Affordable Florida Group Health Insurance
A large number of Americans are insured under group health insurance plans and the regulations governing such plans in Florida are similar to those seen in many other states, although there are a number of differences that can apply for public employees.
If you want to benefit from group health insurance in Florida you first have to make sure that you are eligible for a particular plan. For example, in spite of the fact that an employer may have a group health insurance plan, it might not be open to everybody, possibly being aimed at full-time and not part-time workers. Additionally, the plan may be operated by a Health Management Organization (HMO) and you could discover that you are living outside of the HMO's service area.
If you are eligible for the plan then you must be permitted to join whatever your state of health. In this case your state of health means your current health, taking into account any disability that you may have, together with your previous medical history. It is also interesting to note that you may not be excluded as a result of genetic information.
It is important to understand here that, while an employer is permitted to refuse you membership because you do not for example work sufficient hours, he cannot exclude you based solely on your current or previous medical history.
Most plans has an enrollment period during which you have to join the scheme which could typically be within 30 days or starting work. However, if you choose not to enroll at this stage then an employer is required to give you an opportunity to join during what is generally called a special enrollment period when particular changes take place within your family. Such changes could include things like marriage, the birth or adoption of a child and loss of alternative medical insurance cover as the result of things like the cessation of cover being provided through another family member because of death, legal separation, reduction in working hours, divorce, retirement, termination and similar circumstances.
Nearly all plans also usually have a waiting period for membership that is typically anywhere from 30 days to 3 months. This waiting period has to be applied consistently across all eligible employees and during this time you are not covered under the group plan.
If the group plan that you are joining is operated by an HMO then the HMO can also require a waiting period (frequently called an affiliation period) during which you will once again not be covered. HMO affiliation periods may not usually exceed 2 months and where a waiting period is applied the HMO cannot then impose any pre-existing conditions exclusions.
Under Florida law any group plan that includes cover for dependents must also provide cover automatically for newborns, newly adopted children and children who are placed for adoption for a period of 31 days from birth, adoption or placement. There may also be a requirement for parents to register such children during this 31 day period if cover is to continue beyond this point.
In the case of parents taking care of disabled children who are covered under a group health plan cover will normally continue beyond the age when a child would no longer be classed as a dependent, as long as the parents can show that the individual in question cannot support himself as a result of physical or mental disability and that they are principally dependent upon the plan member for support.
If you work for an employer with at least 50 employees then you will be permitted to take a leave of absence without losing you health insurance for a period of up to 12 weeks in some circumstances. This protection is guaranteed under the Family and Medical Leave Act (FMLA) which is designed to cover things like childbirth, sickness or the need to take care of a seriously ill member of your family.
Federal law permits states, county and local governments to exempt government employees from some areas of coverage in self-insured group health insurance plans and a lot of public employers in Florida take advantage of this to a greater or lesser degree. Because exemptions vary widely amongst employers it is prudent to establish the precise coverage provided if you are a public employee. This information may also be found by contacting The Center for Medicare and Medicaid Services (CMS) which has a list of employer exemptions.
Though under Florida law you may not be excluded from membership of a group health insurance plan for reasons of health, there are certain circumstances in which exclusion periods can be imposed for pre-existing conditions. However, this is a complex area and one that is thus the subject of a separate article.
Claims investigation: The process of obtaining all the information necessary to determine the appropriate amount to pay on a given claim.
Fee-for-service (FFS) payment system: A system in which the insurer will either reimburse the group member or pay the provider directly for each covered medical expense after the expense has been incurred.
Mental Health Parity Act (MHPA): A federal act which prohibits group health plans that offer mental health benefits from applying more restrictive limits on coverage for mental illness than for physical illness.
Renewal underwriting: The process by which an underwriter reviews each year all the selection factors that were considered when the contract was issued, then compares the group's actual utilization rates to those the MCO predicted to determine the group's renewal rate.
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