Coverage for mastectomies

Florida law mandates coverage for prosthetic devices and reconstructive surgery following a mastectomy. 

Florida law also:

• mandates coverage for all surgeries necessary to reestablish symmetry between breasts;
• inpatient hospital coverage for mastectomies;
• requires coverage for outpatient post-surgical care for mastectomies;
• if the person has remained breast cancer free for two years the insurer may not deny coverage for the benefit;
• prohibits breast cancer follow-up care from being considered an evaluation for a preexisting condition, unless breast cancer is found.

Coverage for mammograms

All health insurance issued in Florida must provide coverage for at least the following:

• A baseline mammogram for any woman age 35 to 39
• A mammogram every two years for any woman age 40 to 49 or more frequently if a doctor recommends it
• A mammogram every year for any woman age 50 or older
• Women of any age who are at risk for breast cancer because of a personal or family history must be allowed at least one mammogram a year if recommended by a doctor

Exclusion for fibrocystic condition prohibited

Policies may not be denied to be issued or renewed, nor can they have an exclusion of benefits in a policy solely because the insured has been diagnosed as having a fibrocystic condition, a nonmalignant lesion, a family history of breast cancer, or any combination of these, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer.

Coverage for cleft lip and cleft palate of children

Group and individual health insurance policies in Florida must provide coverage for treatment of cleft lip and cleft palate for the child while the child is under the age of 18.  The coverage must include:

• dental,
• medical,
• speech therapy,
• audiology, and
• nutrition services

if they are prescribed by the treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary for treatment of the cleft lip or cleft palate. This section does not apply to accident, disease, hospital indemnity, limited benefit disability income, or long-term-care insurance policies.

Rebates for participation in wellness program

Insurance companies may encourage maintaining good health or improvement of issues like body mass index and smoking with annual rebates to the insured. The individual will have to show that their health status is the same or better than it was for example by showing weight loss or stopped smoking.

The rebate may not exceed 10% of paid annual premiums. The premium rebate will be paid on an annual basis while the individual is participating in the wellness program.

Experimental Treatments for Terminal Conditions

This statute says that a health plan, third-party administrator or government agency is allowed cover the cost of experimental drugs, products and devices.

This also includes the cost of services related to the use of the experimental drugs, products and devices.

Emergency Services

Network plans, such as HMOs and PPOs, are required to provide the same coverage when the patient is out-of-network (“nonparticipating provider”) as when he/she is in-network (“participating provider”) for emergency services. Any co-payments or co-insurance amounts must be the same as those that apply to a participating providers, meaning that out-of-network emergency claims must be treated like any other claim.

Autism Spectrum Disorder and Down Syndrome

Health insurance plans (major medical plans) and HMOs must provide treatment for both autism spectrum disorder and Down Syndrome

• through speech therapy,
• occupational therapy and
• applied behavioral analysis.

Opioids

Many doctors today prescribe abuse-deterrent pain relief opioid drugs today, and Florida law has a few things to say about it. First, a health insurance policy is not allowed to require that the addiction-prone drug be prescribed before the abuse deterrent drug is described. So, if the abuse deterrent opioid is the first pain medication ever prescribed, then the insurance company would have to cover it like any other pain medication. Second, the health insurance policy is only allowed to require prior authorization for the abuse-deterrent opioid if the policy would have also required prior authorization for the opioid without the abuse deterrent.

Exclusion on Requiring Step-Therapy Protocol

Step-therapy is a way for the insurance company to control costs by requiring that the patient try a cheaper drug, for example a generic drug. Then, if the patient "fails" on that drug the insurance company will approve the coverage for the more expensive drug.

Both group and individual major medical plans are not allowed to use this requirement if the patient has met the following requirements:

• if the insured person completed the step-therapy that was required on a separate plan and was approved for the more expensive drug that way; and
• if the insurance plan has been paying for the drug for the 90 days immediately before the current request for the drug.

NOTE: This law does not require insurance companies to cover any drugs that they do not otherwise cover.

Balance Billing Restriction

Balance billing is the practice of billing the insured the difference between what the insurance company paid and what the health care provider charged. Florida law says this is not allowed if:

• the insured person went to an in-network provider for non-emergency services; and
• the insured person received emergency services regardless of whether it was received in - or out-of-network.