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.

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 and 627.6699 (Group)
• Small Group Health: 627.6471 and 627.6699
• Large Group Health: 627.6471
• Individual Health: 627.6471
• Out-of-State: does not apply

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

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

Exclusive Provider Organizations (EPOs:) In an EPO arrangement, an insurance company contracts with hospitals or specific providers for the exclusive provider provisions of the insurance contract. Insured members must use the contracted hospitals or providers to receive benefits from these plans. Services may also be available by non-contracted providers. 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 and 627.6699
• Individual Health: 627.6472
• Large Group Health: 627.6472
• Out of State Group: does not apply

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.

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 the services of a licensed physician.

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

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

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

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.

The treatment of autism spectrum disorder and Down Syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis must be provided. Applied behavior analysis (ABA) services shall be provided by an individual certified pursuant to s. 393.17, Florida Statutes, or an individual licensed under chapter 490 or chapter 491.

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

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 s. 383.30 - 383.335, Florida Statutes.

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

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.

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

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.

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

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

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 can apply.

Please note: If the policy is subject to the federal Affordable Care Act (ACA), there will 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 and 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

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. 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.

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

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 as 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 statute.

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

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.

Florida Statute References

• HMO: does not apply
• Small Group Health: 627.6699
• Group: 627.419
• Individual: 627.419
• Out-of-State Group: 627.6515

Continuation of Group Coverage (aka 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.)

Unlike federal COBRA requirements, an employer is not required under state law to notify the qualifying individual of the availability of continued coverage. The qualifying individual must request continued coverage directly from the insurer according to statutory requirements. 

Florida Statute References

• HMO (Small Group): 627.6692
• Small Group Health: 627.6692
• Individual Health: does not apply 
• Large Group Health: does not apply 
• Out-of-State Group: does not apply 

Continued Care after HMO Provider is Terminated: When a contract between an 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

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 conversion policy shall be effectuated in such a way as to result in continuous coverage during the 31-day period for such insured.

Large Group, Small Group, and 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 certificate holder, then the written application and first premium must be paid to the insurer not later than 63 days after notice of termination is mailed by the insurer or employer, whichever is earlier, to the employee or certificate holder. The effective date of the converted contract will be the day after the termination date.

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

Please note: The loss of minimum essential health coverage may qualify an individual for a Special Enrollment Period under the Affordable Care Act (ACA).  Contact the federal Marketplace at 1-800-318-2596 for questions and assistance. 

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 and 627.6675

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 option 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

Dental Procedure, Anesthesia and 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 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

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.

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

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 certificate holder for support and
2. The child is living in the household of the policyholder or certificate holder, or the child is a full-time or part-time student.

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 Affordable Care Act (ACA) that cover dependent children must extend coverage until the child's 26th birthday. 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 Small Group Health: 627.6562; 627.6615
• Florida Large Group Health: 627.6562; 627.6615
• Florida Individual Health: 627.602; 627.6562; 627.6041
• Out-of-State: does not apply
• 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.

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

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.

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

Emergency Care:

EPOs: Insurer 's issuing 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 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 that 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

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

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

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

Mental and Nervous Disorder Benefits: Insurers and 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. 

Please note: Mental health and substance use disorder benefits are mandatory under individual ACA insurance and HMO contracts.   If a group insurance policy or contract provides mental health benefits, it must comply with federal Mental Health Parity and Addiction Equity Act (MHPAEA).  

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

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 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.

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

Newborn Hearing Screening: All health insurance and 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

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.

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

OB/GYN Annual Visit: Insurers issuing EPO and 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.

Florida Statute References

• HMO (Individual and Group): 641.51
• Small Group Health: 627.662
• Large Group Health: 627.662
• Individual Health: 627.6472 (EPO Only)
• Out-of-State Group: does not apply

OB/GYN Primary Care Physician: Each female covered by a 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.

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

Ophthalmologists: HMO 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.

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

Optometrists: 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 and 627.419

Osteopaths: Under a HMO contract, osteopath physicians licensed under chapter 459, Florida Statutes, 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

Osteoporosis Coverage: A 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.

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

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.

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

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

Pre-Existing Condition Clause:

Major medical individual and group policies and HMO contracts issued on or after January 1, 2014, cannot impose a pre-existing condition clause under of the federal Affordable Care Act (ACA). 

Primary Care Physician: Under a HMO 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

Psychotherapeutic Providers: An insurer issuing coverage through Preferred Provider Organizations (PPO) or through Exclusive Provider Organizations (EPO) policies 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.

• 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

Substance Abuse (optional coverage): Insurers and 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.

Please note:  Mental health and substance use disorder benefits are mandatory under individual ACA insurance and HMO contracts. If a group insurance policy or contract provides mental health and substance abuse benefits, it must comply with the federal Mental Health Parity and Addiction Equity Act (MHPAEA).  

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

TMJ (Temporomandibular Joint): A health plan, including 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.

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 and 627.65735

Please visit our section devoted to Short-Term Limited Duration Insurance (STLDI).

Download the Purchasing a Short-Term Health Insurance Policy flyer for consumer tips concerning this subject.

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 provide for 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 so 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. Providers that are contracted by the plan can change without advance notice to the member.
3. Some plans contain administrative costs and fees.
4. Plan cancellation and refund policies may be restrictive, beware of paying all costs up front instead of monthly.
5. Plans may be of little or no benefit to you if you move or when you travel out of the area.
6. 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.
7. 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.

Grievance Appeal offer Required:

Individual, Large Group and Small Group: 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 fall under federal guidelines. For more information on the federal internal and external appeal process, you should review the policy or contract or contact your health plan. If you have additional questions, you can call our toll-free Insurance Consumer Helpline at 1-877-693-5236 (within Florida) or 850-413-3089 (direct) 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 two years. After two 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 two-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 medical billing 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 must 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 additional requirements for payment to a contracted provider of the insurer.

Prior to January 1, 2022

You could end up with a big surprise if you received air ambulance transportation services prior to January 1, 2022, even after your insurance company paid its portion of your claim. Your insurance company is required to process the claim as if the provider is in its network if the services were rendered because of an emergency. However, this only means that your in-network deductible, co-insurance, or co-payments will apply. It does not protect you from the out-of-network air ambulance transportation provider from billing you for the difference between its charges and the amount your insurance company paid. This is referred to as balance billing.

Insurance companies and health maintenance organizations (HMOs) are required to pay a reasonable reimbursement to an ambulance service if the services were rendered in the State of Florida. The insured or member should be responsible only for the policy cost sharing amounts such as copayment, coinsurance, and deductibles. There are no minimum payment requirements for air ambulance services received out of state. If you received a balance bill, you should first contact your insurance company or HMO for assistance. If the issue is not resolved, contact our office so we can attempt to assist. You are also encouraged to contact the air ambulance company to attempt to negotiate the amount of the balance bill.

If you have already attempted to negotiate with the transportation company or requested assistance through our office and the situation has not been resolved, you can file an on-line complaint with the U.S. Department of Transportation, Aviation Consumer Protection Division, to determine if their office can be of assistance. Visit their website at https://www.transportation.gov/individuals/aviation-consumer-protection/air-ambulance-operators for more details and contact information for the agency.

DATES OF SERVICE ON OR AFTER JANUARY 1, 2022

The federal Consolidated Appropriations Act of 2021 established requirements to protect consumers from surprise medical bills. The requirements are collectively referred to as the No Surprises Act (NSA). The requirements generally apply to items and services provided to individuals enrolled in employer-based group health plans, group or individual health insurance coverage, and Federal Employees Health Benefits plans. The NSA requirements apply to claims with dates of service on or after January 1, 2022.

The NSA prohibits out of network air ambulance providers, whether services are rendered in or outside the state of Florida, from balance billing individuals for emergency services. If you are being balance billed by an air ambulance company, notify your health insurance company and the air ambulance company of the requirements of the NSA and its balance billing protection. The NSA does not apply to ground ambulance services.

If you need additional details or assistance, you can call the No Surprises Help Desk from 8:00 a.m. to 8:00 p.m., seven days a week at 1-800-985-3059 or visit their website at https://www.cms.gov/nosurprises.

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. If you have an Affordable Care Act (ACA) Marketplace policy and are receiving Advanced Premium Tax Credits (APTC), you have a three-month grace period in which to have 100% of all premium owed paid.

• ONLINE: Get Insurance Help
• EMAIL: Consumer.Services@myfloridacfo.com
• FLORIDA INSURANCE CONSUMER HELPLINE
  Statewide/Toll-free: 1-877-693-5236 Out of State: (850) 413-3089