The following provides a detailed look into the underwriting rules of insurance companies and state coverage regulations prior to the Affordable Care Act. Health plans before 2014 we able to refuse to sell you coverage, restrict your benefits, and raise your premiums if you had health problems that existed before your application date. As this applies to many Americans, the health care law changed the scope of underwriting for insurers and eligibility for consumers. Below, former Florida pre-existing condition laws are outlined with specific instances of how insurers regarded an illness.
Attention Deficit Hyperactivity Disorder
as a Previously Existing Condition
Here are the excerpts from the Aetna Florida Insurance UW guidelines regarding Attention Deficit Hyperactivity Disorder (ADHD), and below that you’ll find the preexisting condition clause details, and Florida statutes… AvMed does not waive the 12 month period regardless if you’ve had prior creditable coverage. Most Florida health insurance companies do actually use a 12 month preexisting period very similar to what you will find in these descriptions. In regards to a question from one of our Florida health insurance brokers, we thought it might be a good idea to not only explain preexisting conditions limitations in Florida but also as it relates to ADHD as an example case to check out.
Firstly, it is important to remember that even if you were to get coverage for this illness you are going to be rated up by most health insurance companies a minimum of 25%. In light of the fact that many of you can use generic medications such as Adderall, it might behoove you to look into staying off the prescription grid with this illness. In other words, PAY FOR YOUR OWN MEDICATION. Why? This will keep you from being blackballed by the Florida health insurance companies as a medication risk. Also, it will keep health insurance premiums down for everyone. Never fill your prescriptions under any circumstances at a chain drugstore such as CVS or Walgreens in Florida, stick to mom and pop stores as they do not report to Ingenix prescription database or whatever prescription database is being used these days.
If you are already 64 than by all means fill away, but otherwise you will find it difficult to obtain a Florida health insurance plan if you decide to switch companies.
AvMed Florida Health Insurance Plan Pre-Existing Rules and Limitations
Preexisting condition is a physical or mental condition, regardless of the cause of the condition, for which medical advise, diagnosis, care, or treatment was recommended or received within the 6 month period immediately prior to the date the Member first becomes covered by this Contract. The time used to satisfy any applicable waiting period will be credited to the preexisting condition limitation period. No waiting period credit will apply to late enrollees.
Also the preexisting condition limitation does not apply to pregnancy or to a newborn, an adopted child under age 18, or a child placed for adoption under age 18, if the child becomes covered under Creditable Coverage within 31 days of birth, adoption, or placement for adoption. Genetic information will not be treated as a preexisting condition in the absence of a diagnosis of the condition related to that information. The preexisting condition limitation does not apply to eligible individuals and any eligible dependents enrolling for coverage under a special enrollment period.
With respect to timely enrollees, treatment received after the Member’s Effective Date of Coverage; and before the end of the 12 month period after the earlier to occur of the Member’s Effective Date of Coverage, or enrollment date; related to a preexisting condition that manifested itself during the 6 month period immediately preceding the Member’s enrollment date, will not be covered.
Florida Pre-Existing Condition and Health Insurance Law
Florida Preexisting Condition : A Health Insurance Policy in Florida Must Comply With The Following:
(1) As used in this section, the term:
(a) “Enrollment date” means, with respect to an individual covered under a group health policy, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period of such enrollment.
(b) “Late enrollee” means, with respect to coverage under a group health policy, a participant or beneficiary who enrolls under the policy other than during:
1. The first period in which the individual is eligible to enroll under the policy.
2. A special enrollment period, as provided under s. 627.65615.
(c) “Waiting period” means, with respect to a group health policy and an individual who is a potential participant or beneficiary of the policy, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the policy.
(2) Subject to the exceptions specified in subsection (4), an insurer that offers group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:
(a) Such exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;
(b) Such exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date; and
(c) The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, as defined in subsection (5), applicable to the participant or beneficiary as of the enrollment date.
(3) Genetic information may not be treated as a condition described in paragraph (2)(a) in the absence of a diagnosis of the condition related to such information.
(4)(a) Subject to paragraph (b), an insurer that offers group health insurance coverage may not impose any preexisting condition exclusion in the case of:
1. An individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage.
2. A child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This provision does not apply to coverage before the date of such adoption or placement for adoption.
(b) 2Subparagraphs 1. and 2. do not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.
(5)(a) The term, “creditable coverage,” means, with respect to an individual, coverage of the individual under any of the following:
1. A group health plan, as defined in s. 2791 of the Public Health Service Act.
2. Health insurance coverage consisting of medical care, provided directly, through insurance or reimbursement, or otherwise and including terms and services paid for as medical care, under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance contract offered by a health insurance issuer.
3. Part A or part B of Title XVIII of the Social Security Act.
4. Title XIX of the Social Security Act, other than coverage consisting solely of benefits under s. 1928.
5. Chapter 55 of Title 10, United States Code.
6. A medical care program of the Indian Health Service or of a tribal organization.
7. The Florida Comprehensive Health Association or another state health benefit risk pool.
8. A health plan offered under chapter 89 of Title 5, United States Code.
9. A public health plan as defined by rules adopted by the commission. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
10. A health benefit plan under s. 5(e) of the Peace Corps Act (22 U.S.C. s. 2504(e)).
(b) Creditable coverage does not include coverage that consists solely of one or more or any combination thereof of the following excepted benefits:
1. Coverage only for accident, or disability income insurance, or any combination thereof.
2. Coverage issued as a supplement to liability insurance.
3. Liability insurance, including general liability insurance and automobile liability insurance.
4. Workers’ compensation or similar insurance.
5. Automobile medical payment insurance.
6. Credit-only insurance.
7. Coverage for on-site medical clinics, including prepaid health clinics under part II of chapter 641.
8. Other similar insurance coverage, specified in rules adopted by the commission, under which benefits for medical care are secondary or incidental to other insurance benefits. To the extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
(c) The following benefits are not subject to the creditable coverage requirements, if offered separately:
1. Limited scope dental or vision benefits.
2. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.
3. Such other similar, limited benefits as are specified in rules adopted by the commission.
(d) The following benefits are not subject to creditable coverage requirements if offered as independent, non coordinated benefits:
1. Coverage only for a specified disease or illness.
2. Hospital indemnity or other fixed indemnity insurance.
(e) Benefits provided through a Medicare supplemental health insurance, as defined under s. 1882(g)(1) of the Social Security Act, coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code, and similar supplemental coverage provided to coverage under a group health plan are not considered creditable coverage if offered as a separate insurance policy.
(6)(a) A period of creditable coverage may not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage.
(b) Any period during which an individual is in a waiting period for any coverage under a group health plan or for group health insurance coverage may not be taken into account in determining the 63-day period under paragraph (a) or paragraph (4)(b).
(7)(a) Except as otherwise provided under paragraph (b), an insurer shall count a period of creditable coverage without regard to the specific benefits covered under the period.
(b) An insurer may elect to count, as creditable coverage, coverage of benefits within each of several classes or categories of benefits specified in rules adopted by the commission rather than as provided under paragraph (a). To the extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services. Such election shall be made on a uniform basis for all participants and beneficiaries. Under such election, an insurer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within such class or category.
(c) In the case of an election with respect to an insurer under paragraph (b), the insurer shall:
1. Prominently state in 10-point type or larger in any disclosure statements concerning the policy, and state to each certificate holder at the time of enrollment under the policy, that the insurer has made such election; and
2. Include in such statements a description of the effect of this election.
(8)(a) Periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in this subsection or in such other manner as is specified in rules adopted by the commission. To the extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
(b) An insurer that offers group health insurance coverage shall provide the certification described in paragraph (a):
1. At the time an individual ceases to be covered under the plan or otherwise becomes covered under a COBRA continuation provision or continuation pursuant to s. 627.6692.
2. In the case of an individual becoming covered under a COBRA continuation provision or pursuant to s. 627.6692, at the time the individual ceases to be covered under such a provision.
3. Upon the request on behalf of an individual made not later than 24 months after the date of cessation of the coverage described in this paragraph.
The certification under subparagraph 1. may be provided, to the extent practicable, at a time consistent with notices required under any applicable COBRA continuation provision or continuation pursuant to s. 627.6692.
(c) The certification described in this section is a written certification that must include:
1. The period of creditable coverage of the individual under the policy and the coverage, if any, under such COBRA continuation provision or continuation pursuant to s. 627.6692; and
2. The waiting period, if any, imposed with respect to the individual for any coverage under such policy.
(d) In the case of an election described in subsection (7) by an insurer, if the insurer enrolls an individual for coverage under the plan and the individual provides a certification of coverage of the individual, as provided in this subsection:
1. Upon request of such insurer, the insurer that issued the certification provided by the individual shall promptly disclose to such requesting plan or insurer information on coverage of classes and categories of health benefits available under such insurer’s plan or coverage.
2. Such insurer may charge the requesting insurer for the reasonable cost of disclosing such information.
(e) The commission shall adopt rules to prevent an insurer’s failure to provide information under this subsection with respect to previous coverage of an individual from adversely affecting any subsequent coverage of the individual under another group health plan or health insurance coverage. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
(9)(a) Except as provided in paragraph (b), no period before July 1, 1996, shall be taken into account in determining creditable coverage.
(b) The commission shall adopt rules that provide a process whereby individuals who need to establish creditable coverage for periods before July 1, 1996, and who would have such coverage credited but for paragraph (a), may be given credit for creditable coverage for such periods through the presentation of documents or other means. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
(10) Except as otherwise provided in this subsection, paragraph (8)(b) applies to events that occur on or after July 1, 1996.
(a) In no case is a certification required to be provided under paragraph (8)(b) prior to June 1, 1997.
(b) In the case of an event that occurred on or after July 1, 1996, and before October 1, 1996, a certification is not required to be provided under paragraph (8)(b), unless an individual, with respect to whom the certification is required to be made, requests such certification in writing.
(11) In the case of an individual who seeks to establish creditable coverage for any period for which certification is not required because it relates to an event that occurred before July 1, 1996:
(a) The individual may present other creditable coverage in order to establish the period of creditable coverage.
(b) An insurer is not subject to any penalty or enforcement action with respect to the insurer’s crediting, or not crediting, such coverage if the insurer has sought to comply in good faith with applicable provisions of this section.
(12) For purposes of subsection (9), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement of this section may not be treated as a termination of such collective bargaining agreement.
(13) This section does not apply to any health insurance coverage in relation to its provision of excepted benefits described in paragraph (5)(b).
(14) This section does not apply to any health insurance coverage in relation to its provision of excepted benefits described in paragraphs (5)(c), (d), or (e), if the benefits are provided under a separate policy, certificate, or contract of insurance.
(15) This section applies to health insurance coverage offered, sold, issued, renewed, or in effect on or after July 1, 1997
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