The principles of Florida group health schemes can be confusing until you are taken through the regulations one at a time.
A lot of Americans are covered by group health plans and the rules governing group plans in Florida are similar to those seen in most of the other states, although there are various differences which might apply for public employees.
If you want to join a group health plan you have to first be eligible for memberships of the scheme. For instance, despite the fact that an employer may run a group health scheme, it does not have to be open to all employees, possibly being aimed at full-time and not part-time workers. Alternatively, the scheme may be operated by a Health Management Organization (HMO) and you may discover that you are living outside of the service area for the HMO.
Should you be eligible for membership of the scheme then you must be permitted to join regardless of your state of health. In this case your state of health refers to your present health, taking into account any disability which you may have, as well as your past medical history. It is also interesting to note that you cannot be excluded from the scheme on the grounds of genetic information.
It is also important to note here that, in spite of the fact that an employer can refuse you membership because you do not for instance work sufficient hours, he is not permitted to refuse you membership solely on your present or previous medical history.
Nearly every scheme has an enrollment period during which you have to elect to join the scheme which may typically be within 30 days or joining the company. However, if you choose not to join at that stage then an employer must give you the opportunity to join during what is normally called a special enrollment period if certain specified changes arise within your family. Such changes may include such things as marriage, the birth or adoption of a child and loss of alternative medical insurance coverage because of such things as the cessation of coverage being provided through another family member as a result of death, divorce, retirement, legal separation, reduction in working hours, termination and similar things.
Nearly all plans will also normally have a waiting period for membership which will typically be anywhere from 30 days to 3 months. Employers must apply this waiting period consistently to all eligible employees and during this time you are not covered by the group scheme.
Where the group scheme which you are joining is being run by an HMO then that HMO may also apply a waiting period (often referred to as an affiliation period) where again you will not be covered. Affiliation periods applied by HMOs cannot normally be greater than 2 months and when a waiting period is required the HMO may not then impose any pre-existing conditions exclusions.
Under the provisions of Florida law any group health plan which includes dependent cover also has to provide cover automatically for newborn babies, newly adopted children and children who are placed for adoption for 31 days after birth, adoption or placement. There may also be a requirement for parents to register these children with the scheme within this 31 day period if cover is to continue beyond this point.
For parents taking care of disabled children who are covered under a group health insurance plan cover will often continue beyond the age when a child would no longer be classed as a dependent, as long as the parents are able to demonstrate that the individual in question cannot support himself (or herself) because of mental or physical disability and that they are mainly dependent upon the plan member for support.
If you work for an employer with more than 50 employees then you can take a leave of absence without losing you health insurance for up to 12 weeks in some circumstances. This protection is guaranteed under the Family and Medical Leave Act (FMLA) which is designed to cover such things as childbirth, illness or the need to take care of a seriously ill member of your family.
Federal law allows states, county and local governments to exempt government employees from some coverage in self-insured group health plans and a lot of Forida's public employers make use of this to some extent. Because exemptions vary widely between employers it is prudent to find out the exact coverage provided if you have a public employer. This information may also be found by contacting The Center for Medicare and Medicaid Services (CMS) which maintains a list of employer exemptions.
Despite the fact that according to Florida law you cannot be excluded from membership of a group health plan for reasons of health, there are some circumstances in which exclusion periods may be imposed for pre-existing conditions. However, this is a complicated area and one which is therefore the subject of another article.
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