Frequently Asked Questions
This page contains a list of questions that are frequently asked about this website and about health insurance for small employers.
  • What insurance companies sell small group health coverage in Florida?
    The companies offering small group health coverage in Florida changes frequently, so please visit the Consumers website for the most recent listing.

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    What does Guaranteed Issue for a Group Health Plan mean?
    Guaranteed issue for a group policy means that a health plan must be offered and issued to an employer, employee, or dependent of the employee, regardless of claims history, pre-existing conditions or health status. Small groups (1-50 eligible employees) are guaranteed issue but large groups (51 or more eligible employees) are not.

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    When is the 1-Life Open Enrollment Period?
    The open enrollment period for 1-life groups is August 1st through August 31st. Coverage issued during the open enrollment period takes effect October 1st.

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    Can a small business be denied coverage solely because it does not have a business checking account?
    An insurer or HMO may consider the use of a business account as evidence that a particular entity is actively engaged in business, but may not rely upon the absence of a business account as the sole basis for denying small group health coverage to an entity which would otherwise qualify as a small employer.

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    Do I have to send a copy of my tax return with my small group application?
    If an insurer or HMO uses tax return documentation in order to determine whether a small employer is actively engaged in business, then the request for a copy of the entire tax return would be permissible.

    A small group insurance carrier may request copies of any of the following documents in order to underwrite a small group application:

    a) IRS form 1040 Schedule C or F

    b) IRS 941 (quarterly wage and tax form)

    c) IRS 1065 (for partnership income)

    d) IRS 1120 (corporate income)

    e) IRS 1099 (which may include payments to independent contractors)

    f) IRS 2106 (employee business expenses)

    g) IRS 990 (for non-profits with annual receipts over $25,000)

    h) Occupational Licenses

    i) State Licenses

    j) Florida UT 6 (unemployment compensation tax form)

    k) Articles of incorporation

    l) Partnership agreements

    m) Affidavits from the customers or suppliers of the small employer

    n) Auditable personal records of receipts, expenditures, invoices

    o) Leases and other contracts

    Reference: Florida Statute 627.6699 (Title XXXVII, Chapter 627) and Florida Administrative Code 69O-149.041

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    Can an insurer ask health questions on a small group application?
    Small group policies are guaranteed issue regardless of claim history, health status, or pre-existing conditions. Even though the policies are guaranteed issue, the insurer is allowed to ask medical questions on the application. The insurer cannot use the information to deny coverage but the health information may be used for determining pre-existing conditions and premiums.

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    Can an employer offer group health insurance to some employees and not others?
    The small employer (50 or fewer eligible employees) group plan must be offered to all eligible employees once the waiting period has been met and during open enrollment.

    Reference: Florida Statute 627.6699(5)(h)(5) (Title XXXVII, Chapter 627)

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    What is considered a Full-Time Employee for a small group health plan or HMO?
    A full-time employee under a small group or HMO health plan is an employee with a normal workweek of 25 hours or more. The term includes a self-employed individual, a sole proprietor, a partner of a partnership, or an independent contractor, if the sole proprietor, partner, or independent contractor is included as an employee under a health benefit plan of a small employer, but does not include a part-time, temporary, or substitute employee.

    A part-time employee would be an employee that has a normal workweek of less than 25 hours.

    Reference: Florida Statute 627.6699(3)(h) (Title XXXVII, Chapter 627)

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    If I do not sign up for group health coverage when I am eligible, can I obtain coverage later?
    Employers must offer an annual 30-day open enrollment period (HMO plans must offer a 30-day period every 18 months) when eligible employees may enroll in the group health plan. Also, a person may also enroll in the medical plan as a special enrollee if they meet the following conditions for special enrollment:

    1) At the time of initial enrollment, the person made a written statement indicating they were declining coverage because they were covered under another plan; and

    2) The coverage was later terminated because the COBRA benefits were exhausted, there was a legal separation, divorce, death, or termination of employment, or reduction in the number of hours of employment, or the prior coverage was terminated as a result of the termination of the employer premium contributions.

    A late enrollee is anyone that enrolls during a period other than the first period in which they are eligible for coverage or special enrollment. Late enrollees are subject to an 18-month pre-existing exclusion clause unless they can provide proof of creditable coverage.

    Reference: Florida Statute 627.65615, 627.6699 and 627.6561 (Title XXXVII, Chapter 627)

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    How do I prove that I have creditable coverage when applying for group health coverage?
    Insurers and plan administrators are required to provide a certificate of creditable coverage (COCC) when an individual either loses coverage under the plan, becomes entitled to elect COBRA or State continuation (mini-COBRA) coverage, or when an individual's COBRA or State continuation (mini-COBRA) coverage ceases. Replacement COCCs must also be provided by the carrier or administrator if requested by the covered individual within 24-months of termination from the plan. If a person does not have a certificate of creditable coverage, the insurer must also accept other types of proof of prior coverage such as paycheck stubs showing withholding for health insurance, plan identification cards, a copy of the original application for coverage, explanation of benefits, and copies of cancelled checks if paying for COBRA or State continuation (mini-COBRA).

    Reference: Florida Statute 627.6561 (Title XXXVII, Chapter 627)

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    Does the insurance company have to provide advance notice of cancellation or non-renewal of a group health policy?
    The group health plan insurer must mail to the last known address of the employer a 45-day advance notice of cancellation, expiration, non-renewal, or a change in rates. The policyholder shall notify the employees as soon as practicable after receipt of the notice.

    If an insurer fails to provide the required 45-days notice, the coverage shall remain in effect at the existing rates until 45-days after the notice is given or until the effective date of replacement coverage obtained by the insured, whichever occurs first.

    If cancellation is for non-payment of premium, the insurer may terminate coverage on the premium due date if the notice is mailed within 45-days after the due date.

    Reference: Florida Statute 627.6645 (Title XXXVII, Chapter 627)

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    What is Extension of Benefits?
    Group policies must provide for a 12-month extension of major medical benefits for a person who is totally disabled at the date of discontinuance of the policy, regardless of whether replacement coverage is obtained.

    Specific requirements apply to extension of benefits for maternity expense and dental procedures; provides continuity of coverage for disabling conditions, maternity and dental benefits, if an insurer terminates a plan or a group.

    For major medical policies, a 12-month reasonable extension of benefits is provided to the previously covered individual, who loses coverage when an insurer terminates his or her group. Hospital medical surgical policies provide for a 90-day extension of benefits.

    PLEASE NOTE: An employer's voluntary termination of a plan does not necessarily provide an automatic extension. Often a master policy will remain in effect and therefore negate the extension of benefits provision. The requirements for dental procedures do not apply to HMOs.

    Reference: Florida Statute 627.667 (Title XXXVII, Chapter 627)

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    Can I keep my group health coverage after I terminate employment?
    A person may be able to maintain health coverage after termination of their employment under what is known as an "individual conversion policy," if they were covered under the group plan for three continuous months prior to the termination of employment.

    Conversion allows a person to purchase a medical policy from the company that provided the group coverage on a guarantee issue basis, but the benefits and premium rates are NOT necessarily the same as the original group plan.

    If a person is eligible for COBRA or State Continuation (mini-COBRA), this coverage must be exhausted prior to applying for an individual conversion policy.

    Reference: Florida Statute 627.6675 (Title XXXVII, Chapter 627)

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    What is an Individual Conversion Policy?
    An individual conversion policy or contract is a plan of coverage for employees leaving a group health plan. This plan will offer continuous coverage and can only exclude a pre-existing condition, if it was not covered under the previous group plan.

    The insurer must offer two plan options, and one plan must be equivalent to the benefits under the Small Group Standard Plan. If a person is eligible for COBRA or State Continuation (mini-COBRA), these benefits must be exhausted prior to applying for an individual conversion policy or contract.

    Reference: Florida Statute 627.6675 and 627.6699 (Title XXXVII, Chapter 627)

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    Do I have to pay an additional premium for my newborn to be covered under my group health policy?
    Additional premium can be charged for the addition of a newborn to a group health plan, if the plan charges an additional premium for each family member. However, if the insured notifies the plan of the birth during the specified notice period (no less than 30 days after the birth), the insurer may not charge for the notice period.

    If timely notice is not given, the insurer may charge an additional premium from the date of birth. If the plan does not have a specific notification period, they must give a 45 day notice of a premium increase for the additional premium.

    Reference: Florida Statute 627.6575, 627.6699 and 627.6515 (Title XXXVII, Chapter 627)

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    Will our baby be covered from the moment of birth under my group health policy?
    A group health plan or HMO must provide coverage for a newborn from the moment of birth, if the plan provides coverage for family members of the insured. The insurer may require that they be notified of the birth of a child within a certain time period (not less than 30 days).

    The policy or contract must provide details of when notification should occur in order for there to be immediate coverage. A group health or HMO plan may deny coverage for the child if proper notice is not given within the specified time period.

    Reference: Florida Statute 627.6699, 627.6575, 641.31(9)(a) and 627.6515 (Title XXXVII, Chapter 627 and Title XXXVII, Chapter 641)

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    Does a group health insurer have to cover an adopted child with a pre-existing condition?
    A group health plan that provides coverage for a family member of the employee shall provide that benefits applicable to children of the employee also apply to an adopted child, from the moment of placement in the residence of the employee or moment of birth, if a written agreement to adopt such child has been entered into prior to the birth of the child.

    The policy may not exclude coverage for any pre-existing condition of the child. Additional premium can be charged for the addition of an adopted child to a group health plan, if the plan charges an additional premium for each family member.

    Reference: Florida Statute 627.6578, and 627.6699 (Title XXXVII, Chapter 627)

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    Does a group health insurer have to cover a foster child with a pre-existing condition?
    A group health plan that provides coverage for a family member of the employee shall provide that benefits applicable to children of the employee also apply to a foster child, from the moment of placement in the residence of the employee.

    The policy may exclude coverage for any pre-existing conditions of the child. Additional premium can be charged for the addition of a foster child to a group health plan if the plan charges an additional premium for each family member.

    PLEASE NOTE: This requirement does not apply to Health Maintenance Organization (HMO) contracts (except small group Standard and Basic plans).

    Reference: Florida Statute 627.6578 (Title XXXVII, Chapter 627)

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    Are my child's well baby visits and shots required to be covered under a group health plan?
    Group health plans or Health Maintenance Organizations (HMOs) issued or delivered in the State of Florida, must provide for child health supervision services delivered or supervised by a physician. Coverage must include periodic visits which shall include a history, a physical examination, a developmental assessment and anticipatory guidance, and appropriate immunizations and lab tests.

    Visits and periodic visits shall be provided in accordance with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics. Policy deductibles do not apply.

    This benefit is commonly referred to as "Well Baby Care." Florida Law does not apply to disability income, specified disease, Medicare Supplement, hospital indemnity or self-funded health plans.

    Reference: Florida Statute 627.6579, 641.31(30), 627.6515, 627.6416 (Title XXXVII, Chapter 627) and Florida Administrative Code 69O-191.024(15)(e)(1)and(4)

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    What is the maximum age for my child to qualify for coverage as a dependent under my group insurance policy?
    If a group health plan or HMO offers coverage that insures dependent children of the employee, the policy must insure a dependent child of the employee at least until the end of the calendar year in which the child reaches the age of 25, if the child meets ALL of the following:

    a) The child is dependent upon the employee for support, and

    b) The child is living in the household of the employee or is a full-time or part-time student.

    The contract must also provide in substance that attainment of the limiting age does not terminate the coverage of the child while the child continues to be both:

    a) Incapable of self-sustaining employment by reason of mental retardation or physical handicap, and

    b) Chiefly dependent upon the employee for support and maintenance.

    PLEASE NOTE: This requirement does not apply to the small group Standard and Basic plans; however, the maximum age under these policies will be outlined in the insurance contract.

    Reference: Florida Statute 627.6562 and 641.31(29) (Title XXXVII, Chapter 627 and Title XXXVII, Chapter 641)

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    Do all small group plans offer maternity coverage?
    No. Only the Basic and Standard plans are required to cover maternity claims.

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    Do all small group plans offer mental or substance abuse coverage?
    No. Only the Basic and Standard plans are required to cover mental and substance abuse claims.

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    Where can I find additional information with regard to HMO, Small Group, and General Health Insurance coverage?
    Small Group: Small Business Owners Insurance

    General Health Insurance: Health Insurance

    HMO: HMO Guide for Consumers

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    What is the purpose of the Small Employer Sample Rate Search (SESRS)?
    The SESRS website is designed to give consumers the ability to view small group major medical health insurance rates for standard, basic, and high deductible health plans currently available in the State of Florida. By displaying the information contained on the website, the Office of Insurance Regulation (OIR) does not endorse or recommend any particular carrier or plan. Consumers should carefully consider the benefits provided by each plan before selecting a particular plan. Additional information on particular carriers may be obtained by visiting Consumer Services. Additional information regarding a particular plan may be obtained by contacting the carrier directly.

    Please be aware that the premium rates on this website are an example and not the final premium rates to be charged to the consumer. Additional adjustments may be made to the premium rates due to claims experience, health status, or duration of coverage based on information supplied by the consumer during the underwriting process.

    The premium rates are based on the current effective premium rates on file with OIR, for each company, using specific examples. A listing here DOES NOT imply or guarantee that a company will sell you insurance at the listed premium. This is intended to be referential information only. Please verify all premium rates with the applicable carrier.

    OIR considers the information displayed on this website to be generally reliable. Although OIR takes reasonable care to keep the information displayed on the website accurate and up-to-date, there may be occasions where this is not possible. Accordingly, OIR does not guarantee, either expressly or by implication, the information’s accuracy, completeness, or timeliness; nor is OIR responsible for any decisions taken, based on this information. OIR is not liable for any inaccuracies or omissions in this data.

    OIR has not reviewed all the sites that may be linked to its sites and does not endorse and is not responsible for the content of any off-site pages or any other sites linked to these sites. Your linking to such sites is at your own risk.

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    Why can’t I search by company name?
    The system does not allow a search by company name; however the search results can be sorted by company name by clicking on the Company Name column heading of the Search Results page.

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    How is the premium rate for a small employer group calculated if employees work and reside in multiple counties?
    Some carriers refer to the county as the county the employee works in, while others refer to the county the employee resides in. Please contact the carrier for more information.

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    Why doesn’t every carrier offer coverage in every county?
    Indemnity and PPO coverage, or a combination of the two, must be offered in every county. HMO, EPO, and POS plans are not required to be offered in every county.

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    Why can I only search by a single county?
    Once you choose to display rates for a particular plan, SESRS then allows an option to search by one more county.

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    Do the benefits provided by Standard and Basic plans differ between small employer group carriers?
    The benefits provided by Standard and Basic plans are mandated by the State of Florida. Every small employer group carrier must offer at least two Standard and two Basic plans. Please click here to view the Standard and Basic Schedule of Benefits required to be used by every small employer group carrier.

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    Why does the SESRS only show sample rates for basic, standard, and high deductible health plans?
    The benefits provided by basic and standard plans are mandated by statute and do not vary between carriers. This makes these plans ideal for comparison purposes. Please contact carriers for other plan options that may be available.

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    Do co-pay amounts and co-insurance percentages reflect the members cost?
    Yes.!

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    Does the information displayed on the Search Results page reflect individual or family coverage?
    All information (deductible, out-of-pocket maximums, etc.) reflects individual coverage only. Contact the carrier for information regarding family coverage.

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    What are the Rx tiers for the Prescription Benefits column on the Search Results page?
    generic/brand/non-formulary/injectables/miscellaneous 5th tier that varies by carrier.

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    What does 65+Medicare Primary and 65+Medicare Secondary mean?
    The rate quoted for the 65+ Medicare Primary category assumes the employee and spouse are both Medicare eligible with Medicare paying benefits first and the small employer group health plan paying remaining benefits.

    The rate quoted for the 65+ Medicare Secondary category assumes the employee and spouse are both Medicare eligible and the small employer group health plan pays benefits first with Medicare paying remaining benefits.

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    Why does the carrier’s final quote differ from the rates shown on the SESRS?
    Additional adjustments due to claims experience, health status, or duration of coverage may apply, as well as trend adjustments based on the requested effective date of coverage. Additional charges may also apply depending upon plan options selected. Please verify all premium rates with the applicable carrier.

    Additionally, statute does not allow composite rating methodology on small employer groups with fewer than 10 employees. Composite rating methodology means a rating methodology that averages the impact of the rating factors for age and gender in the premiums charged to all of the employees of a small employer.

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    How do I obtain more information or get coverage after finding a plan of interest on the SESRS?
    Contact the company by using the provided 1-800 number or company website to obtain additional information or request a quote.

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    This page was rendered on: Monday, August 03, 2015 at 9:06:14 AM