The national guide covers plan designs (indemnity, HMO, PPO, EPO, POS), cost-sharing, HSAs and FSAs. Florida adds a long list of mandated benefits, HMO rules under Chapter 641, emergency-care protections, and prompt-pay deadlines. The health part of the Florida exam tests these directly.

Plan types under Florida law

• An HMO arranges comprehensive care on a prepaid basis through contracted providers (641.19).
  • It needs a certificate of authority from OIR and a health care provider certificate from the Agency for Health Care Administration (641.21, 641.49).
  • HMOs must keep a grievance procedure. Grievances must be filed within one year of the action (641.511).
  • HMO members who leave can convert by applying and paying within 63 days (641.3922).
• PPOs must provide a current list of preferred providers, including on their website (627.6471).
• Exclusive provider provisions pay benefits only when contracted providers are used (627.6472).
• Prepaid limited health service organizations provide limited benefits such as dental or vision (Chapter 636).
• Discount medical plans must be licensed by OIR. They must disclose that they are not insurance and only provide discounts (636.204, 636.212).

Dependents and newborns

• Newborns are covered from the moment of birth, including congenital defects, prematurity and certain transport. The policy may require notice within at least 30 days. If notice is given within 60 days, coverage can't be denied (627.6575).
• A grandchild (newborn of a covered child) is covered from birth, but that coverage ends at 18 months.
• Adopted children are covered from placement, with no preexisting-condition exclusion. If an adoption agreement was signed before the birth, coverage starts at birth (627.6578).
• Dependent children:
  • covered to the end of the year they turn 25 if dependent and living at home or a student
  • group plans must offer coverage to the end of the year they turn 30 if they are unmarried with no dependents, a Florida resident or student, and otherwise uninsured (627.6562)
• Disabled dependents who can't support themselves stay covered (627.6041).

Mandated benefits

• Mammograms: a baseline at 35 to 39, every two years at 40 to 49 (or more often if recommended), and every year from 50 (627.6418).
• Child health supervision from birth to 16, exempt from the deductible (627.6579).
• Autism spectrum disorder, including applied behavior analysis (627.6686).
• Diabetes equipment, supplies and self-management training (627.6408).
• Cleft lip and palate treatment (627.64193).
• Osteoporosis for high-risk people (627.6409).
• Off-label cancer drugs that are medically necessary (627.4239).
• Mastectomy inpatient care as the doctor determines (627.64171).
• Maternity care by certified nurse-midwives, licensed midwives and birth centers (627.6406).
• Dental anesthesia in a hospital or surgery center for children under 8 with complex conditions, and for others with qualifying medical risks (627.65755).

Emergency care

• No prior authorization for emergency services, and coverage applies in or out of network (627.64194).
• For out-of-network emergencies, the insurer alone owes the provider. The insured pays only the normal in-network cost-sharing.
• HMOs use the prudent-layperson standard and can't deny payment for failing to notify them in advance (641.513).

Claims, notices and underwriting

• Prompt pay (627.6131): electronic provider claims are paid, denied or contested within 20 days.
• Insured's own claims (627.613): paid or contested within 45 days, and finally paid or denied within 120 days.
• Medical necessity denials can be appealed, including by phone, to the insurer's physician, who responds within 15 business days (627.6141).
• Notice of changes (627.6043): individual health insurers give 45 days' notice of cancellation, nonrenewal or a rate change, and 10 days for nonpayment. A late rate notice keeps the old premium in effect.
• Genetic information can't be used to deny, limit or rate health, life or LTC coverage without a diagnosis (627.4301).
• HIV (627.429):
  • testing requires written informed consent
  • positive results are delivered through a designated physician or the Department of Health, with counseling
  • group plans can't exclude someone for a positive test
• Florida Healthy Kids serves school-age children who aren't eligible for Medicaid, as part of Florida KidCare (624.91).
• Small employers: 1 to 50 employees, with guaranteed issue in the small-group market (627.6699).

Exam traps

• Newborn notice must be allowed at least 30 days, and coverage can't be denied if notice comes within 60. A grandchild's coverage ends at 18 months.
• Dependents are covered to 25, with an option to 30.
• Emergency care needs no prior authorization, in or out of network.
• HMOs need both an OIR certificate and an AHCA certificate.