Key Takeaways
- Florida requires a 10-day free look period for individual health insurance policies
- Florida has not expanded Medicaid under the ACA, maintaining traditional eligibility requirements
- The Florida Healthy Kids Corporation provides coverage for uninsured children
- Pre-existing condition exclusions are prohibited under ACA-compliant individual and small group plans
- Florida allows short-term health plans up to 364 days with renewals up to 36 months total
Florida Health Insurance Policy Requirements
Florida has specific health insurance regulations that work alongside federal ACA requirements. Understanding these state-specific rules is essential for the licensing exam.
Regulatory Structure
Florida health coverage is regulated primarily by:
| Agency | Responsibility |
|---|---|
| Office of Insurance Regulation (OIR) | Regulates insurers, approves rates and forms |
| Department of Financial Services (DFS) | Licenses agents, handles complaints |
| Agency for Health Care Administration (AHCA) | Manages Medicaid program |
Free Look Period
Florida requires a 10-day free look period for individual health insurance:
- Policyholder can return for full premium refund
- Begins when policy is delivered
- Applies to individual health policies
- Different from the 14-day period for life insurance
Exam Tip: Health insurance has a 10-day free look in Florida, while life insurance and annuities have 14 days.
Short-Term Health Insurance
Florida permits short-term limited duration health insurance:
Florida Short-Term Plan Rules
| Feature | Florida Allows |
|---|---|
| Initial Term | Up to 364 days |
| Renewals | Yes, with new underwriting |
| Total Duration | Up to 36 months |
| Pre-existing Exclusions | Permitted |
| ACA Benefits | Not required |
Required Disclosures
Short-term plans must disclose:
- Not ACA-compliant coverage
- May exclude pre-existing conditions
- Not guaranteed renewable
- May not cover essential health benefits
- Does not satisfy individual mandate (when applicable)
Florida Medicaid (Not Expanded)
Florida has not expanded Medicaid under the Affordable Care Act:
Traditional Medicaid Eligibility
| Category | Income Limit (Approximate) |
|---|---|
| Pregnant Women | Up to 185% FPL |
| Children under 19 | Up to 200% FPL |
| Parents/Caretakers | Very limited income |
| Aged/Blind/Disabled | SSI recipients |
| Adults without children | Generally not eligible |
Coverage Gap
Because Florida did not expand:
- Adults earning 0-100% FPL may have no coverage options
- Cannot qualify for Medicaid (too much income)
- Cannot qualify for ACA subsidies (too little income)
Florida Healthy Kids Corporation
Florida Healthy Kids provides coverage for uninsured children:
Program Features
| Feature | Description |
|---|---|
| Eligibility | Children 5-18, not Medicaid eligible |
| Coverage | Comprehensive health and dental |
| Subsidies | Based on family income |
| Administration | Through participating health plans |
Individual Market Requirements
For ACA-compliant individual plans:
Required Provisions
- Guaranteed Issue - Must accept all applicants
- No Pre-existing Exclusions - Cannot deny or limit based on health
- Essential Health Benefits - Must cover 10 EHB categories
- Rate Restrictions - Limited rating factors (age, tobacco, geography)
Small Group Market
Florida small group market (2-50 employees):
Guaranteed Issue
- Insurers must offer coverage to all small employers
- Cannot deny based on employee health status
- Cannot exclude employees from coverage
Rating Rules
Small group rates can vary by:
- Age (within limits)
- Tobacco use (limited)
- Geographic area
- Family size
Cannot vary by:
- Health status
- Claims history
- Industry
Required Policy Provisions
Florida health policies must include:
| Provision | Requirement |
|---|---|
| Grace Period | 31 days for premium payment |
| Reinstatement | Must allow within 3 years |
| Time Limit on Defenses | 2 years for misstatement |
| Claims | Timely payment required |
Mental Health Parity
Florida follows federal mental health parity requirements:
Coverage Requirements
- Mental health benefits comparable to medical
- Same cost-sharing requirements
- Cannot have stricter limits
- Applies to group health plans
Maternity Coverage
Under ACA, individual and small group plans must cover:
- Prenatal care
- Delivery services
- Postnatal care
- Newborn care
How long is the free look period for individual health insurance policies in Florida?
What is the maximum initial term for short-term health insurance in Florida?
Has Florida expanded Medicaid under the Affordable Care Act?