Florida Health Insurance Law for the 2-40
18% of the exam 2 min
The Florida rules behind the 15 health-law questions on the 2-40: free look periods, Medicare supplement enrollment and limits, long-term care lapse protection, small employers and mini-COBRA, dependents and newborns, claim deadlines and HIV testing.
Free look: 10 days, or 30 for Medicare supplements and long-term care
An individual health policy can be returned within 10 days of delivery for a refund, and it is then void from the beginning (Rule 69O-154.003, F.A.C.). Medicare supplement and long-term care policies get 30 days (ss. 627.674 and 627.9407, F.S.). The life free look, 14 days, belongs to a different exam.
Medicare supplements: open enrollment and limits
For six months beginning with the first month a person is 65 and enrolled in Part B, a Medicare supplement must be offered without medical underwriting; the same right applies to people under 65 who qualify for Medicare by disability or ESRD (s. 627.6741, F.S.). A preexisting-condition exclusion may last no longer than 6 months. A policy may be cancelled only for nonpayment or material misrepresentation, and selling someone a second Medicare supplement is prohibited (Rule 69O-156.017, F.A.C.).
Long-term care: protection against an accidental lapse
The insurer must tell the policyholder at least once a year of the right to name a secondary addressee, and it cannot cancel for nonpayment without 30 days' notice after the grace period. A policy lost because of cognitive impairment or loss of functional capacity can be reinstated if that is shown within 5 months after cancellation (s. 627.94073, F.S.).
Employers: small groups and mini-COBRA
A small employer averaged at least 1 and no more than 50 employees in the past year, and an eligible employee works a normal week of 25 hours or more (s. 627.6699, F.S.). Employers with fewer than 20 employees fall under Florida's mini-COBRA instead of federal COBRA: 18 months of continuation, 29 if disabled, at up to 115% of the premium (s. 627.6692, F.S.).
Dependents, newborns and claims
A child must be covered at least to the end of the year the child turns 25, with an option to continue to the end of the year the child turns 30 (s. 627.6562, F.S.). A newborn is covered from the moment of birth, and any notice requirement may not be shorter than 30 days after birth. An insurer must pay or contest a claim from an insured within 45 days (s. 627.613, F.S.), and after 2 years only a fraudulent misstatement can void the policy (s. 627.607, F.S.).
Where people lose points
✗ "Every health policy has a 30-day free look."
✓ Individual health is 10 days; Medicare supplements and long-term care are 30.
✗ "Medicare supplement open enrollment starts at 65."
✓ It starts the first month the person is both 65 and enrolled in Part B.
✗ "Federal COBRA covers every Florida employer."
✓ Employers with fewer than 20 employees fall under Florida mini-COBRA.
✗ "A small group needs at least 2 employees."
✓ Florida counts an average of 1 to 50 employees.
Numbers to memorize
| Free look — individual health | 10 days from delivery; does not apply to single-premium nonrenewable or travel accident policies (Rule 69O-154.003, F.A.C.) |
| Free look — Medicare supplement | Prominently displayed no-loss cancellation clause: return within 30 days after receiving the policy or certificate, full refund of premium paid (s. 627.674(4)(d), F.S.) |
| Free look — long-term care | 30 days after delivery, premium refunded (s. 627.9407(8), F.S.) |
| Medicare supplement open enrollment | 6-month period beginning with the first month the individual is 65 and enrolled in Medicare Part B; must also be offered to those under 65 eligible for Medicare by disability or ESRD; no medical or health-status underwriting or pricing during the window (s. 627.6741, F.S.) |
| Medicare supplement preexisting condition limit | No longer than 6 months, and no more restrictive than a condition for which advice or treatment was given within 6 months before the effective date (s. 627.6741(2)(b), F.S.) |
| Medigap cancellation grounds (FL) | Nonpayment of premium or material misrepresentation only — s. 627.6741, F.S. |
| Duplicate Medigap coverage (FL) | Prohibited — any sale that would provide an individual with more than one Medicare supplement policy or certificate — Rule 69O-156.017, F.A.C.; parallel agent rule 69B-156.017, F.A.C. |
| Long-term care unintentional lapse protection | Insurer must notify the policyholder at least annually of the right to designate a secondary addressee; no cancellation for nonpayment without 30 days notice after the grace period, and notice may not be given until 30 days after a premium is due and unpaid (s. 627.94073, F.S.) |
| Long-term care reinstatement for cognitive impairment | Not less than 5 months after cancellation to demonstrate the nonpayment was unintentional and due to cognitive impairment, loss of functional capacity or continuous confinement (s. 627.94073, F.S.) |
| Small employer definition | Employed an average of at least 1 but not more than 50 employees on business days during the preceding calendar year; an annual 30-day open enrollment period must be offered (s. 627.6699, F.S.) |
| Eligible employee — small group | Works full time with a normal workweek of 25 or more hours (s. 627.6699, F.S.) |
| Florida mini-COBRA | Fewer than 20 employees; 18 months, 29 if SSA-disabled; premium up to 115% of the applicable premium, up to 150% during the 11-month disability extension; beneficiary notice to carrier within 63 days of the qualifying event; carrier election and premium notice within 14 days; elect within 30 days (s. 627.6692, F.S.) |
| Dependent child coverage | Must cover at least to the end of the calendar year the child turns 25; must also offer the option to continue at least to the end of the calendar year the child turns 30 (s. 627.6562, F.S.) |
| Newborn coverage | Covered from the moment of birth; any notice requirement may not be less than 30 days after the birth (s. 627.641 individual and s. 627.6575 group, F.S.) |
| Claim payment — from the insured or assignees (s. 627.613, F.S.) | Pay or contest in writing within 45 days; pay or deny within 60 days of receiving requested additional information; 120 days outer limit; 10% simple interest per year on overdue payments |
| Time limit on certain defenses (s. 627.607, F.S.) | 2 years from the issue date; afterward only fraudulent misstatements can void the policy or deny a claim |
| Florida KidCare / Healthy Kids | A child who has not reached 19 with family income at or below 300% of the federal poverty level is eligible (s. 409.814, F.S.); the Florida Healthy Kids Corporation is created as a not-for-profit corporation by s. 624.91, F.S. |
| HIV testing for insurance | Insurer must disclose its intent to test and obtain written informed consent; strict confidentiality of results; sexual orientation may not be used in underwriting or to determine who is tested (s. 627.429, F.S.) |
Test yourself
No answers here on purpose — retrieving them is the practice. Drill this domain if any of these stall you.
- What are the free look periods for individual health, Medicare supplement and long-term care policies?
- On what two grounds alone may a Medicare supplement be cancelled?
- How many employees make a Florida small employer, and how many hours make an eligible employee?
- Until what age must a health policy cover a dependent child?
- What must an insurer get before testing an applicant for HIV?