Health Insurance Florida Statutes, Rules, and
Regulations Exam with complete solutions | Verified &
Updated
Minimum Benefit Standards - Contracts available in Florida - ANSWER - Basic
Medical Expense plans
- Basic Physician's (nonsurgical) Expense plans
- Major Medical Expense plans
- Supplemental Major Medical plans
- Comprehensive Major Medical plans
- Health Maintenance Organization (HMO) plans
- Preferred Provider Organization (PPO) plans
- Exclusive Provider Organization (EPO) plans
- Prepaid Limited Health Service Organization plans
- Group Health Insurance plans
Entire Contract - ANSWER Policy + copy of application
Time Limit on Certain Defenses - ANSWER Statements on the application are
incontestable after 2 years (except for fraud)
Grace Period: - ANSWER - Weekly: 7 days
- Monthly: 10 days
- All others: 31 days
Reinstatement - ANSWER 45 days
Claims Procedure - ANSWER - Notice of Claims: submitted by insured within 20
days
- Claims forms: provided by insurer within 15 days
- Proof of loss: submitted by insured within 90 days
- Time of Payment of Claims: benefit paid immediately by insurer after proof of loss
received
- Denial of Claims: if a claim was denied, the claimant has a right to appeal
- Legal Action: no sooner than 60 days, no later than 5 years
- Change of Beneficiary: beneficiary can be changed by policyowner at any time,
unless irrevocable
Group Policies must - - ANSWER • be Guaranteed Renewable
• cover Mental and Nervous disorders, Alcoholism and Drug dependency treatment
Additional Requirements (excluding those of Group policies) - ANSWER • Cover
children of insured
- Newborn children must be covered from moment of birth
,- Handicapped children must have coverage beyond the limiting age (with proof of
incapacity and dependency)
• Policies that cover maternity care mush also cover services certified nurse-
midwives, midwives, and service of licensed birth centers
HMO State Requirements - ANSWER • Can offer only contracts approved by the
Department; may not engage in insurance transactions. However, Insurance
companies can own an HMO
• Must file annual reports with 3 months of the end of each fiscal year
• Additional requirements:
- Obtain a certificate of authority from the Department;
- Obtain a valid Health Care Provider Certificate form the Department of Health and
Rehabilitation Services;
- Meet capital and surplus minimum requirements, rate filing contract and forms;
- Make a deposit of $10,000 to the Rehabilitation Administration Expense Fund; and
- Become a member of the Florida Health Maintenance Organization Consumer
Assistance Plan
Exclusive Provider Organizations (EPOs) - ANSWER PPO in which individual
members use particular preferred providers rather than having a choice of a variety
of preferred providers
Multiple Employer Welfare Associations (MEWAs) - ANSWER Any entity that
establishes an employee benefit plan to provide accident and sickness or death
benefits to the employees of at least 2 employers, including self-employed
individuals and their dependents
Discount Medical Plan Organization (DMPO) - ANSWER A business arrangement
or a contract (not insurance) in which a person, for a fee, provides access for plan
members to providers of medical services and the right to receive those services at a
discount
Medicare Supplement Insurance basics - ANSWER • Florida laws regarding
Medicare Supplement insurance are for enforcement purposes
• Has 30-day free-look provision
Long-Term Care policy Disclosure - ANSWER • Must disclose renewability
provisions, riders, endorsements, limitations, or conditions of eligibility
• must define "usual and customary" or "reasonable and customary"
• Shopper's guide to applicant before completion of application
• Outline of coverage to insured before application or enrollment form
Long-Term Care policy Marketing - ANSWER • Company must retain
advertisements for at least 3 years from first use
• Unfair or deceptive trade practices prohibited
Long-Term Care policy Required Provisions - ANSWER • Required minimum
benefits:
- Daily nursing benefits of at least 80% of state average for up to 365 days
, - Daily home/community-based benefits of at least 50% (not more than daily nursing
benefit)
• Inflation protection:
- 80% to 110% of average daily nursing benefit pay rate
- Automatic increases in per diem dollar level of consumer price index or a 5%
increase
Long-Term Care policy Unintentional Lapse - ANSWER LTC policies cannot be
issued without either
• Written designation of at least 1 person (in addition to applicant) who receives
notice of lapse of policy for nonpayment of premium; or
• Written, dated and signed waiver reflecting applicant's decision to not designate
additional people
Long-Term Care policy Additional Definitions - ANSWER Activities of Daily Living
(ADLs)- include eating, bathing, dressing, toileting, transferring, and maintaining
continence
• Continuing Care Coverage - Benefits for residents of continuing care retirement
communities that cater to medical and social needs of residents
• Hospice - short, continuous care for terminally ill people with life expectancies of 6
months or less
Long-Term Care policy Replacement - ANSWER • Time periods applicable to pre-
existing conditions, waiting periods and probationary periods on the new LTC policy
must be waived to the extent that they have been satisfied on the previous policy
LTC Partnerships - ANSWER • Insureds who have exhausted private LTC benefits
may apply for Medicaid coverage without meeting same requirements
• Disregards some or all assets of Medicaid applicants; also exempts those assets
from estate recovery after insured's death
Small Employers Definitions - ANSWER • Small Group Employer - any person, firm,
corporation, or association that has at least 2, but no more than 50 eligible
employees
• Eligible Employee - any full-time employee working 25 or more hours a week who
has met any waiting period or other requirements
Florida Employee Health Care Access Act - ANSWER • Governs group health
insurance provisions provided by insurers and HMOs to small employee
• Key Provisions:
- Benefits must be issued on a guaranteed issue basis
- Carriers must base premium for each small employer on eligible empoyees' and
eligible dependents' age, gender family composition, tobacco use or geographic area
- Coverage must be renewed by carriers except for failure to pray premiums, fraud or
intentional misrepresentation, failure to comply with a plan's contractual provisions,
or when the insurer ceases to offer coverage in the market
Small Employers Coverage and Benefits - ANSWER • Carriers doing business in
Florida must offer at least a basic plan and a standard plan
Regulations Exam with complete solutions | Verified &
Updated
Minimum Benefit Standards - Contracts available in Florida - ANSWER - Basic
Medical Expense plans
- Basic Physician's (nonsurgical) Expense plans
- Major Medical Expense plans
- Supplemental Major Medical plans
- Comprehensive Major Medical plans
- Health Maintenance Organization (HMO) plans
- Preferred Provider Organization (PPO) plans
- Exclusive Provider Organization (EPO) plans
- Prepaid Limited Health Service Organization plans
- Group Health Insurance plans
Entire Contract - ANSWER Policy + copy of application
Time Limit on Certain Defenses - ANSWER Statements on the application are
incontestable after 2 years (except for fraud)
Grace Period: - ANSWER - Weekly: 7 days
- Monthly: 10 days
- All others: 31 days
Reinstatement - ANSWER 45 days
Claims Procedure - ANSWER - Notice of Claims: submitted by insured within 20
days
- Claims forms: provided by insurer within 15 days
- Proof of loss: submitted by insured within 90 days
- Time of Payment of Claims: benefit paid immediately by insurer after proof of loss
received
- Denial of Claims: if a claim was denied, the claimant has a right to appeal
- Legal Action: no sooner than 60 days, no later than 5 years
- Change of Beneficiary: beneficiary can be changed by policyowner at any time,
unless irrevocable
Group Policies must - - ANSWER • be Guaranteed Renewable
• cover Mental and Nervous disorders, Alcoholism and Drug dependency treatment
Additional Requirements (excluding those of Group policies) - ANSWER • Cover
children of insured
- Newborn children must be covered from moment of birth
,- Handicapped children must have coverage beyond the limiting age (with proof of
incapacity and dependency)
• Policies that cover maternity care mush also cover services certified nurse-
midwives, midwives, and service of licensed birth centers
HMO State Requirements - ANSWER • Can offer only contracts approved by the
Department; may not engage in insurance transactions. However, Insurance
companies can own an HMO
• Must file annual reports with 3 months of the end of each fiscal year
• Additional requirements:
- Obtain a certificate of authority from the Department;
- Obtain a valid Health Care Provider Certificate form the Department of Health and
Rehabilitation Services;
- Meet capital and surplus minimum requirements, rate filing contract and forms;
- Make a deposit of $10,000 to the Rehabilitation Administration Expense Fund; and
- Become a member of the Florida Health Maintenance Organization Consumer
Assistance Plan
Exclusive Provider Organizations (EPOs) - ANSWER PPO in which individual
members use particular preferred providers rather than having a choice of a variety
of preferred providers
Multiple Employer Welfare Associations (MEWAs) - ANSWER Any entity that
establishes an employee benefit plan to provide accident and sickness or death
benefits to the employees of at least 2 employers, including self-employed
individuals and their dependents
Discount Medical Plan Organization (DMPO) - ANSWER A business arrangement
or a contract (not insurance) in which a person, for a fee, provides access for plan
members to providers of medical services and the right to receive those services at a
discount
Medicare Supplement Insurance basics - ANSWER • Florida laws regarding
Medicare Supplement insurance are for enforcement purposes
• Has 30-day free-look provision
Long-Term Care policy Disclosure - ANSWER • Must disclose renewability
provisions, riders, endorsements, limitations, or conditions of eligibility
• must define "usual and customary" or "reasonable and customary"
• Shopper's guide to applicant before completion of application
• Outline of coverage to insured before application or enrollment form
Long-Term Care policy Marketing - ANSWER • Company must retain
advertisements for at least 3 years from first use
• Unfair or deceptive trade practices prohibited
Long-Term Care policy Required Provisions - ANSWER • Required minimum
benefits:
- Daily nursing benefits of at least 80% of state average for up to 365 days
, - Daily home/community-based benefits of at least 50% (not more than daily nursing
benefit)
• Inflation protection:
- 80% to 110% of average daily nursing benefit pay rate
- Automatic increases in per diem dollar level of consumer price index or a 5%
increase
Long-Term Care policy Unintentional Lapse - ANSWER LTC policies cannot be
issued without either
• Written designation of at least 1 person (in addition to applicant) who receives
notice of lapse of policy for nonpayment of premium; or
• Written, dated and signed waiver reflecting applicant's decision to not designate
additional people
Long-Term Care policy Additional Definitions - ANSWER Activities of Daily Living
(ADLs)- include eating, bathing, dressing, toileting, transferring, and maintaining
continence
• Continuing Care Coverage - Benefits for residents of continuing care retirement
communities that cater to medical and social needs of residents
• Hospice - short, continuous care for terminally ill people with life expectancies of 6
months or less
Long-Term Care policy Replacement - ANSWER • Time periods applicable to pre-
existing conditions, waiting periods and probationary periods on the new LTC policy
must be waived to the extent that they have been satisfied on the previous policy
LTC Partnerships - ANSWER • Insureds who have exhausted private LTC benefits
may apply for Medicaid coverage without meeting same requirements
• Disregards some or all assets of Medicaid applicants; also exempts those assets
from estate recovery after insured's death
Small Employers Definitions - ANSWER • Small Group Employer - any person, firm,
corporation, or association that has at least 2, but no more than 50 eligible
employees
• Eligible Employee - any full-time employee working 25 or more hours a week who
has met any waiting period or other requirements
Florida Employee Health Care Access Act - ANSWER • Governs group health
insurance provisions provided by insurers and HMOs to small employee
• Key Provisions:
- Benefits must be issued on a guaranteed issue basis
- Carriers must base premium for each small employer on eligible empoyees' and
eligible dependents' age, gender family composition, tobacco use or geographic area
- Coverage must be renewed by carriers except for failure to pray premiums, fraud or
intentional misrepresentation, failure to comply with a plan's contractual provisions,
or when the insurer ceases to offer coverage in the market
Small Employers Coverage and Benefits - ANSWER • Carriers doing business in
Florida must offer at least a basic plan and a standard plan
