Chapter 12 - Florida Statutes, Rules, and Regulations Pertinent to Health Insurance Flashcards
What is the statute of limitation on lawsuits for health insurance policies?
5 years
When are HMOs required to file a report of their activities with the Department of Financial Services?
Within 3 months of the end of each fiscal year
In Florida, what is the maximum fine for an HMO that is found to be involved in unfair trade practices?
$200,000
What is a policy that pays benefits for the treatment of a specific condition named in the policy up to a specified maximum amount called?
Dread disease policy
A long-term care insurance shopper’s guide must be provided in the format developed by whom?
NAIC (National Association of Insurance Commissioners)
In order for an employee to be considered eligible for small group insurance, the employee must work at least how many hours per week?
25
Are HMOs allowed to solicit health insurance?
No
HMOs may not engage in any services that do not fall within Florida’s definition of “comprehensive health care services”
The Florida Health Insurance Coverage Continuation Act requires insurers that sell health plans to small employers to offer in those plans a right to elect to continue coverage, without providing evidence of insurability, to employees who lose their coverage and are unable to replace it. The premium rate for this coverage may NOT exceed
115% of the regular group rate
If an insurance company offers Medicare supplement policies, it must offer which Medicare plans?
A and C
After an insurer stops offering health insurance for small employers in this state, how long must the insurer wait before selling small employer insurance in the market again?
5 years
Any health insurance policy that provides coverage for maternity care must also cover the services of what three options?
- Certified nurse-midwives
- Midwives
- Services of licensed birth centers
What type of group would most likely be covered under a blanket accident policy?
Those groups that have members that are constantly changing
In individual health insurance coverage, the insurer must cover a newborn from the moment of birth, and if additional premium payment is required, how many days should be allowed for payment?
Within 30 days of the birth
When an applicant applies for Medicare supplement insurance, whose responsibility is it to confirm whether the applicant has an accident or sickness insurance policy in force?
The insurer’s
At what point must an Outline of Coverage be delivered on a standard policy?
At the time of application or upon delivery of the policy
When does Medicare cover nursing home care?
Only if it is part of treatment for a covered illness or injury
Health insurance policies issued in Florida may extend the limiting age for children covered under their parents policy to what age?
30
HMOs that contract with outside physicians to provide health care service to their subscribers compensate those providers on what basis?
Capitation basis or a fixed amount per subscriber in exchange for the medical services agreed upon
Florida regulations allow the extension of the limiting age to age 30, as long as what four conditions are met?
- Unmarried
- A state resident
- A student
- Not covered by another health policy
When must an insurance company present an outline of coverage to an applicant for a Medicare supplement policy?
At the time of application
When may an insurer require genetic information from an insured?
Never
What is the Florida version of the Policy Summary?
The Outline of Coverage
A group policy used to provide accident and health coverage on a group of persons being transported by a common carrier, without naming the insured persons individually is called
A blanket policy
Can a person who purchased a Medicare supplement policy forego the pre-existing condition waiting period if they replace the policy two months later?
Yes
What does the Florida Employee Health Care Access Act do?
It regulates group health insurance provisions provided by insurers or HMOs to small employers
At what age do individuals become INELIGIBLE for Florida Healthy Kids coverage?
19
It covers kids through high school
What Florida act was designed to ensure continued access to affordable health insurance coverage for employees of small employers, their dependents, and other qualified beneficiaries not currently protected by COBRA?
Florida Health Insurance Coverage Continuation Act
Where can an insured find details about the free look period after deciding to replace their policy?
The Notice Regarding Replacement
In the case of producer solicitation, at what point must a long-term care Shopper’s Guide be presented to the applicant?
Prior to the time of application
In a long-term care policy, how are pre-existing condition limitations handled?
They must appear as a separate paragraph and be clearly labeled
A corporation can be considered a “small group employer” if it has at least one and a maximum of how many employees?
50
Health plan issuers are prevented from collecting genetic information for underwriting purposes or limited in their requests for genetic tests by
The Genetic Information and Nondiscrimination Act
Under a Florida Health insurance policy, medical coverage of a newborn begins
At birth
A 65-year-old enrolls for benefits under Medicare Part B and submits an application for a Medicare supplement policy two months later. What is the only reason the insurer may use to deny the application?
Material misrepresentation
How long must an insurer retain an advertisement for its long-term care policies?
3 years
When can a Long-Term Care policy deny a claim for losses incurred because of a pre-existing condition?
Within 6 months of the effective date of coverage
For what single reason may an insurer terminate a small employer health insurance policy?
Non-payment of premiums
Within how many days of the termination of the insured’s group coverage must the insured notify the insurer of the decision to convert to individual coverage?
31 days
Medicare supplement policies, by law, must provide a free-look provision of how long?
30 days
The inflation protection feature in long-term care policies issued in this state must provide protection for inflation at what percent annually?
5%
Coverage of a newborn includes transportation costs up to what amount if medically necessary?
$1000
What is the maximum elimination period in long-term care policies issued in Florida?
180 days
In Florida, long-term care benefits may be triggered by inability to perform how many activities of daily living?
3
What type of coverage is Workers Compensation?
Liability coverage
It pays those medical expenses of employees that an employer is legally liable to provide
Before an organization can operate as an HMO in Florida, it must deposit how much with the Rehabilitation Administration Expense Fund?
$10,000
