30 FLORIDA LAWS AND RULES PERTINENT TO HEALTH INSURANCE – Flashcards

1.C

2.A

3.B

4.A

5.C

6.A

7.D

8.D

9C

10 B

11 C

12 C

13 D

14 B

15 D

16 B

17 C

18 A

19 B

20 D

21 B

22 A

23 D

24 C

Head of the Department of Financial Services Regulates insurance agents, insurance fraud ; insurance consumer protection

Governor, CFO, Attorney General, Commissioner of Agriculture Supervises The Office of Insurance Regulation ; The Office of Financial Regulation

The Office serves Floridians through its responsibilities for regulation, compliance and enforcement of statutes related to the business of insurance. The Office is also entrusted with the duty of carefully monitoring statewide industry markets. Regulates banks, credit unions and finance companies Investigates suspected wrong doings Has access to all books and records of people who the office has supervision over. Office of Financial Regulation 1. General duties and powers 2. Agency Actions 3. Investigations

Issues insurer certificates of authority to agents Rehabilitates or liquidates insurers where necessary Supervises licensing of agents http://www.floir.com/

Enforces the insurance code Conduct investigations of insurance matters Collect, propose and publish or disseminate info regarding the duties imposed upon it by the code 1. General duties and powers a. Agent and adjuster licensing and investigations b. Consumer services The Division of Consumer Services helps consumers make informed insurance and financial decisions. Our dedicated and experienced staff are trained in the 26 different categories of insurance. Consumer assistance and protection is our mission. c. Insurance Fraud Insurance Fraud is attempting to locate these subjects in reference to outstanding warrants. The Division of Insurance Fraud is the law enforcement arm that investigates all types of insurance fraud and insurance agent crimes. d. Receivership The situation in which a business is being held by a receiver. e. Unclaimed Property Unclaimed property held by the state consists of money from dormant accounts in financial institutions, insurance and utility companies, securities and trust holdings, and includes tangible property from abandoned safe deposit boxes. f. Other powers

Issues insurer certificates of authority to agents Rehabilitates or liquidates insurers where necessary Supervises licensing of agents Office of Insurance Regulation 1. General duties and powers a. Policy approval authority b. Rates and forms 2. Market Conduct Examinations 3. Agency Actions 4. Investigation

Definitions 1. Enforceable by law Are aleatory -there is an element of chance for both of the contracting parties -the dollard values exchanged may not be equal insurance transaction Preliminary negotiations effecting a contract of insurance -Negotiations toward the sale of insurance -Solicitation to purchase insurance 3. 4. Specialized branch of the insurance industry because they insure insurers 5. A company that does business in the state it is incorporated in. 6. A company that is licensed and doing business in states other than the one in which it is incorporated in. 7. Insurers incorporated in a country other than the US when doing business in the US. 8. Organizations must be non-profit Have a lodge system that includes ritualistic work maintain representative form of government with elected officers 9. Authorized and unauthorized companies/admitted and non-admitted companies 10. Owners are policyholders board of directors Participating so policyholders share company earnings 11. Mutual insurance company formed to insure people in the same business, occupation or profession 12. Unlicensed entities 13. Necessary to sell insurance. 3rd degree felony t for unauthorized selling.

Enforceable by law Are aleatory -there is an element of chance for both of the contracting parties -the dollard values exchanged may not be equal

Preliminary negotiations effecting a contract of insurance -Negotiations toward the sale of insurance -Solicitation to purchase insurance

Company assuming the risk

Specialized branch of the insurance industry because they insure insurers

A company that does business in the state it is incorporated in.

A company that is licensed and doing business in states other than the one in which it is incorporated in.

Insurers incorporated in a country other than the US when doing business in the US.

Organizations must be non-profit Have a lodge system that includes ritualistic work maintain representative form of government with elected officers

Private organization Non-Participating Dividends are paid to stock holders and not policy holders

Owners are policyholders board of directors Participating so policyholders share company earnings

Mutual insurance company formed to insure people in the same business, occupation or profession

F. Licensing 1. Purpose 2. License types a. Agent b. Adjuster c. Agency 3. Appointments 4. License Requirements a. Education b. Application c. Background Check d. Examination 5. Maintaining a license a. Continuing education b. Communicating with the Department c. Record keeping d. Criminal and administrative actions e. Appointments

An agent has a fiduciary responsibility to the insured, the insurer, the applicant for insurance, current clients, and so forth. The agent has a fiduciary duty to just about any person or organization that he or she comes into contact with as part of the day-to-day business of transacting insurance.

C. Money collected with respect to an insurance transaction must be held in a position of trust by the agent or broker.

C. Maryland is CORRECT! A foreign insurer is an insurance company that is incrported in another state or territorial possession. Mexico and Canada are foreign countries, so their insurers will be conisered alien. An insurer that is incorported and that operates in Washington D. C. would be considered domestic.

C. Misrepresentation is issuing, publishing or circulating any illustration or sales material that is false, misleading or deceptive as the policy bebefits or terms, the payment of dividents, etc. This includes oral statements.

An agent has a fiduciary responsibility to the insured, the insurer, the applicant for insurance, current clients, and so forth. The agent has a fiduciary duty to just about any person or organization that he or she comes into contact with as part of the day-to-day business of transacting insurance.

B. To be charactized as a fraternal bebefit society the organization mustbe nonprofit, have a lodge system that includes ritualistic work and maintain a representative form of vernment with elexted officers. Insurance may only be sold to members of the society.

c. Insurers who meetthe state's financial requirements and are approved to transact business in the state are considered authorized or admitted into the state as a legal insurer.

An agent has a fiduciary responsibility to the insured, the insurer, the applicant for insurance, current clients, and so forth. The agent has a fiduciary duty to just about any person or organization that he or she comes into contact with as part of the day-to-day business of transacting insurance.

An insurance producer or any other representative of an insurer involved in procuring an insurance contract must report to the insurer the exact amount of consideration charged as premium for such contract. The amount collected must be shown in the contract and in the records of the insurance producer.

All funds representing premiums and return premiums received by a producer must be promptly deposited in a separate account (a.k.a. Trust Account). The account may be interest bearing. The Separate (Trust) Account Funds may be deposited in a checking or savings account located in the State. A business entity may utilize one separate account for use by all of its affiliated persons.

Unless the agency-insurer agreement provides to the contrary, an insurance producer may receive the following compensation: A commission paid by the insurer A fee paid by the insured A combination of commission paid by the insurer and a fee paid by the insured If the compensation received by an insurance producer who is dealing directly with the insured includes a fee, the insurance producer must disclose in writing to the insured for each policy: The full amount of the fee paid by the insured The full amount of any commission paid to the producer The full name of the insurance company that paid the commission An explanation of any offset or reimbursement of fees or commissions Written disclosure of compensation must be provided by the insurance producer to the insured prior to the sale of the policy. Written disclosure must be signed by the insurance producer and the insured, and the writing must be retained by the insurance producer for five years. In the case of a purchase over the telephone or by electronic means for which written consent cannot be reasonably obtained, consent documented by the producer will be acceptable.

A producer may be permitted to enter into reasonable arrangements with any person to charge a fee, but only with the prior written consent of the state commissioner. This may be allowed in situations where services beyond the scope of services customarily provided in connection with the solicitation and procurement of insurance are provided. The charge or fee to the individual or insured must be reasonable, taking into account receipt of commissions and their relation to the value of the total work performed. The person must be given written notice in advance of what the fixed charge will be, or the basis for determining the charge.

The Division of Consumer Services is happy to assist you with your insurance questions and concerns or open a formal complaint. Our dedicated and experienced helpline specialists are continuously trained and informed about any changes that occur to the 26 different categories of insurance they confront on a daily basis. We are ready to contact the insurance company on your behalf to assist you with your insurance complaint.

A fund mandated by state law. The fund is comprised of money from the insurers currently conducting business in that state, which is available to companies unable to cover debts or unpaid claims. These are sometimes called Insolvency Funds.

Charging for a coverage without the clients consent. Saying a product is required when it is not. Or that an additional charge for a product is not required when it is. - Is like misrepresentation - When an agent tells or implies that it is a requirement that the client purchase specific coverage's or products in conjunction with the policy being purchased

- Forcing somebody to do something against their will through the use of force or threats - "Do not apply pressure and/or unfair restrictions"

Misrepresentation is issuing, publishing or circulating any illustration or sales material that is false, misleading or deceptive as the policy bebefits or terms, the payment of dividents, etc. This includes oral statements.

- Can take place in the form writing or spoken - A personal attack on somebody's good name, character or reputation

- Prohibited from showing any type of partiality to individuals in regard to their premium and benefits

Boycott, coercion and intimidation. Misrepresentations and false advertising of insurance policies Defamation Unfair Discrimination

Failing to adopt and implement standards for proper investigation of claims Misrepresenting pertinent facts Failing to acknowledge claims Denying claims without conducting reasonable investigations Failing to notify the insured of necessary info to process a claim

Unfair Methods of Competition Boycott, coercion and intimidation. Misrepresentations and false advertising of insurance policies Defamation Unfair Discrimination No more than $25 in advertising gifts permitted False statements and entries

Act or course of deception, an intentional concealment, omission, or perversion of truth, to (1) gain unlawful or unfair advantage, (2) induce another to part with some valuable item or surrender a legal right, or (3) inflict injury in some manner

The amount of insurance sold by an insurance provider to family and friends. In some states, a limit is placed on this type of business.

Illegal Replacement with another company

Using the cash value from one policy to purchase another.

Return of a portion of a purchase price by a seller to a buyer, usually on purchase of a specified quantity, or value, of goods within a specified period. Unlike discount (which is deducted in advance of payment), rebate is given after the payment of full invoice amount. See also refund.

An employer can cover any employee who is on the payroll and for whom he or she pays payroll taxes. Although employees can opt out of the benefit program, virtually all insurers do require that a minimum number of your employees participate in their plan. Eligible employees generally include those who are on paid vacation, maternity or sick leave. With few exceptions, employees who are on unpaid leave are ineligible until they return to active work.

1. employer/employee groups; 2. labor unions and association groups; 3. debtor groups; and 4. any other group that is eligible for group life insurance. [Secs. 627.653, .654, .655, .656, F.S.]

Florida law does not specify any minimum number for employee group health insurance. [Sec. 627.653, F.S1

Under Florida law there is no specific minimum percentage participation of employ-ees under employee group health insurance. [Sec. 627.653, F.S.]

A. Excess coverage provision B. Coordination of benefits provision C. Other insurance with this insurer provision D. Double indemnity provision

https://www.medmutual.com/Healthcare-Reform/The-Basics/Grandfathered-Status.aspx

Four different types of groups are eligible for group health insurance. The types of groups eligible for group health coverage are: 1. employer/employee groups; 2. labor unions and association groups; 3. debtor groups; and 4. any other group that is eligible for group life insurance. What is the minimum number of employees specified by Florida law that must be included before a group health insurance policy can be issued? Florida law does not specify any minimum number for employee group health insurance. What minimum percentage participation is required by Florida law under employee group health insurance before a policy can be issued? Under Florida law there is no specific minimum percentage participation of employ-ees under employee group health insurance.

NOTE WELL: Under Colorado Law HB 1353, effective 1/1/03, the employer must notify the insurance company of a termination NOT LATER THAN the last day of the month terminated! Premium payment is required for the month in which the insurance company receives notification. Under Colorado law*, departing employees may continue medical, and dental,† coverage under an employer-sponsored group health plan IF they were covered under the employer's current group plan, or any group plan it replaced, for the 6-month period prior to their termination of coverage. Every eligible departing employee must be offered - IN WRITING - the option to continue coverage. It is STRONGLY RECOMMENDED that the continuation forms be given to the departing employee in person prior to his/her departure. If this is not possible, it is STRONGLY RECOMMENDED that the forms be mailed to the employee by Certified-Mail-Return-Receipt as proof that the employee was offered continuation. Copies of the notification should be attached to the receipt and filed. FAILURE TO FOLLOW THESE PROCEDURES COULD RESULT IN FUTURE EXPENSIVE LEGAL LIABILITY FOR THE EMPLOYER! If a departing employee is not eligible, the employee should be so advised, preferably in writing. When an employee is terminated, follow the procedures below. Use the Group Health Insurance Continuation Form AND any additional form(s) required by your insurance company. (Most insurance companies require their own special form.)

The ability, in some states, to switch your job-based coverage to an individual policy when you lose eligibility for job-based coverage. Family members not covered under a job-based policy may also be able to convert to an individual policy if they lose dependent status (for example, after a divorce).

A way to figure out who pays first when 2 or more health insurance plans are responsible for paying the same medical claim.

Statutory revelation by the applicant (in the application for an insurance policy) of all known information about the risk to be covered. Outline of coverage required. (1) Issuers must provide an outline of coverage to all applicants at the time an application is presented to the prospective applicant and, except for direct response policies and certificates, must obtain an acknowledgment of receipt of the outline from the applicant. (2) The "outline of coverage," is set forth on the commissioner's web site, and incorporated by reference herein in this rule. The issuer's form of outline of coverage must be completed in substantially the form set forth on the commissioner's web site, and filed with the commissioner before being used in this state. (3) If an outline of coverage is provided at the time of application and the medicare supplement policy or certificate is issued on a basis that would require revision of the outline, a substitute outline of coverage properly describing the policy or certificate must accompany the policy or certificate when it is delivered and contain the following statement, in no less than twelve point type, immediately above the company name: "NOTICE: Read this outline of coverage carefully. It is not identical to the outline of coverage provided upon application and the coverage originally applied for has not been issued." (4) The outline of coverage provided to applicants set forth in this section consists of four parts: A cover page, premium information, disclosure pages, and charts displaying the features of each benefit plan offered by the issuer. The outline of coverage must be in the language and format prescribed in WAC 284-66-092 in no less than twelve point type. All plans A- N must be shown on the cover page, and the plan(s) that are offered by the issuer must be prominently identified. Premium information for plans that are offered must be shown on the cover page or immediately following the cover page and must be prominently displayed. The premium and mode must be stated for all plans that are offered to the prospective applicant. All possible premiums for the prospective applicant must be illustrated. (5) Where inappropriate terms are used, such as "insurance," "policy," or "insurance company," a fraternal benefit society, health care service contractor, or health maintenance organization must substitute appropriate terminology.

An insurer that provides individual or group health insurance coverage must renew the coverage at the option of the individual or group policyholder 90 days before date of nonrenewal by insurer. If a particular health insurance is discontinued 180 days notice before date of nonrenewal if discontinued in Florida (All plans)

Advertising materials must clearly indicate that it is related to insurance products

Each employee covered under a group policy must receive a certificate of coverage when they enroll in a group health insurance plan. Must contain the group # & ensential features of the insurance coverage.

Covers special groups of individuals -Passengers on common carriers Institution of learning (school, college) Volunteer fire dept. or first aid group An organization (Boy scouts, FFA) Newspaper carriers Health care provider covering patients HMO covering the subscribers Required provisions for Group Blanket Health - An individual application is not required from a person covered. - A certificate of coverage must be issued to schools, colleges and universities only.

Using various deceptive, fraudulent or unethical methods to obtain business. Unfair trade practices include misrepresentation, false advertising, tied selling and other acts that are declared unlawful by statute. It can also be referred to as deceptive trade practices. Most state unfair trade practices statutes were originally enacted between the 1960s and 1970s. Since then, many states have adopted these laws to prevent unfair trade practices. Consumers that have been victimized should contact the unfair trade practice statute in their state to determine whether they have a cause of action.

A preexisting illness or preexisting condition is defined as any disease or sickness that was diagnosed by a physician or treated within a stated period prior to health insurance taking effect, or any disease or sickness that was diagnosed by a physician and not treated prior to the effective date of coverage; or any disease or sickness that exhibited within a period before coverage symptoms that a physician could have diagnosed and for which a prudent person would have sought treatment. (Specific requirements for small employers will be discussed later in this chapter.) Florida law prohibits individual health insurance policies (other than disability income insurance) from excluding coverage for preexisting conditions for longer than 24 months following the effective date of coverage, based upon a condition that had manifested itself during the previous 24-month period in such a manner as would cause an ordinarily prudent person to seek medical advice or treatment. Insurers are required to provide credit for preexisting conditions for the time a person was covered under previous coverage that was similar to or exceeded the coverage under the new policy, if such previous coverage was effective within the 63 days prior to the effective date of the new coverage. These are minimum standards and any more favorable to an insured may be used by an insurance company as policy conditions. The application must clearly request information about preexisting conditions if this provision is to apply.

The application provides the insurance company with necessary information regard- ing the insured's age, address, health history and other factors. This information is important so that the insurance company can properly determine if the applicant meets their underwriting rules and can determine the proper premium.

The application must contain the name of the insurance company, the name of the soliciting agent and the agent's identification number as it appears on his or her license. This information may be printed, typed, stamped or handwritten, if legible. [Sec. 627.4085, F.S.]

There is a series of questions on the application that provide information for underwriting the policy. These questions include name, address, age, height, weight, sex, occupation, earnings, beneficiary, insurance history and medical history.

The policy is issued based on the statements and agreements contained in the application. The insured or a beneficiary may not have a valid claim unless the questions have been answered truthfully and correctly on the application. [Sec. 627.409, F.S.]

No. The insurance company home office can make certain changes for administrative purposes. This must be done in such a manner that they are clearly not to be ascribed to the applicant. [Sec. 627.407, F.S.J

This health history provides the insurance company the information needed to determine if the applicant is acceptable, to determine the proper premium and for reinsurance purposes.

No. In this case the agent should return it to the applicant and have a new application completed.

No. The application only becomes a part of the policy and subject to legal contest by the insurance company when it is attached to the policy. [Sec. 627.561, F.S.]

This can be done when information is withheld by the insured on the application or when the application is incorrect as to the past health history of the insured. The law states: The falsity of any statement in the application for any policy may not bar the right to recover thereunder unless such statement materially affected either the acceptance of the risk or the hazard assumed by the company.

Yes. The existence of the 14 -day free look must be disclosed. It provides that after the policyholder has received and read the policy, if the decision is made that it is not the coverage desired, the policy may be returned and a full refund of premiums received. This would not apply to short-term single premium policies (e.g., aviation accident policies). [Rule 690-154.003, F.A.0 .; Sec. 626.99(4), F.S.1 accident policies).

Yes, but in the case of Medicare supplements and long-term care policies the period is 30 days.

An Outline of Coverage must accompany every individual or family accident and health insurance policy when it is delivered or issued for delivery. Or the Outline of Coverage can be delivered to the applicant at the time the application is taken. Certification must be given to the insurance company of the outline with the application for insurance. [Sec. 627.642, F.S.]

An Outline of Coverage must contain the following information: 1. A statement that identifies the applicable category of coverage afforded by the policy based on minimum basic standards. 2. A brief description of the principal benefits and coverages provided in the policy. 3. A summary statement of the principal exclusions and limitations or reductions contained in the policy, including, but not limited to, preexisting conditions, probationary periods, elimination periods, deductibles, coinsurance and any age limitations or reductions. 4. A summary statement of the renewal and cancellation provisions, including any reservation by the insurer of a right to change premiums. 5. A statement that the outline contains a summary only of the details of the policy as issued (or of the policy as pplied for) and that the issued policy should be referred to for the actual contractual governing provisions. 6. When home health care coverage is provided, a statement that such benefits are provided in the policy. [Sec. 627.642, F.S.J

No. This would violate the Florida rules on discrimination. [Rule 69B-125.001, F.A.C.; Secs. 626.9541, .9706, .9707, 636.022, 641.3102, F.S.]

No. The law prohibits this unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer. [Sec. 627.6419, F.S.]

No, provided the particular use of the bone man-ow procedure is determined to be acceptable and not experimental under rules adopted by the Department of Health. [Sec. 627.4236, F.S.]

How are health insurance rates governed? The law provides that the benefits must be reasonable for the premium charged. The Office of Insurance Regulation has established various criteria that insurance compa-nies must meet before rates can be approved. These are based on loss ratios and expense ratios and are designed to prevent the insured from being overcharged by the insurance company. [Rule 690-149.007. F.A.C.; Sec. 627.411, F.S.] Prior rate approval does not apply to group health insurance policies, effectuated and delivered in this state, insuring groups of 51 or more persons, except for Medicare supplement insurance, long-term care insurance, and any coverage under which the increase in claim costs over the lifetime of the contract due to advancing age or dura-tion is prefunded in the premium. Also, see Florida Employer Health Care Access Act in Chapter 30. [Rule 690-149.007, F.A.C.; Secs. 627.410; 627.411, F.S.]

The Florida Health Insurance Plan is a mechanism designed by the legislature to guar-antee health insurance to any Florida resident who, for health reasons, is unable to secure coverage from the voluntary health insurance market. The 2004 Florida Legislature created the Florida Health Insurance Plan with the intent that, once established, it would replace the Florida Comprehensive Health Association (FCHA), and the FCHA would be legally abolished. All persons enrolled in the FCHA at the time the Florida Health Insurance Plan is implemented are eligible for the benefits offered by the new plan. The benefits provided by the plan are the same as the standard and basic plans for small employers as outlined in s. 627.6699, Florida Statutes. The plan must also pro-vide an option of alternative coverage such as catastrophic coverage that includes a minimum level of primary care coverage, and a high deductible plan that meets the federal requirements of a health savings account. The plan is required for the delivery of cost-effective health care services, including the use of preferred provider organi-zations, health maintenance organizations, and other limited network provider arrangements. Eligibility for the plan is limited to individuals who have received a rejection or refusal to issue coverage for health reasons from at least two insurers or health maintenance organizations. Dependents of such individuals are also eligible are any persons enrolled in the FCHA at the time the plan is implemented. It is considered a violation of the Unfair Trade Practices Act for an agent to refer or arrange for an individual employee to apply to the plan for the purpose of separating that employee from group health insurance coverage provided by the employee's employer. The plan is intended to be "the payor of last resort" whenever any other benefit or source of third -party payment is available. Benefits that are payable by the plan must be reduced by all amounts paid or payable through any other health insurance policy, any workers' compensation coverage, automobile coverage or liability insurance. The plan, governed by a board of directors, has the authority to establish and modify rates, rate schedules, expense allowances and agents' commissions. Rates and rate schedules may be adjusted for factors such as age, sex and geographic variation in claims costs. Usual and customary commissions are payable to agents for initial placement of coverage with the plan and for one renewal only. The plan, its board of directors and plan of operations have not been established yet. The board of directors may not implement the plan until funds are appropriated by the Legislature. Until such time as the plan is fully implemented, the Florida Comprehen-sive Health Association remains in effect. [Secs. 627.64872, F.S.]

A preexisting illness or preexisting condition is defined as any disease or sickness that was diagnosed by a physician or treated within a stated period prior to health insur-ance taking effect, or any disease or sickness that was diagnosed by a physician and not treated prior to the effective date of coverage; or any disease or sickness that exhibited within a period before coverage symptoms that a physician could have diag-nosed and for which a prudent person would have sought treatment. (Specific require-ments for small employers will be discussed later in this chapter.) Florida law prohibits individual health insurance policies (other than disability income insurance) from excluding coverage for preexisting conditions for longer than 24 months following the effective date of coverage, based upon a condition that had manifested itself during the previous 24-month period in such a manner as would cause an ordinarily prudent person to seek medical advice or treatment. Insurers are required to provide credit for preexisting conditions for the time a person was covered under previous coverage that was similar to or exceeded the coverage under the new policy, if such previous coverage was effective within the 63 days prior to the effec-tive date of the new coverage. These are minimum standards and any more favorable to an insured may be used by an insurance company as policy conditions. The application must clearly request information about preexisting conditions if this provision is to apply. [Rules 690-156.003, 690-157.006,

Group health insurance policies are required to make available to the policyholder (i.e., to the employer, not to individual employees) coverage for mental and nervous disorders. If such coverage is elected by the policyholder, the benefits must meet cer-tain minimum standards. [Sec. 627.668, F.S.J

Both individual and group health insurance policies must continue to provide cover-age for a handicapped child, covered under a family policy, when that child becomes an adult. This requirement applies when the child is, and continues to be, both (1) incapable of self-sustaining employment by reason of mental retardation or physical handicap and (2) chiefly dependent upon the policyholder for support and maintenance. This rule applies even though the family policy would normally terminate coverage for a child who reaches a specified age. [Sec. 627.6615, F.S.]

Both individual and group health insurance policies that provide coverage for a family member of the insured must also provide that the health insurance benefits for chil-dren will be payable for a newborn child of the insured from the moment of birth. The law also requires that coverage be provided for a newborn child of a covered fam-ily member (e.g., the newborn of a covered daughter or son) for a period of 18 months. [Sec. 627.6575, F.S

Florida law provides that individual and group health insurance policies and HMO contracts must be renewed at the option of the individual or the policyholder except for: 1. failure to pay or untimely payment of premiums; 2. fraud or intentional misrepresentation of a material fact; 3. failure to meet minimum participation or minimum contribution requirements of a group policy; 4. the insurer ceases offering coverage in a market. If a policy form is no longer issued, the insurer may terminate coverage under current forms if it provides 90 days' notice and offers policyholders any other coverage offered. If all coverages in the individual or group market are discontinued, the insurer must give 180 days' notice and is prohibited from issuing any coverage in Florida for five years; and 5. for network plans, or bona fide associations, no individual or no group enrollee resides or works in the service area provided this requirement is applied 'nu" 7 formly. [Secs. 627.6425, 627.6571. 641.3104, F.)

This is a situation where the costs of injury or illness treatment are already paid for and private insurance benefits would duplicate the payment of expenses unnecessarily. [Rule 690-157.008, F.A.C.]

This term refers to insurance companies coordinating the payment of benefits when an insured is covered by two or more group health insurancepolicies. Its purpose is to limit benefits from multiple plans to no more than 100percent of expenses incurred and to designate the order in which insurers are top4 benefits. As a cost containment measure, this section was amended to require or allow a greater degree of coordination so as to avoid duplication of benefits. As this section now pro-vides, coordination of benefits is required among group health insurance policies that contain similar benefits. Coordination continues to be prohibited against indemnity-type policies, excess insurance policies, specified accident or illness policies or Medicare supplement policies. [Sec. 627.4235, F.S.]

Since most states' workers' compensation laws provide for payment of medical care costs for work-related injury or illness, the exclusion in private insurance of these costs would be an effort to avoid duplication of payments. [Rule 690-154.105(4)(a), F.A.C.]

Since the services of a Veterans Administration hospital are received without charge by a qualified recipient, the exclusion of benefit payments avoids duplicate payments by the health insurance company. [Rule 690-154.105, F.A.C.]

Yes. Group health insurance policies are required to offer coverage for alcoholism and chug dependency to the policyholder (i.e. the employer, not the employee). Although Certain minimum benefits must be offered, the statute allows the policy-holder to selec.... " any alternative benefits or level of benefits as may be offered by the insurer. [Sec. 627.669, F.S.]

Both individual and group health insurance policies are required to provide coverage or qualified services performed in an ambulatory surgical center. This applies if the service normally would have been covered on an inpatient basis. [Secs. 627.6056, .6616, F.S.]

All health insurance policies are now required by Florida law to provide coverage for treatment performed outside of a hospital if the treatment would have been covered on an inpatient basis and if the treatment is provided by a health care provider whose services would be covered in a hospital. [Sec. 627.4232, F.S.

Yes. The law requires that the words physician or medical doctor, when used in such policies, include a dentist when the policy covers surgical procedures that are specified in the coverage or are performed in an accredited hospital in consultation with a licensed physician and are within the scope of a dentist's professional license. [Sec. 627.419(2), F.S.]

The law requires medical expense policies to provide for payment to an optometrist or a podiatrist for procedures specified in the policy that are within the scope of their respective professional licenses. [Sec. 627.419(3), F.S.

Florida law requires insurance companies to either provide or offer chiropractic coverage. Specifically, if an insurance company offers a policy that does not provide for payment of chiropractic services, the insurer must offer coverage that provides payment to a chiropractor for procedures specified in the policy which are within the scope of the chiropractic practice. Under group health insurance policies, employees are entitled to elect chiropractic coverage. [Sec. 627.419(4), F.S.]

What is Medicare supplemental insurance and what is its purpose? Medicare supplemental insurance is a form of private insurance designed to pay some or all of the deductible and co-payment amounts that Medicare recipients are required to pay. The coverage applies to both the hospital and medical insurance plans administered l government for the elderly and permanently disabled. The purpose of by the federal goverment for the elderly and permanent disabled. The purpose of the Medicare supplemental insurance is to relieve the insured of the significant total costs not paid by Medicare due to its deductible and co-payment provisions. [Sec. 627.672, F.S.

Yes. Florida law requires an agent to ask every person solicited whether he or she is currently covered under another contract. The agent must explain the extent to which the proposed coverage will overlap or duplicate the existing coverage. Before an application is taken, the Department of Financial Services requires that an agent obtain a signed form from the prospect acknowledging that this information has been provided. [Rule 690-156.015, F.A.C.; Sec. 627.6743, F.S.]

This term refers to those provisions that must be included in health insurance con-tracts as a matter of law. The next few questions cover some of these provisions. [Sec. 627.605, F.S.]

The clause states that the policy, its endorsements and any attached materials, including the application, constitute the entire contract of insurance. This assures that no other documents that are not actually a part of the contract can be used to deny claims or coverage. [Sec. 627.605, F.S.]

Only such provisions of the charter or bylaws that are incorporated in full into the pol-icy may be used in a legal proceeding under the policy. [Secs. 627.415, .602, 641.3103, F.S.]

What is the "time limit on certain defenses" provision? This provision states in general that after two years, no misstatements except fraudu-lent ones, made by the applicant on the application, shall be used to void the policy or to deny a claim for loss incurred commencing after the end of such two-year period. • — ',,,"-irc, from the date of issue

This provision states in general that after two years, no misstatements except fraudu-lent ones, made by the applicant on the application, shall be used to void the policy or to deny a claim for loss incurred commencing after the end of such two-year period. It also provides that no claim for loss incurred after two years from the date of issue shall be denied on the grounds that a disease or physical condition, not specifically excluded by name, had existed prior to that date. [Sec. 627.607, F.S.]

The grace period is a stated period of time after the premium due date during which the policy remains in force even though the premium has not been paid. The grace period applies to premiums other than the initial premium. [Sec. 627.608, F.S.]

The law provides that there must be a grace period of not less than seven days on weekly premium policies, ten days for monthly premium policies and 31 days for all [Sec. 627.608, FS.]

A policy lapses and insurance ceases when the premium is not paid when due nor within the grace period. [Sec. 627.4555, F.S.]

The term means placing a policy in force again after it has lapsed. [Sec. 627.609, F.S.]

The policy becomes effective for accident coverage immediately, but does not become effective for any illness coverage until after ten days from the date of acceptance. [Sec. 627.609, F.S.]

In the first situation the claim would not be valid. An illness would have had to occur more than ten days after reinstatement for a claim to be valid. In the case of the accident, the insurance company would be liable for the claim because the insured would be entitled to full benefits as soon as the policy was rein-stated.

The insurance company must furnish the claimant with proof-of-loss forms within 15 days. If it does not furnish the claimant with its forms, the claimant may present proof in any reasonably written manner showing the nature of loss, extent of loss and other [Sec. 627.611, F.S.]

The insurance company must furnish the claimant with proof-of-loss forms within 15 days. If it does not furnish the claimant with its forms, the claimant may presentproof in any reasonably written manner showing the nature of loss, extent of loss and other information. [Sec. 627.611, F.S.]

Written notice must be given within 20 days, giving the name of the policyowner, nature of the loss and other information to identify the claimant to the insurance com-pany. In the event it is not reasonably possible to give notice within this time, notice must be given as soon as reasonably possible. [Sec. 627.610, F.S.]

The proof of loss is a written statement covering the occurrence of the accident or illness and the character and extent of the loss for which claim is made. It is usually submitted on forms furnished by the insurance company. [Secs. 627.610, .612, F.S.]

What is the agent's responsibility in the event a claim is reported to him or her? The agent must immediately report the claim to the insurance company. The law pro-vides that the policyowner, in the event of claim, may notify the insurance company or any of its agents. [Sec. 627.610, F.S.]

Yes. It may request such an examination as often as it reasonably requires. [Sec. 6615, F.S.]

The insurance company uses the medical examination to determine the extent of the disability of the insured.

Yes, provided: 1. the suit is filed at least 60 days after proof of loss has been given; 2. the loss is not paid within 120 days from the date of filing proof of loss as required by the policy if the claim is contested; and 3. the suit is brought within five years after proof of loss is furnished to the insurance company. [Secs. 627.613, .616, 95.11(2)(b), F.S.]

This provision stipulates the time after proof of loss is received by the insurance com-pany within which the claim payment must be made. [Sec. 627.613, F.S.]

Those policies that provide benefits in the event of the insured's death.

The policyowner has the right to change the beneficiary upon proper notification to the insurance company and without consent of the beneficiary. [Sec. 627.617, F.S.]

Yes. These are known as the "optional provisions," and are found in some health insurance policies. Some are noted in the next few questions. [Sec. 627.618, F.S.]

When an insurance company charges a different rate for persons in different occupa-tions, the policy may provide for a reduction in benefits if the insured changes to a more hazardous occupation, unless the insured has previously notified the insurance company and has paid an increased premium. However, if the insurance company wrote all risks at the same rate, then the change in occupation would not affect the benefits [Sec. 627.619, ES.]

No. The claim will be paid in full unless the policy contains a provision setting forth that in clirh rases there will be a reduction in benefits. [Sec. 627.619, F.S.]

The policy will provide, in substance, "If the age or sex of the insured has been mis-stated, all amounts payable under this policy shall be such as the premium paid would have purchased at the correct age or sex." [Sec. 627.620, F.S.

This provision operates when there is other insurance coverage in force which the insured has failed to give written notice about to the insurance company prior to the time that a claim begins. This clause gives the insurance company the right to prorate benefits and make appropriate premium refunds. The purpose of this clause is to pre-vent overinsurance through multiple policies. [Sec. 627.622. F.S.

Yes. It states a Medicare Supplement policy must, -Contain a prominently displayed no-loss cancellation clause enabling the insured to return the policy within 30 days of the date of receipt of the policy, or the certificate issued thereunder, with return in full of any premium paid." [Sec. 627.674(4)(d), F.S.1

Maternity benefits may or may not be offered under individual health insurance poli¬cies. There is no requirement provision under Florida law. However, group medical expense plans must provide maternity benefits.

A health maintenance organization is a health care delivery system which provides comprehensive health care services for its members. The members are typically enrolled on a group basis by their employer. The employer pays a fixed periodic con-tribution in advance for the services of participating physicians and cooperating hos-pitals. The employee may also contribute to the prepayment in some groups. (Refer also to Chapter 26.) [Sec. 641.31, F.S.

A major difference is that the HMO provides medical service while emphasizing pre-ventive medicine and early treatment through routine physical examinations and diag-nostic screening techniques. At the same time, the HMOs also provide complete hospital and medical care for sickness and injury. Traditional health insurance plans are designed to provide reimbursement for medical costs incurred in the treatment of sickness or injury. These plans emphasize curative rather than preventive medicine and contribute toward the cost of medical services rather than delivering the service. (Refer also to Chapter 26.)

Following the passage of legislation in 1983, insurance companies were authorized to enter into "alternative rates of payment" agreements with licensed health care pro-viders. Those entering into the agreements are called preferred provider organizations (PPOs). The concept is that if one provider or a group of providers has a large volume of busi-ness from a group of insureds, it can afford to give them health care at lower guaran-teed costs. This savings in health care costs can then be used to prevent health insurance premiums from increasing for that particular group of insureds. [Sec. 627.6471, F.S.]

An EPO, or exclusive provider organization, is a new type of entity authorized by the 1992 Legislature. It is a provider that has entered into a written agreement with a health insurance company to provide health care services for certain insureds. It can offer these services through its own facilities or a network of health care profession-als, or it may use another facility, such as an HMO. [Sec. 627.6472, F.S.]

It's any person, corporation, partnership or any other entity that, in return for a pre-payment, undertakes to provide or arrange for, or provide access to, the provision of a limited health service to enrollees through an exclusive panel of providers for the following services: Ambulance services Dental care services Vision care services Mental health services Substance abuse services Chiropractic services Podiatric care services Pharmaceutical services These limited health service plans differ from typical, broad-ranged HMO services in that the law doesn't allow for the provision of inpatient, hospital surgical services or emergency services, except as such services are provided incident to the limited health service. A formal complaint system that provides reasonable procedures for resolving written complaints initiated by enrollees and providers is mandatory for all PLHS0s. PLHSOs are prohibited from using the words "insurance," "casualty," "surety," "mutual" or "HMO" as part of their name, contracts or other literature. Florida law provides that no person may solicit contracts or procure applications or hold himself or herself out as engaging in the business of analyzing or abstracotingiopnres paid limited health sere pre-ices contracts or of counseling or advising or giving opinions to persons relative to such contracts, other than as a consulting actuary unless licenced, and appointed as a health insurance agent, pursuant to Chapter 626. [Sec. 636 generally; Secs. 636.003, .005 007, .016, .032, .038, .044, F.S.]

Group accident and health insurance is that form of health insurance covering groups of persons under a master group policy as limited by law. [Sec. 627.652, ES.]

1. basic medical expense insurance; 2. major medical insurance; 3. comprehensive medical insurance; 4. accidental death and dismemberment insurance; and 5. disability income insurance. [Rule 690-154.106, F.A.C.]

Four different types of groups are eligible for group health insurance. The types of groups eligible for group health coverage are: 1. employer/employee groups; 2. labor unions and association groups; 3. debtor groups; and 4. any other group that is eligible for group life insurance. [Secs. 627.653, .654, .655, .656, F.S.]

Florida law does not specify any minimum number for employee group health insurance. [Sec. 627.653, F.S1

Under Florida law there is no specific minimum percentage participation of employ-ees under employee group health insurance. [Sec. 627.653, F.S.]

The law provides that all employees or all members, as the case may be, must be eligible regardless of individual health history. The insurer may decline the entire group, but not individual employees. [Sec. 627.65625, F.S.]

Yes. The law provides that each member of the insured group must receive a certifi-cate that sets forth the essential features of the master insurance contract. In health insurance, this certificate is usually in the form of a booklet describing the benefits. [Sec. 627.657, F.S.]

No. Such policies may insure the spouses and dependent children of members, but not individuals who are not members of the association or dependents thereof. [Sec. 627.654, F.S.]

A contributory plan is one that requires that each participating employee pay some specified part of the cost of the plan. This payment is usually made through a payroll deduction.

One advantage of a contributory plan is that greater benefits can be provided than if only the employer portion was used for funding. Another advantage is that employees take a greater interest in the plan, since they share in its cost.

A noncontributory plan is one in which the employer pays the total cost. Employees are not required to contribute to the plan through payroll deduction.

The primary advantages of a noncontributory plan are employer control and total participation by all eligible employees, since no contribution is required of them.

The following extensions of benefits are required: 1. Every group, blanket or franchise policy or contract renewed, delivered or issued for delivery in the state of Florida shall contain a reasonable provision for extension of benefits in the event of total disability at the date of discontinuance of the policy or contract. The extension shall be required whether the group policyholder or other entity secures replacement coverage from a new insurer or forgoes the provision of coverage. 2. Discontinuance of the policy during a disability shall have no effect on benefits payable for that disability or confinement under a group plan providing benefits for loss of time from work or specific indemnity during hospital confinement. 3. In the case of hospital maternity expense, a reasonable extension-of-benefits or accrued-liability provision is required, which provides for continuation of policy benefits in connection with the treatment of a specific accident or illness incurred while the policy was in effect. 4. An extension of benefits is required in a group, blanket or franchise policy or con-tract that provides coverage for dental procedures either in the form of reimbursed expenses or services performed. 5. In the case of maternity expense coverage, a reasonable extension of benefits or accrued liability provision is required. The required provision must provide for continuation of policy benefits in connection with maternity expenses for a pregnancy that began while the policy was in effect. The extension shall be for the period of that pregnancy and may not be based upon total disability. 6. Any applicable extension of benefits or accrued liability shall be described in any policy or contract involved as well as in group insurance certificates. The benefits payable during any period of extension or accrued liability may be subject to the regular benefit limits of the policy or contract. 7. This section also applies to holders of group certificates which are renewed, deliv-ered or issued for delivery to residents of this state under group policies effectu-ated or delivered outside this state, unless a succeeding carrier under a group policy has agreed to assume liability for such benefits. [Sec. 627.667, F.S.]

Yes, unless it is a group policy approved in its home state, which is issued to a group that is substantially the same as an authorized group in Florida. However, the policy or certificate must contain (in contrasting color and 10-point or larger type) the fol-lowing statement: "The benefits of the policy providing your coverage are governed by the law of a state other than Florida." [Sec. 627.6515, F.S.]

The exclusions clarify the causes of loss and types of losses that are not covered. [Rule 690-154.105, F.A.C.]

Common causes of loss not covered by typical health insurance contracts are: 1. intentional self-inflicted injury 2. act of war 3. military service 4. injuries in private aviation as pilot or crew member 5. losses due to preexisting conditions 6. cosmetic surgery 7. expenses not associated with treatment of injury or sickness 8. mental disorders [Rule 690-154.105, F.A.C.]

Age, occupation, physical condition, medical history, moral factors, financial status and hobbies.

A noncancellable policy is continuable at the option of the policyowner at the premium stated in the policy. The insured thus may continue it until its stated termination date by timely payment of the fixed premium. No change in benefits or premiums may be made by the insurer. [Rule 690-154.004, F.A.C.]

Most family basic policies cover maternity claims. Usually the hospital expenses are covered up to ten times the room and board benefit. The insured would receive $1,000 if the room and board were $100. This item ($1,000) would be paid if the hospital charges were equal to (or greater than) this amount regardless of the length of time the patient was in the hospital. [Sec. 627.6406, ES.]

Florida law provides that no preexisting condition exclusion may apply to pregnancy for groups of two or more. Consequently, maternity benefits go into effect when a family basic policy is issued. [Sec. 627.6561, F.S.]

Florida's small group health insurance law passed in the 1992 legislative session and was amended in the 1993 legislative session. (Amendments were part of the Health Care and Insurance Reform Act of 1993.) The act governs group health insurance provisions provided by insurers or HMOs to small employers. [Sec. 627.6699, F.S.]

A small employer is an employer who employs not more than 50 employees, and the majority of whom are employed in Florida. The law applies to employers with 1 to 50 employees. (This includes sole proprietors, independent contractors and self-employed individuals.) [Sec. 627.6699, ES.]

The act requires small group health insurance contracts to comply with a number of specified conditions. The act's key provisions are: • All small group health benefit plans must be issued on a "guarantee-issue" basis, which means an insurance policy that must be offered to an employer, employee or dependent of the employee, regardless of health status, preexisting conditions or claims history. For groups of one, guarantee issue is limited to the basic, standard, and high-deductible small employer health benefit plans and is available only during an annual open enrollment period from August 1 through 31 of each year. Coverage provided begins on October 1 of the same year as the date of enrollment unless the small employer carrier and the small employer agree to a different date. Any high-deductible plan offered must meet the requirements of a health savings account plan as defined in federal law or a health reimbursement arrangement as authorized by the Internal Revenue Service. Any one-person small employer obtaining coverage must not be formed primarily for the purpose of buying health insurance. If an individual hires his or her spouse and dependent children as employees, the entire family unit would be considered a one-person group unless both spouses are working full-time (25 hours or more per week). • Carriers must use a "modified community rating" methodology in which the premium for each small employer must be determined on the basis of the eligible employee's and eligible dependent's gender, age, family composition, tobacco use or geographic area. Boundaries of geographic areas must be the same as county lines. Limited use of health status, claims experience or duration of coverage is allowed to adjust a small employer's rate by a maximum plus or minus 15 percent of the carrier's approved rate. The renewal premium is allowed to be adjusted a maximum of 10 percent annually for health status, claims experience or duration of coverage, subject to the 15 percent total rate deviation. Any adjustments for claims experience, health status or duration of coverage may not be charged to individual employees or dependents, but must be averaged over the entire group. • Small group carriers are allowed to rate one-life groups, separate from the rating pool for groups with 2-50 employees, but not to exceed 150 percent of the rate for groups of 2-50 employees. Renewal rates for policies in effect July 1, 2002 are further limited for groups of one to not exceed 125 percent of the 2-50 groups for the first renewal. Thereafter, the 150 percent rate cap is in effect. All health plans that are offered to small employers are exempt from laws limiting deductibles, coinsurance, co-payments and maximum annual and lifetime benefits unless the law is made expressly applicable to a health plan or policy. • Small group carriers are allowed to provide small employer groups a credit to reflect administrative and acquisition expense savings resulting from the size of the group. • Small group carriers may not use composite rating for employers with fewer than 10 employees. Composite rating is a methodology that averages rating factors for age and gender in the premiums charged to all employees, rather than separately listing the applicable rate for each employee. • Preexisting exclusions are limited to 12 months for conditions manifested during the previous 6 months for small employers with two (2) to 50 workers. Florida law provides that no preexisting condition exclusion may apply to pregnancy for groups of two or more. Exclusions are limited to 24 months for conditions manifested during the previous 24 months for employers with one worker. • Under the act's "portability" provision, a worker or dependent will have to meet the waiting period for an existing condition only once, even if the individual changes employers and insurers. Eligibility for this "portability" provision is limited to workers or dependents who have had qualifying previous coverage continually to a date not more than 63 days before the effective date of the new coverage. • Coverage must be renewed by carriers except for failure to pay premiums; fraud or intentional misrepresentation; failure to comply with a plan's contractual pro-visions; or when the insurer ceases offering coverage in the market, with certain notice restrictions. [Secs. 627.6699(12); 627.6699, F.S.]

In 1993, the Florida legislature created Community Health Purchasing Alliances (CHPAs) as state-chartered, non-profit, private organizations intended to pool small employer purchasers of health care together in organizations that broker health plans under what was termed "managed competition." Due to the extremely small impact of the CHPAs, the Florida legislature in the year 2000 repealed the laws establishing CHPAs. The legislature in the year 2000 authorized health insurers to issue a group policy to any Small Employer Health Alliance organized as a not-for-profit corporation under chapter 617 of the Florida statutes. This could include a former CHPA that continues to operate as a private not-for-profit corporation, or any other alliance organized as provided under the law. An alliance may be formed for the purpose of obtaining insur-ance. Group policies issued to an alliance may insure small employers, as defined in 627.6699 of the Florida statutes (an employer with 1 to 50 employees). Rates for a policy issued to an alliance or association are allowed to reflect a premium credit for expense savings resulting from administrative activities performed by the alliance or group association. [Secs. 408.70, 617, 627.654, 627.6699, F.S.]

The 2004 legislature determined that increased access to health care coverage for small employers with up to 25 employees could improve employees' health and reduce the incidence of costs of illness and disabilities among residents of Florida. As a result, the legislature created the Small Employers Access Program which includes the creation of the Small Business Health Plan. This plan is intended to provide small employers the option and ability to provide health care benefits to their employees through the creation of purchasing pools. These pools may be comprised not only of employers with up to 25 employees, but any municipality, county, school district or hospital employer located in rural areas as defined in s. 288.0656(2)(b), F.S., as well as any nursing home employer regardless of the number of employees. Insurers wish-ing to provide such coverage must be selected by the Office of Insurance Regulation through a competitive bidding process and must offer basic, standard and high-deductible plans as outlined in s. 627.6699, F.S. Selected insurers must maintain pub-lic awareness programs, encourage the effective use of health saving accounts and demonstrate the ability to deliver cost-effective health care services. [Sec. 627.6699(15), F.S.]

This legislation (627.6691) requires insurers that sell health plans to small employers (less than 20 employees) to offer in those plans a right to elect continued coverage, without providing evidence of insurability, to the covered employee or their depen-dents who will lose employer-sponsored group coverage for various reasons and who may not be able to obtain replacement insurance. Coverage may be continued in most circumstances for up to 18 months beyond the time when it would have otherwise ended. The law requires that the premium for continuation of group coverage not exceed 115 percent of the regular group rate, except in cases where the beneficiary was disabled at the time continuation coverage begins, in which case, the beneficiary may extend coverage for an additional 11 months and pay a premium of 150 percent of the group rate during those additional months. The law authorizes insurers to contract with inde-pendent administrators to administer the continuation benefits and relieves these administrators of regulatory requirements when they meet specified conditions. This Florida law extends essential provisions similar to the federal COBRA to employers in Florida with less than 20 employees. [Sec. 627.6692, F.S.]

Yes, Florida law (627.419; 627.6515) prohibits health care providers, insurance policies, insurers, and health maintenance organizations which provide coverage for diagnostic procedures including the bones and joints of the skeleton from discriminating against coverage for similar diagnostic or surgical procedures involving the bones or joints of the jaw and facial region, if under accepted medical standards, such proce-dure or surgery is medically necessary. [Secs. 627.419, 6515, F.S.]

Yes, Florida law (627.6408; 627.65745; 641.31) requires health insurance policies and HMO contracts to provide coverage for all medically necessary equipment, sup-plies and services used to treat diabetes when the patient's physician certifies that they are medically necessary. This includes outpatient self-management training and edu-cation services if medically necessary. [Secs. 627.6408, .65745, 641.31, F.S.]

Florida Statutes require that an individual or group health insurance policy or HMO contract that provides coverage for maternity care may not limit coverage for the length of maternity stay in a hospital, or for follow-up care outside of a hospital, to a time period below that which is determined to be medically necessary by an obstetrical provider or a pediatric provider in accordance with prevailing medical standards. Coverage for postdelivery care after the mother and newborn leave the hospital must also be included in accordance with prevailing medical standards. [Secs. 627.6406, .6574, 641.31, F.S.]

Most individual and group health insurance and HMO contracts are required by Florida law (627.6409; 627.6691; 641.31) to provide coverage for medically neces-sary diagnosis and treatment of osteoporosis for high-risk individuals. Specified-accident, specified disease, hospital indemnity, medicare supplement and long-term care health insurance policies are not included in the requirement. Osteoporosis is a bone-thinning disease which increases the risk of bone fractures. [Secs. 627.6409, .6691, 641.31, F.S.]

Yes, Florida insurance law prohibits health insurers, HMOs and other health plans from requiring or soliciting genetic information, using genetic test results, or considering a person's decisions or actions relating to genetic testing for any insurance purpose. Also, they may not cancel, limit or deny coverage, or establish differentials in premium rates based on genetic information in the absence of a condition related to genetic information. Genetic information or testing does not include routine physical examinations or chemical, blood or urine analysis, unless conducted to obtain genetic information, or questions regarding family history, unless asked to obtain genetic information. The prohibition regarding use of genetic testing and information does not apply to the underwriting of a life insurance, disability income, long-term care, accident-only, hospital indemnity or fixed indemnity, dental or vision policy. [Sec. 627.4301, F.S.]

What are Florida's laws concerning insurance coverage for breast cancer and mastectomies? Florida law: • mandates coverage for prosthetic devices and reconstructive surgery following a mastectomy, including all surgery necessary to reestablish symmetry between breasts; • prohibits inpatient hospital coverage for mastectomies from being limited to less than what is determined to be medically necessary by the physician after consul-tation with the patient; • requires that outpatient postsurgical care for mastectomies be comparable to inpatient postsurgical care for mastectomies; •prohibits a person from being denied or excluded from coverage for breast cancer, if the person has remained breast cancer free for two years; and • prohibits breast cancer follow-up care from being considered an evaluation for a preexisting condition, unless breast cancer is found. These provisions apply to individual, group, and out-of-state health insurance poli-cies, multiple employer welfare arrangements and HMO contracts. [Secs. 627.6417, .64171, .64172, F.S.]

Is health insurance coverage for cleft lip and cleft palate required under Florida law? Florida law Sec. 627.64193, F.S., requires an insurance policy that covers a child under age 18 to provide coverage for treatment of cleft lip and cleft palate for the child. Insurers must cover medical, dental, speech therapy, audiology and nutrition services only if such services are prescribed by a treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary and consequent to treatment of cleft lip or cleft palate. The law specifies that terms and conditions applicable to other benefits apply to these coverage requirements, and specifies the inapplicability of the coverage requirement to specified-accident, specified disease, hospital indemnity, limited benefit disability income or long-term care insurance policies. The law applies this coverage requirement to a policy of individual insurance (Sec. 627.64193, ES.); group, blanket or franchise accident or health insurance (Sec. 627.6515(2)(c), F.S.); and small group health insurance (Sec. 627.6699(12)(b), F.S.); and to a contract issued by a health maintenance organization.

HIPAA requires that any person with 18 months of creditable coverage, who does not have access to other health insurance, must be given access to an insurance policy. Creditable coverage includes a group health plan, individual health insurance delivered in Florida, Medicare and Medicaid as well as coverage by the Florida Comprehensive Health Association and others. However, the last period of creditable coverage must have been under a group health plan. Federal law permits states to adopt acceptable alternative mechanisms for access to health insurance for HIPAA eligibles. Consequently, Florida law contains the following provisions: • For HIPAA eligibles who have access to a conversion policy, the policy serves as access to an insurance policy. Insurers must mail to individuals who are eligible for a conversion policy an election and premium notice form, including an outline of coverage, within 14 days of request or notice to the insurer that an individual is considering applying for a conversion policy. • The premium rate on HMO conversion policies is capped at 200 percent of the standard risk rate, which is the same as conversion policies offered by insurers. • All other HIPAA eligibles must be given access to an individual health insurance by an insurer selling individual polcies in Florida.

Florida law requires eligibility for guaranteed-issuance of an individual health insurance policy to include persons with 18 months of prior coverage under a group health plan; or under an individual plan, if the prior insurance coverage is terminated due to the insurer or HMO becoming insolvent or discontinuing all policies in the state, or due to the individual no longer living in the service area of the insurer or HMO.

Mental Health Parity. The Florida Office of Insurance Regulation must require that lifetime and annual dollar limitations on mental health benefits (if provided) under group policies be the same as for other medical and surgical benefits under the policy, subject to certain exemptions. Small groups (1-50) are exempt and other groups are exempt if the requirement results in an increase in cost of at least 1 percent. Maternity Coverage. An insurer may not: • deny the mother or her newborn eligibility, or continued eligibility, to enroll or renew coverage, for the purpose of avoiding the requirements of the bill; • penalize, reduce or limit payment to a provider who complies with the bill; • offer incentives to a provider to render care inconsistent with the law; or • restrict benefits for hospital length of stay which are less favorable than the benefits provided. [Secs. 627.6406, .6574, 641.31, F.S.]

All policies are renewable except for the following reasons: • failure to pay premiums; • fraud or intentional misrepresentation; or • the insurer ceases offering coverage, in which case the insurer is prohibited from selling coverage for a specified period of time.

Preexisting Conditions (applies to groups of two or more and HMO group policies only). • Policies may not exclude coverage for preexisting conditions for longer than 12 months (18 months for late enrollees), with a six-month look back. • Genetic information is not a preexisting condition in the absence of a diagnosis. • No preexisting condition period may be applied to newborns, adopted children, or pregnancy. • Credit must be given for time served under other creditable coverage.

Special Enrollment Periods (applies to group, small group, and HMO group policies only). • Employees and their dependents must be allowed to enroll if they previously declined enrollment because they had coverage. • New dependents must be allowed to enroll within 30 days of marriage, birth or adoption. [Secs. 627.65615, 641.31072, F.S.]

Policies may not condition eligibility or continued eligibility on an individual's health status, medical claims experience, receipt of health care, medical history, genetic information, or evidence of insurability.

Florida law Sec. 624.123 authorizes the sale of international health insurance policies only to residents of foreign countries (not citizens or residents of the United States) at international airports in Florida without being subject to rate or form regulation by the Office of Insurance Regulation. Such international health insurance policies may be solicited and sold only by Florida licensed and appointed health insurance agents, representing a Florida authorized insurer. An international health insurance policy is health insurance, as defined in Florida law Sec. 627.6561(5)(a)2, offered to an individual, covering only a resident of a foreign country on an annual basis.

Florida has a statewide comprehensive and coordinated program of universal hearing screening, identification and follow-up care for newborns and infants. Hearing screening for all newborns, provided prior to discharge by hospitals and birthing facilities, and any medically necessary follow-up reevaluation leading to diagnosis, must be a covered benefit under all health insurance policies and HMO contracts as child health supervision services.

A Discount Medical Plan is an arrangement or contract in which a person, in exchange for fees or other consideration, provides access for plan members to the services of providers of medical services at a discount. Although organizations offering such plans must be licensed by the Office of Insurance Regulation, such plans are not considered insurance. Such organizations may not use in their advertisements the terms "health plan," "coverage," "copay," "preexisting conditions," "guaranteed issue," "premium" and certain other terms typically associated with insurance products. Marketers of such plans are not required to be licensed as insurance agents. [Secs. 636.202, .204, .210, F.S.]