List of Mandated HMO Benefits in Florida

Title XXXVII of the Florida statutes details the requirements for health-insurance coverage provided by health-maintenance organizations (HMOs) in the state of Florida. Chapter 641 contains regulations specific to HMOs. The Florida legislature includes in the statutes its objective to "ensure that comprehensive prepaid health care plans deliver high-quality health care." To meet that objective, the legislature mandates that HMOs provide certain types of coverage.

Required Benefits - General

• An HMO must cover emergency medical care without requiring prescreening. It must cover diabetes treatment, equipment and supplies if deemed medically necessary by the treating physician and must allow up to five office visits annually, without prior authorization, to a dermatologist who is under contract with the HMO.

  An HMO policy must provide for a 12-month extension of benefits for a person who is totally disabled at the date of discontinuance of the policy. Exclusion of preexisting conditions is limited to 12 or 18 months depending on the enrollment details. An HMO must offer a conversion to an individual policy if the covered person has lost eligibility through termination of employment or through termination of the group coverage by the employer. Conversion is not required under certain circumstances, such as fraud, geographical relocation and failure to pay premiums due.

Required Benefits - Children

• If an HMO covers children, it must provide coverage for child-health supervision services from birth through age 16 including physical examinations, immunizations and laboratory testing. If deemed medically necessary by treating physicians, the policy must cover anesthesia and hospitalization for dental procedures for patients under 8 years of age and cleft-palate surgery and therapy for patients up to 18 years of age.

  If covered, a child must have coverage from the moment of birth. If a policy covers children and establishes an age for termination of child coverage, it must continue to provide coverage for a child who is mentally retarded or physically disabled as long as the child is not capable of supporting himself and dependent on the covered parent for care.

Required Benefits - Women

• An HMO must allow a yearly visit for a woman to see a gynecologist without prior authorization and must cover any necessary follow-up care. It must cover baseline and continuing mammograms based on recommended frequency.

  If a policy provides coverage for maternity, it must allow extended inpatient treatment if deemed necessary by the treating physician. If maternity coverage is provided, the policy must cover the services of certified nurse midwives or other appropriately licensed midwives and birthing centers.

  If a policy provides coverage for breast cancer, it may not limit inpatient care deemed necessary by a physician. Mastectomy coverage must include prosthesis and reconstructive surgery.

Required Optional Coverage

• An HMO must offer to the group policyholder, for an appropriate additional premium, coverage for mental and nervous disorders including at least 30 days' inpatient treatment plus at least $1,000 per year in outpatient benefits. An HMO must also make available outpatient benefits for the treatment of substance abuse under the supervision of a licensed physician or psychologist.