Florida Laws — Health Insurance
Florida's health-specific overlay: mandated benefits, group rules and blanket coverage, mini-COBRA and conversion, disclosure and advertising, Medicare supplement standards, the long-term care rulebook, small employers, and the state programs.
Take a shot at these. Being wrong here is the point — it primes you for the answers, which are all in this lesson.
Which practice is PERMITTED in a Florida long-term care policy?
Sun Grove Nursery has 30 employees who each work 30-hour weeks. Under the Employee Health Care Access Act, a small employer carrier must:
The Kellers' covered daughter gives birth while on the family policy. The insured's new grandchild is covered:
This chapter piles Florida-specific rules onto general health insurance — and it runs on number chains. Mini-COBRA's clockwork is 63 → 14 → 30 days at 115% premium (150% disabled); conversion is 3 months → 63 days → 200%; associations are 25 members → 1 year → 15 enrolled; Medigap gives 30-day free looks and three different 6-month rules; LTC runs on 30/120/5-months/180. Around the numbers sit the mandates (newborns, mastectomy, autism, balance billing), the two competing definitions of "small employer" (1–50 vs fewer than 20), and the disclosure paperwork — outline at application, Shopper's Guide before it. Where Florida law and the general course content conflict, Florida law wins.
Minimum Standards & Mandated Benefits
Minimum Benefit Standards · Required CoveragesThe floor first: grandfathered plans (enrolled March 23, 2010, continuously covered since) escape some ACA rules but still owe no-lifetime-limits, age-26 dependents, 90-day waiting caps — and lose status by cutting benefits, raising cost-sharing, or shrinking the sponsor's contribution. Every carrier must shelf at least one comprehensive policy with no preexisting-condition exclusion. Then the mandates: diabetes equipment/supplies/training and osteoporosis care; newborns from the moment of birth (a covered family member's newborn for 18 months, and late notice can cost premium but never coverage); the child quartet — adoption-at-placement, well-child care to 16, the two-part disabled-dependent test, cleft lip/palate; mastectomy reconstruction, the mammogram calendar, and the fibrocystic rule; 10% wellness rebates; autism and Down syndrome therapies; opioid and step-therapy shields; and no-prior-auth emergencies with the balance-billing ban.
An insured has emergency surgery at an in-network hospital, but the anesthesiologist is out-of-network and bills her $2,200 beyond what the insurer paid. Under Florida law:
The Kellers' covered daughter gives birth while on the family policy. The insured's new grandchild is covered:
Group Health: Eligible Groups & Blanket Coverage
Group Health [627.6516–.660]Florida's group menu: employer and trustee groups — trustee policies need 5+ persons per employer unit, and "full-time" statewide means a 25+ hour workweek; associations and labor unions on the 25 members · 1 year · 15 enrolled chain with bylaws and the association as policyholder; debtor groups — credit disability needs 100 new entrants a year (evidence of insurability allowed under 75% participation), mortgage insurance covers 10+ year first-mortgage debt. Blanket health covers the ever-changing group — bus passengers, students, campers, volunteer responders — with no individual applications and no certificates, except for schools. Ordinary groups DO get a certificate of coverage: group number, essential features, who gets paid — one per family unit.
Which requirement applies to an association seeking a Florida group health policy?
A blanket health policy generally requires no certificate of coverage for insureds. The exception — where certificates ARE required — is a policy issued to:
Continuation, Conversion & Coordination of Benefits
Mini-COBRA [627.6692] · Conversion · COB [627.4235]Florida's Health Insurance Coverage Continuation Act is mini-COBRA for employers under 20 employees — and unlike the federal law, the INSURER administers it. The clockwork: beneficiary notifies the insurer within 63 days of the qualifying event → insurer responds by certified mail within 14 days → the beneficiary elects and pays within 30 days, all retroactive, at up to 115% of the group rate for a maximum of 18 months (an SSA-determined disabled beneficiary adds 11 months — 29 total — at up to 150%). The conversion privilege is the other exit: 3 months continuously insured → apply and pay within 63 days → no evidence of insurability, premium capped at 200% of the standard risk rate. Coordination of benefits keeps double coverage honest: coordinating plans together pay 100% of reasonable expenses, the working senior's own employer plan pays before Medicare, married parents' kids follow the birthday rule, divorce runs custodial → step-parent → noncustodial — and COB never touches indemnity, excess, specified-disease, or Medigap policies.
A child's married parents each have group coverage. Dad's birthday is March 3, 1980; Mom's is January 20, 1985. Which plan pays the child's claim first?
Bay Décor has 12 employees. When Tina's hours are cut and she loses group health eligibility, which law lets her continue coverage — and who administers it?
Disclosure, Renewal, Advertising & Agent Duties
Outline [627.642] · Renewal [627.6425, .6571] · Advertising [69O-150]The outline of coverage goes to the applicant at application (receipt acknowledged with it): category, main benefits, the exclusion summary, renewal/cancellation terms, and a summary-only warning. Renewal belongs to the policyholder except for listed outs — nonpayment, fraud, market exit, leaving the service area, contribution/participation violations (group) — with 90 days' notice to drop a form, 180 days to exit a group market, and a 5-year ban for abandoning Florida health business entirely. Advertising law bans the exaggerators ("all, full, complete, unlimited"), hospital-cash "extra income" phrasing, and dressed-up limitations; limited policies must shout "THIS IS A LIMITED POLICY"; agent ads need insurer approval and live in the home-office file 4 years. The agent's application duties are fiduciary: ask every question, record honestly, warn self-completers, gather signatures — and never sign for the applicant.
While taking a paper application, a health applicant asks the agent to 'just sign it for me — I'm late for work.' The agent should:
The outline of coverage for a Florida health policy must be delivered:
Medicare Supplement in Florida
Medicare Supplement [627.674–.6744; 69O-156]Florida Medigap minimums: preexisting conditions sidelined at most 6 months (none at all for the continuously covered), a 30-day free look, guaranteed renewability, and benefits that automatically track Medicare's deductibles and coinsurance. Open enrollment: at 65+, 6 months from Part B enrollment with every plan on the carrier's shelf offered at standard rates; under 65, Florida adds windows for disability/ESRD eligibles and the 60 days after group coverage ends; the annual OEP runs October 15 – December 7. Marketing standards demand the first-page "Notice to buyer," ban twisting, high-pressure tactics, and cold lead advertising — and prohibit selling anyone more than one Medigap policy or selling to Medicaid or Medicare Advantage enrollees (Advantage covers everything Original Medicare does except hospice). Replacement mechanics: direct questions on the application, the replacement notice, 5 working days to alert the existing insurer — and a policy in force 6 months carries its served waiting periods into the new one.
An agent selling Medicare Supplement policies must provide every applicant with a(n)
A replacing insurer receives a Medicare supplement application indicating replacement. It must send a copy of the replacement notice to the existing insurer within:
Long-Term Care: the Florida Rulebook
LTC [627.9404–.94073; 69O-157]Florida LTC standards: guaranteed renewable or better, priced on issue age, 30-day free look, elimination periods capped at 180 days, never a prior-hospitalization requirement — and benefits of at least 24 months of nursing home care plus one lower level at 50%+. The 6/6 pre-ex rule and the permitted-exclusions list follow, with the exam's favorite carve-out: mental/nervous disorders may be excluded — never Alzheimer's. Home-care benefits can't smuggle nursing-home tests back in; insurers must OFFER 5%-compounded inflation protection and a nonforfeiture benefit (floor: the greater of premiums paid or 30× the daily benefit, with a contingent benefit if a rate hike lapses a decliner within 120 days). The lapse protections stack a 30-day grace, a secondary addressee-style designee notice, and a 5-month reinstatement for cognitively impaired or confined insureds. Disclosure: Shopper's Guide BEFORE the application, outline AT it. Benefit triggers are the six ADLs and cognitive impairment; the care-level ladder sorts skilled → intermediate → custodial; and group LTC and replacement add 6-month conversion, signed acceptance for benefit cuts, and the 5-working-day replacement notice — with the Partnership Program's dollar-for-dollar Medicaid asset protection on top.
Which practice is PERMITTED in a Florida long-term care policy?
A Florida LTC policy excludes 'mental and nervous disorders.' For an insured later diagnosed with Alzheimer's disease, the policy:
Small Employers, State Programs & Plan Types
Small Employers [627.6699] · Healthy Kids [624.91] · HIV [627.429]The Employee Health Care Access Act defines the small employer as 1–50 eligible employees (25-hour weeks, no part-timers or temps) — a different animal from mini-COBRA's under-20 employer — and its ground rules demand guaranteed issue, modified community rating (age, gender, family composition, tobacco), rates locked 12 months, 30-day enrollment windows, and fair marketing that never steers by health status; employers of 50+ must offer coverage. Florida Healthy Kids (1990) pools local, state, federal, and family money so commercial insurers cover school-age children who miss Medicaid. The HIV/AIDS rules require written informed consent to test, physician-delivered results, strict confidentiality — and ban sexual orientation (or its proxies) from underwriting entirely. The plan-type lineup closes the chapter: HMO's closed network and gatekeeper, PPO's in/out pricing, EPO, PLHSO's limited menu, fixed-rate indemnity plans, the DMPO that is licensed but NOT insurance, and lump-sum dread disease coverage.
Sun Grove Nursery has 30 employees who each work 30-hour weeks. Under the Employee Health Care Access Act, a small employer carrier must:
Which concept does this describe? Every small employer carrier must issue all employer health benefit plans on a guaranteed-issue basis (the statute's guaranteed-issue text covers groups of 2–50 eligible employees; one-life groups enroll through a limited annual open-enrollment window); riders adding benefits MAY be medically underwritten but attach only to the standard plan. Per the note, a late enrollee (for employers with fewer than two employees) may be excluded no longer than twenty-four (24) months if not continuously covered by creditable coverage within 63 days before the new effective date. Enrollment: an initial enrollment period of at least 30 days; an annual 30-day open enrollment; and a special enrollment period when prior coverage ended (COBRA exhausted; loss of eligibility through legal separation, divorce, death, termination, or reduced hours; or employer contributions ended) — requested within 30 days of termination. Required disclosures: premium-change provisions and rating factors, renewability, preexisting-condition provisions, and all plans the employer qualifies for. Carriers may decline only for listed reasons (outside the geographic service area — no smaller than a county; no in-network capacity; or inadequate financial reserves applied uniformly — which locks the carrier out of the small-group market for 180 days). Fair marketing: no steering employers away (or toward another carrier) because of health status, claims experience, industry, occupation, or geographic location; no agent compensation or contract termination based on those factors; never encourage firing an employee to get coverage; denials require written notice with reasons. Rates: modified community rating, unchangeable for twelve (12) months unless group composition or benefits change, applied to all eligible employees and dependents. Employees may decline coverage — then wait for open enrollment or a qualifying event. Employers with 50 or more employees must offer health insurance; smaller employers are not required to.
Close your eyes for a moment, then write everything you remember from this chapter — rules, numbers, traps. Recalling first is worth more than rereading.
Recall captured. Compare it against the summary below.
What this chapter covered
- Minimum Standards & Mandated BenefitsNewborn trap: late notice → back premium, not denial (protected when notice lands within 60 days of birth). Mammograms: baseline 35–39, every 2 years in the 40s, yearly at 50+. Balance billing dies in emergencies and at in-network facilities without a choosable in-network provider.
- Group Health: Eligible Groups & Blanket CoverageBlanket coverage's certificate exception is pure exam bait: no certificates required — EXCEPT schools, colleges, and universities. And 25 hours = full time in two different Florida statutes.
- Continuation, Conversion & Coordination of Benefits63 days appears twice — mini-COBRA event notice AND the conversion application window. Federal vs Florida: 20+/employer/102% vs under-20/insurer/115%.
- Disclosure, Renewal, Advertising & Agent DutiesExit tolls: one product = 90 days' notice · a whole group market = 180 days · all Florida health business = 5 years locked out.
- Medicare Supplement in FloridaThree different 6-month rules share this section: the pre-ex cap, the 65+ enrollment window, and the replacement credit. Read which one the question is asking about.
- Long-Term Care: the Florida RulebookADLs — bathing, dressing, toileting, transferring, continence, eating; 'chronically ill' = 2 ADLs / 90 days or severe cognitive impairment. And LTC premiums ride ISSUE age, never attained age.
- Small Employers, State Programs & Plan TypesWhich "small employer"? Access Act = 1–50; mini-COBRA = fewer than 20 — the question's context picks the number. And a DMPO sells discounts, not coverage: calling it insurance is always the wrong answer.
Lesson complete — every check passed from memory. Your pretest answers above are now revealed.