Disclosures
These are all general disclosures that apply to group and individual insurance. This section of the chapter is rather repetitive, but is still very important in the licensing process. As topics are repeated we will not repeat all of the information, but rather just the primary things you need to get licensed.
Outline of Coverage *****
Outline of Coverage will be mentioned several times, and each time it is the same thing - it outlines what is covered. This will come up for group health plans, Medigap, and Long-Term Care plans, but it's the same thing every time. Outlines of coverage have to be given with nearly every type of health plan application in Florida. It must be given at the time of application and includes information about:
- benefits
- exclusions
- renewal rules
The insured must sign a receipt that the outline of coverage was received and the agent returns this to the insurance company. Since the outline of coverage is given with nearly every type of health plan, the category of coverage must also be included. If the plan covers home care then the outline must include a statement that those benefits are provided in the policy.
Renewal Agreements/Nonrenewal and Cancellation
All insurers in Florida must renew the coverage at the option of the individual or group policyholder (so as long as the premiums are paid). Some of the few circumstances when the insurance company can cancel the group policy include fraud, benefits being exhausted, and the company stops offering that coverage altogether. Below we look at renewal, nonrenewal and cancellation for both individual and group insurance.
Individual Health Insurance
During renewal, an insurer may change the health insurance coverage for a policy as long as it is for everyone who has that coverage (uniform). An insurer may only nonrenew or discontinue an individual health policy because of:
- Nonpayment of premiums
- Individual has performed fraud or made an intentional misrepresentation of material fact
- Insurer will no longer offer coverage in the individual market
- In the case of a network plan (HMO/PPO), the individual no longer resides in the service area
- Benefits under the plan have been exhausted
If the insurance company stops offering that type of coverage or policy in the market, then they can only do that if they provide each covered individual a notice at least 90 days before the date of nonrenewal, and they also have to offer each person an option to buy any other policy the company offers on the individual market.
If the insurance company stops offering all health insurance in the individual market in Florida then they have to give each individual a notice at least 180 days before the date of nonrenewal, and the company will not be allowed to write individual health insurance in Florida for five years after the date of the last health insurance coverage was not renewed.
Group Health Insurance
This is exactly the same as above "Individual Health Insurance" but is for group insurance.
- Reasons for discontinuing the policy (bullet points) are the same as above.
- 90 days' notice before the insurance company stops offering the policy, each policyholder has to be given the option to buy another plan, and canceling the plan has to be done uniformly to every group that had that plan.
- 180 days' notice before the insurance company stops offering all health coverage in the state, and the company can not write health insurance in Florida for five years after that.
