A significant number of Americans are members of group health insurance plans and the rules governing group plans in Florida are similar to those in most of the other states, although there are some differences which could apply for public employees.
To join a group health insurance scheme you need to first be eligible for memberships of the plan. For example, although an employer may run a group health insurance plan, it may not be open to everyone, possibly being reserved for only full-time workers. Also, the plan may be operated by an HMO and you may discover that you live outside of the service area for the HMO.
Assuming that you are eligible for the plan then you have to be allowed to join regardless of your state of health. In this context your state of health means your current health, including any disability which you may have, and to your previous medical history. It should also be noted that you cannot be excluded from the scheme on the basis of genetic information.
It is important to understand here that, while an employer may exclude you from a plan because you do not for example work sufficient hours, he in not allowed to refuse you membership solely on your present or previous medical history.
Most schemes will have an enrollment period during which you need to elect to join the scheme which could typically be within 30 days or starting work. However, if you decide not to join at that stage then an employer has to give you an opportunity to join during what is usually called a special enrollment period when particular changes arise within your family. Such changes could include such things as marriage, the adoption of a child and loss of other medical insurance cover as the result of such things as the cessation of cover being provided through another family member because of death, termination, legal separation, reduction in working hours, divorce, retirement and similar circumstances.
Vitually all plans will also usually have a waiting period for membership which is typically anything from 30 days to 3 months. This waiting period has to be applied consistently across all eligible employees and during this time you will not be covered under the group plan.
Where the group plan which you are joining is operated by an HMO then the HMO may also require a waiting period (generally called an affiliation period) where once again you will not be covered. HMO affiliation periods cannot usually exceed 2 months and if such a waiting period is required the HMO is not allowed to then impose any pre-existing conditions exclusions.
Under Florida law any group plan which provides dependent cover also has to provide cover automatically for newborn babies, newly adopted children and children placed for adoption for a period of 31 days from the date of birth, adoption or placement. There may also be a requirement for parents to register these children with the plan within this 31 day period for cover to continue thereafter.
For parents taking care of disabled children who are covered under a group health plan cover will normally continue beyond the age when a child would no longer be classed as a dependent, providing the parents are able to show that the individual in question cannot support himself as a result of mental or physical disability and that they are largely dependent upon the scheme member for support.
If you work for an employer with at least 50 employees then you are allowed to take a leave of absence without loss of health insurance for a period of up to 12 weeks in some circumstances. This protection is guaranteed by the Family and Medical Leave Act (FMLA) which is intended to cover such things as childbirth, sickness or the need to take care of a seriously ill member of your family.
Federal law permits states down to local government level to exempt government employees from specific areas of coverage in self-insured group health plans and a lot of Forida’s public employers take advantage of this to some extent. As exemptions vary widely between employers it is wise to find out the exact coverage provided if you have a public employer. These details may also be found by getting in touch with The Center for Medicare and Medicaid Services (CMS) which maintains a list of exemptions for individual employers.
Although under Florida law you cannot be refused membership of a group health insurance plan on the basis of health, there are certain circumstances where exclusion periods are allowed to be imposed for pre-existing conditions. However, this is a complex area and one which is therefore the subject of another article.