A significant number of Americans are insured under group health plans and the rules governing group plans in the state of Florida are similar to those seen in many other states, although there are several differences which might apply for public employees.
To join a group health plan you must first be eligible for memberships of the scheme. For instance, while an employer may operate a group health scheme, it might not be open to everybody, perhaps being aimed at only full-time workers. Additionally, the scheme may be run by a Health Management Organization (HMO) and you may find that you are living outside of the HMO’s service area.
Assuming that you are eligible to participate in the scheme then you have to be allowed to join whatever your state of health . For this purpose your state of health refers to your current health , taking into account any disability which you may have, as well as your previous medical history. It should also be noted that you cannot be excluded on the basis of genetic information.
It must be understood here that, while your employer is allowed to exclude you from a scheme because you do not for instance work enough hours, he is not permitted to exclude you based solely on your current or prior medical history.
Most plans has an enrollment period during which you must elect to join the scheme which may typically be within about 30 days or joining the company. However, if you decide not to join at this stage then your employer must give you the opportunity to join during what is often called a special enrollment period where particular changes take place within your family. Such changes may include such things as marriage, the adoption of a child and the loss of alternative health insurance cover as the result of such things as the cessation of cover being provided through another family member because of death, legal separation, divorce, termination, retirement, reduction in working hours and similar changes.
Almost all plans will also normally have a waiting period for membership which will typically be anywhere from 30 days to about 3 months. This waiting period must be applied consistently to all employees and during this time an employee is not covered by the group scheme.
Where the group scheme which you are joining is being operated by an HMO then the HMO can also require a waiting period (often known as an affiliation period) where you will once again not be covered. HMO affiliation periods cannot normally be greater than 2 months and where a waiting period is required the HMO is not allowed to then impose any pre-existing condition exclusion periods.
Under the provisions of Florida law any group health plan which provides dependent cover also has to provide cover automatically for newborns, newly adopted children and children who are placed for adoption for 31 days from the date of birth, adoption or placement. The can also require parents to register such children with the scheme within this 31 day period for cover to continue thereafter.
For parents caring for disabled children who are covered under a group health insurance plan cover will generally continue beyond the age when a child would cease to qualify as a dependent, as long as the parents are able to show that the person in question cannot support himself because of mental or physical disability and that they are largely dependent upon the plan member for support.
If you are working for an employer with at least 50 employees then you may take a leave of absence without losing you health insurance for up to 12 weeks in certain circumstances. This protection is guaranteed under the Family and Medical Leave Act (FMLA) to cover such things as childbirth, sickness or the need to take care of a seriously ill member of your family.
Federal law allows states down to local government level to exempt government employees from specific coverage in self-insured group health plans and a lot of public employers in Florida take advantage of this to a greater or lesser degree. Because exemptions vary widely from one employer to the next it is wise to find out the precise coverage provided if you are a public employee. These details can also be found by contacting The Center for Medicare and Medicaid Services (CMS) which maintains a list of exemptions for individual employers.
In spite of the fact that under 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 thus the subject of a separate article.