Florida Statutes, Rules and Regulations Pertinent to Health Insurance 18- Questions and Answers 2025

Florida Statutes, Rules and Regulations
Pertinent to Health Insurance 18% Questions
and Answers 2025
MinimumABenefitAStandardsA-ACORRECTAANSWERSA-
FloridaAlawAregulatesAtheAminimumAstandardsAforAcoverage.
GrandfatheredAHealthAPlanA-ACORRECTAANSWERSA-
SectionA42&18011AofAtheAUSACodeAsaysAthatAanyAgroupAhealthAplansAparticipantsAhaveAth
eArightAtoAmaintainAcoverageAwhenAtheAinsured'sAchangesAplansAandAtoAhaveAcreditableAc
overageAcountAtowardAHIPAAAeligibilityArelatingAtoApre-existingAconditionsAexclusions.
Non-grandfatheredAhealthAplansA-ACORRECTAANSWERSA-
PlansAorApolicyAcontractsAthatAdoAtoAhaveAtoAprovideAtheAcreditableAcoverageAbenefits.
IndividualAHealthAInsuranceAPoliciesA-ACORRECTAANSWERSA-
CannotAexcludeAcoverageAforApre-
existingAconditionsAforAlongerAthanA24AmonthsAfollowingAtheAeffectiveAdateAofAcoverage.A

InsurerAareArequiredAtoAcreditAtoAprovideAcreditAforApre-
existingAconditionsAforAtheAtimeAtheirApersonAwasAcoveredAunderAtheApreviousAcoverageAin
AtheAnewApolicy.AIfApreviousAcoverageAwasAeffectiveA63AdaysApriorAtoAtheAnewAcoverageA.A*

TheAapplicationAmustAclearlyArequestAinformationAaboutAp[re-
existingAconditionsAifAtheAprovisionAisAtoAapply.*
GroupAHealthAInsuranceAPolciesA-ACORRECTAANSWERSA-
MustAmakeAavailableAtoApolicyAholdersAcoverageAforAmentalAandAnervousAdisorders.AThes
eAbenefitsAmustAmeetAminimumAstandards
IndividualAandAGroupAHealthACoverage:AMinimumAStandardsA-ACORRECTAANSWERSA-
BOTHAMUST
A

•AProvideAcoverageAforAhandicappedAchildren
•AProvideAcoverageAforAaAnewlyAbornAchildAforAtheA1stA18Amonths
•AMustAbeArenewableAatAtheAoptionAofAtheAindividual
CoverageAExceptionsAorAExclusionsA-ACORRECTAANSWERSA-Exceptions:

FloridaALawAprovidesAthatAindividualAandAgroupAhealthAinsuranceApoliciesAandAHOMAcontr
actsAmustAbeArenewableAatAtheAoptionAofAtheApolicyAholderAUNLESS:

•AFailureAtoApayApremiumsAinAaAtimelyAmanner
•AFraudAorAmisrepresentingAofAmaterialAfact
•AFailureAtoAmeetAminimumAparticipationAorAminimumAcontributionArequirementsAofAaAgrou
pApolicy.A
•AInsurerAceasesAofferingAthatAcoverageAinAaAmarket
•AForAnetworkAplansAorAbonfireAassoc.AthereAisn'tAanAindividualAorAgroupAenrolleeAresidesAo
rAworksAinAtheAserviceAarea,AprovidedAthatAthisArequirementsAisAappliedAuniformly.A

, HealthAInsurersAmayAexcludeApaymentAofAbenefitsAunderAaAhealthAplanAthatAareAcoveredAu
nderAWorkersACompensationAorAareAservicesArenderedAbyAtheAVeteransAAdministration.
CoordinationAofABenefitsA-ACORRECTAANSWERSA-
InsuranceAcompaniesAmayAworkAtogetherAbetweenAgroupAinsuranceAandAind.AhealthAinsur
anceAbenefits.A

DoesAnotAincludeAIndemnityAplans.
HMO'sAFLoridaAStatuesAandARegulations:A-ACORRECTAANSWERSA-HMO's:

•ACanAonlyAofferAplansAapprovedAbyAtheADepartmentAandAcannotAengageAinAanyAotherAacti
vity.A
•AAnAinsuranceAcompanyAcanAownAorAsponsorAanAHMO
•ARequiredAtoAfileAaAreportAofAitsAactivitiesAwithinA3AmonthsAofAtheAendAofAeachAfiscalAyear.A
•ADepartmentAcanAandAmayAconductAon-siteAvisits.A
•ACanAoperateAtheirAownAhospitalsAandAclinics
•AEnterAintoAvolumeAdiscountAarrangementsAwithAphysiciansAtoAprovideAserviceAonAaAprear
rangedAperAcapitaAbasis.ACalledA(Capitation)
•AOperateAonAEITHERAtheAclosed-panelAorAopen-panelAbasis.
HMO'sARequirementsAForAProvidersA-ACORRECTAANSWERSA-HMOARequirements:

•AObtainAaAcertificateAofAauthorityAfromAtheADepartment
•AObtainAaAvalidAHealthACareAProviderACertificateAfromAtheADepartmentAofAHealthAandAReh
abilitativeAServices.
•AMayAonlyAbeAsoldAbyAaAlicensedAandAappointedAhealthAinsuranceAagentAorAaAfull-
timeAsalariedAemployeeAorAanAofficerAofAanAHMOAwhoAdevotesAtheirAtimeAtoAsomethingAoth
erAthanAsolicitingAplans.ATheyAcannotAreceivedAcommissionAorAcompensationAforAprocurin
gAtheseAcontracts.A
•AMeetAcapitalAandAsurplusAminimumArequirement,ArateAfilings,AcontractAandAformsAandAan
yAotherAcriteriaAestablishedAbyAtheALegislatureA
•AMakeAaAdepositAofA$10,000.00AtoAtheARehabilitationAAdministrationAExpenseAFund
•ABecomeAaAmemberAofAtheAFloridaAHealthAMaintenanceAOrganizationAConsumerAAssista
nceAPlan
ProhibitedAPractices:AHMO'sA-ACORRECTAANSWERSA-ProhibitedAPractices:AHMO's

•AMisrepresentationAandAfalseAadvertisingAofAHMOAcontracts
•AFalseAinformationAandAmisrepresentationAinAgeneral
•ADefamation
•AFalseAstatementsAandAentriesA
•AUnfairAclaimApracticesAsettlementApractices
•AFailureAtoAmaintainAclamAhandlingAproceduresA
•AOperatingAwithoutAaAsubsistingAcertificateAofAauthority
•AMisrepresentationAinAHMOAapplications
•ATwisting
•AIllegalAdealingAinApremiums
•AFalseAclaims,AobtainingAmoneyAdishonestly
•AFinesAcanAbeAupAtoA$200,000.00