurance
You may also offer your employees disability income insurance to provide them income if they become disabled from illness or injury and cannot work. Disability income insurance replaces a significant portion of an individual’s income through periodic payments while the individual is disabled due to sickness or injury. Disability income benefits provide monthly or weekly payments of a specified amount for a period of time stated in the policy.
Disability income insurance comes in both short-term and long-term coverage.
Short-term disability income insurance generally refers to policies with a maximum benefit coverage of two years or less, although some companies may apply this designation to policies with benefit coverage of up to five years.
Long-term coverage includes policies with maximum benefit periods of 10 years, to age 65, or in a few instances, for the lifetime of the insured.
For the first 12 months of the disability, this type of income policy must provide benefits if the policyholder is unable to perform material and substantial duties of his or her regular occupation. After the first 12 months, the company may base the continuance of benefits on the person’s ability to perform any work for which he or she is reasonably trained.
Your Rights and Responsibilities
You have the right to have your claim processed within 120 days.
You have the right to change insurance companies every August if you are in a one-person group.
You have the right to receive your policy within 60 days of the date your policy becomes effective.
You are responsible for evaluating your needs and making sure the insurance company and policy or contract you choose can fit those needs.
You are responsible for shopping around and comparing costs and services.
You are responsible for finding out the licensure status of an insurance agent and company. To verify a license, call the Consumer Helpline toll-free at 1-800-342-2762.
You are responsible for reading your policy or contract and making sure you understand what it covers.
You are responsible for filling out your application truthfully and disclosing all pertinent information.
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