Health plans - Florida

Summary of differences between federal and state regulations

Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).

Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. Florida laws include the following provisions:

• If the plan provides coverage on a medical, hospital, or surgical expense-incurred basis, it must cover treatment performed outside a hospital for any accident or illness, provided that such treatment would be covered on an inpatient basis and is provided by a health care provider whose services would be covered under the policy if the treatment were performed in a hospital and provided that treatment of the accident or illness is medically necessary and is provided as an alternative to inpatient treatment in a hospital. (§627.4232)
• The plan must cover the treatment of cancer for any drug prescribed for the treatment of cancer on the ground that the drug is not approved by the FDA for a particular indication. (§627.4239)
• If the plan covers cancer, it must cover bone marrow transplant procedures recommended by the referring physician and the treating physician. (§627.4236)
• If the plan covers family members, it must continue to cover dependents despite having reached a limiting age while the child continues to be both incapable of self-sustaining employment by reason of mental retardation or physical handicap; and chiefly dependent upon the policyholder or subscriber for support and maintenance. (§627.6041, §627.6615)
• If the plan covers family members, it must at least cover dependents until the end of the calendar year in which the child reaches the age of 25, if the child meets all of the following: The child is dependent upon the policyholder or certificateholder for support, and the child is living in the household of the policyholder or certificateholder, or the child is a full-time or part-time student. (§627.6562)
• If the plan covers diagnostic or surgical procedure involving bones or joints of the skeleton, it must cover any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if medically necessary. (§627.65735)
• The plan must cover medically appropriate and necessary equipment, supplies, and diabetes outpatient self-management training and educational services used to treat diabetes. (§627.65745)
• If the plan provides coverage on an expense-incurred basis and covers family members, it must cover newborn children from the moment of birth. This coverage includes the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and also includes transportation costs. Coverage for a newborn child terminates 18 months after the birth of the newborn child. (§627.6575)
• If the plan covers general anesthesia and hospitalization it must cover such services to persons who are under 8 years of age and is determined by a licensed dentist, and the child's physician to require necessary dental treatment in a hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center. (§627.65755)
• If the plan provides dental coverage only upon the condition that services be rendered by an exclusive list of dentists or groups of dentists, it must provide an alternative to enable the insured to have a free choice of dentist. (§627.6577)
• If the plan covers family members, it must cover adopted children or foster children of a participant from the moment of placement in the residence of the participant. The plan must also provide that benefits applicable for children shall be payable with respect to a foster child or other child in court-ordered temporary or other custody of the participant. (§627.6578)
• If the plan provides coverage on an expense-incurred basis and covers family members, it must cover child health supervision services from the moment of birth to age 16 years. (§627.6579)
• The plan must cover services performed in an ambulatory surgical center, if such service would have been covered under the terms of the policy or contract as an eligible inpatient service. (§627.6616)
• If the plan provides coverage on an expense-incurred basis, it must cover home health care by a home health care agency. (§627.6617)
• Upon application for coverage, the plan must offer optional coverage for the necessary care and treatment of mental and nervous disorders. (§627.668)
• Upon application for coverage, the plan must offer optional coverage for necessary care and treatment of substance abuse impaired persons. (§627.669)
• The plan must cover the medically necessary diagnosis and treatment of osteoporosis for high-risk individuals. (§627.6691)
• If the plan covers a child under the age of 18, it must cover treatment of cleft lip and cleft palate for the child. (§627.66911)
• Notwithstanding any other provision of the Florida Insurance Code that is in conflict with federal requirements for a health savings account (HSA) qualified high-deductible health plan, insurers or HMOs may offer a high-deductible plan that meets federal requirement of an HSA and is offered in with an HSA. (HB 811 - §627.413)

Florida Health Choices Program

This program was created as a single, centralized market for the sale of health-benefit related goods and services such as health insurance plans, health maintenance organization plans, prepaid services, service contracts, and flexible spending accounts. The state encourages participation from eligible employers who have 1 to 50 employees. Participation is voluntary. (§408.9091)

State

Contact

Florida Department of Financial Services, Office of Insurance Regulation

Regulations

Florida Statute Title XXXVII, Chapter 627 - Part VI – Health insurance policies
www.flsenate.gov/Laws/Statutes/2010/Chapter627/Part_VI

Florida Statute Title XXXVII, Chapter 627, Part VII - Group, blanket, and franchise health insurance policies
www.flsenate.gov/Laws/Statutes/2010/Chapter627/Part_VII

Florida Statute Title XXIX, Chapter 408 - Cover Florida Health Care Access Program (§408.9091)
www.flsenate.gov/Laws/Statutes/2010/408.9091

For more information on health benefits for women, see the topic Women’s Health Rights.

Federal

Contact

Employee Benefits Security Administration (EBSA)

Regulations

29 CFR chapter XXV (Parts 2509 – 2590)