Note: We have completed our discussion on the Affordable Care Act. Beginning now, the rest of the chapter discusses Florida laws specifically.

Please use the charts contained in this chapter as a summary or review.

Required and optional coverages (Florida Law)

Florida law requires specific coverages in health insurance policies. These coverages do not necessarily apply to every person being insured, but the insurance company still has to offer these coverages in the policy because Florida law says so. We will look at each one in detail, but here is a quick list with which we recommend you become familiar:

1. Medical Providers
2. Diabetes Coverage
3. Osteoporosis Coverage
4. Coverage for Newborns (including grandkids and any child under permanent or temporary custody, step-children, foster and adoption placement, and children with disabilities)
5. Coverage for Mastectomies
6. Coverage for Mammograms
7. Coverage for Cleft Lip/Palate
8. Rebate for Wellness Programs
9. Experimental Treatment for Terminal Conditions
10. Emergency Services
11. Autism Spectrum Disorder and Down Syndrome
12. Opioid (abuse-deterrent drug products)
13. Exclusion on Requiring Step-Therapy Protocol
14. Balance Billing Restriction

Medical providers

The words "physician" or "medical doctor", when used in health insurance policies in Florida, includes a dentist when oral surgery is being performed in a hospital with a physician, as well as coverage for optometrists, podiatrists and chiropractors.

So medical expense policies must include coverage for

1. dentists
2. optometrists
3. podiatrists
4. chiropractors

NOTE: Florida law also states that if the Affordable Care Act is ever repealed, that all insurance companies offering major medical plans and HMOs in Florida must offer at least one plan that does not exclude coverage for pre-existing conditions.

Diabetes coverage: equipment, supplies, and outpatient self-management training

Florida law requires that if a physician says it is medically necessary, then health policies and HMO contracts must provide coverage for all medically necessary equipment, supplies, and services used to treat diabetes, including outpatient self-management training and education services if medically necessary.

Osteoporosis coverage

Diagnosis and treatment of osteoporosis for high-risk individuals is required by health insurance policies and HMO contracts under Florida law.  Specified accident, specified disease, hospital indemnity, Medicare supplement, long-term care health insurance, and the Florida state employee health program are not included in the requirement. Osteoporosis is a bone-thinning disease that increases the risk of bone fractures.

Coverage for newborn children *****

Both individual and group health insurance policies that provide coverage for a family member of the insured must also provide benefits for a newborn child of the insured from the moment of birth. The law also requires that coverage be provided for a newborn child of a covered family member (e.g., the newborn of a covered daughter or son, so a grandchild) for a period of 18 months. This is a Florida Law.

The coverage for newborn children must include coverage for:

• injury or sickness,
• necessary care or treatment of medically diagnosed congenital defects,
• birth abnormalities,
• prematurity, and
• transportation costs of the newborn to and from the nearest available facility appropriately staffed and equipped to treat the newborn's condition.

A policy may require notification to the insurer of the birth of a child within a time period of not less than 30 days after the birth.  If timely notice is given, the insurer may not charge an additional premium for coverage of the newborn child for the duration of the notice period.  If timely notice is not given, the insurer may charge an additional premium from the date of birth.  The insurer may not deny coverage for a child due to the failure of the insured to timely notify the insurer of the birth of the child.

If the policy does not require the insured to notify the insurer of the birth within a specified time period, the insurer may not deny coverage for such child or retroactively charge the insured an additional premium for such child. However, the insurer may prospectively charge the insured an additional premium for the child if the insurer provides at least 45 days' notice of the additional premium required.

This section does not apply to disability income or hospital indemnity policies or to normal maternity policy provisions applicable to the mother.

Coverage for adopted, foster, custodial care, and natural-born children *****

A health insurance policy that provides coverage for a family member of the insured must provide benefits for children of the insured, including

• an adopted child or
• a foster child prior to the child's 18th birthday, from the moment of placement in the residence of the insured. 

Except in the case of a foster child, the policy may not exclude coverage for any preexisting condition of the child.

Children's Health Supervision Services

The following is a Florida specific law and not to be confused with the ACA that mandates coverage to age 26.

All reimbursement-type health insurance policies that provide coverage for a family member of the insured must also provide health insurance benefits for children from the moment of birth to age 16 years for the following:

• Medical history
• Physical examination
• Developmental assessment and anticipatory guidance
• Appropriate immunizations and laboratory tests

Continued coverage for children with disabilities *****

Just as was discussed in chapter 22, all individual and group health insurance policies must continue covering the disabled child (no age limit) while the child is both:

• incapable of self-sustaining employment by reason of an intellectual or physical disability; and
• chiefly dependent upon the employee or member for support and maintenance.