Health insurance mandates differ from state to state and often contain detailed criteria. This chart provides a general overview of health insurance mandates and is provided to you for general informational purposes only.  It summarizes mandates contained in state statutes, but does not include references to other legal resources (such as supporting regulations, or formal or informal opinions of state departments of insurance), unless specifically noted. Please seek qualified and appropriate counsel for further information and/or advice regarding the application of health insurance mandates to your employee benefits plans.© 2012-2013 Zywave, Inc. All rights reserved. EM 10/13, DMK 5/15

Provided By Sapoznik Insurance

Health Insurance MandatesState health insurance mandates are laws regulating the terms of coverage for insured health plans. Mandates can affect various parts of health insurance plans as follows:

Benefit mandates require health insurance plans to cover specific treatments, services or procedures.

Provider mandates require health insurance plans to pay for services provided by specific health care professionals. Often, provider mandates are in the form of nondiscrimination mandates that require coverage only if the health plan already reimburses services within the scope of the health care professional’s practice.

Person mandates require health insurance plans to cover specific categories of people.

Additional mandates for health plans exist at the federal level. For instance, effective for plan years beginning on or after Jan. 1, 2014, the Affordable Care Act (ACA) requires non-grandfathered plans in the small group and individual markets to provide coverage for items and services designated as “essential health benefits.” Health plan sponsors and issuers should work with their advisors to determine how to comply with applicable federal and state mandates.This Employment Law Summary contains a chart outlining Florida’s benefit, provider and person mandates for group health insurance plans. Please keep in mind that the following chart does not address federal benefit mandates, such as the ACA’s mandates.

Benefit Mandate Description

Autism Spectrum Disorders

Coverage to an eligible individual for: Well-baby and well-child screening for diagnosing the

presence of autism spectrum disorder; and Treatment of autism spectrum disorder through speech

therapy, occupational therapy, physical therapy and applied behavior analysis.

This coverage is limited to $36,000 annually and $200,000 in total lifetime benefits (subject to adjustments for inflation). This coverage cannot be subject to dollar limits, deductibles or coinsurance provisions that are less favorable than those that apply to covered physical illnesses under the plan. “Autism spectrum disorder” means any of the following disorders: autistic disorder; Asperger's syndrome; and pervasive developmental disorder not otherwise specified. “Eligible individual” means an individual under 18 years of age or an individual 18 years of age or older who is in high school who has been diagnosed as having a developmental disability at 8 years of age or younger. This mandate does not apply to any health insurance plan provided to a small employer (50 or fewer employees).

Health Insurance MandatesBone Marrow Transplant

ProceduresPolicies covering cancer treatment cannot exclude coverage for bone marrow transplant procedures recommended by the referring physician and the treating physician under a policy exclusion for experimental, clinical investigative, educational or similar procedures, if the particular use of the bone marrow transplant procedure is determined to be accepted within the appropriate oncological specialty and not experimental (based on rules issued by the Florida Agency of Health Care Administration). Covered bone marrow transplant procedures must include costs associated with the donor-patient to the same extent and limitations as costs associated with the insured, except the reasonable costs of searching for the donor may be limited to immediate family members and the National Bone Marrow Donor Program.

Breast Cancer Cannot include any benefits exception or exclusion solely: Because the insured has been diagnosed as having a fibrocystic

condition or a nonmalignant lesion that demonstrates a predisposition to developing breast cancer;

Due to the family history of the insured related to breast cancer; or Due to any combination of these factors.

This mandate does not apply if the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer.Cannot include any benefits exception or exclusion of benefits solely due to breast cancer, if the insured has been free from breast cancer for more than two years before the applicant's request for health insurance coverage.

Cancer Treatment Drugs – Off Label Use

Policies that cover cancer treatment cannot exclude coverage for any drug prescribed for the treatment of cancer on the basis that the drug is not approved by the FDA for a particular indication, if that drug is recognized for treatment of the indication in a standard reference compendium or recommended in the medical literature.Coverage must also include the medically necessary services associated with the administration of the drug.

Cancer Treatment Medication—Orally

Administered (Effective for policies

issued or renewed on or after July 1, 2014)

Policies that cover cancer treatment medications must also cover prescribed, orally administered cancer treatment medications and may not apply cost-sharing requirements for orally administered cancer treatment medications that are less favorable to the covered person than cost-sharing requirements for intravenous or injected cancer treatment medications. However, if the cost-sharing for intravenous or injected cancer treatment medications is less than $50 per month, the cost-sharing for orally administered cancer treatment medications may be up to $50 per month.

Cleft Lip/Cleft Palate Policies covering children under the age of 18 must provide coverage for treatment of cleft lip and cleft palate for these children. The coverage must include medical, dental, speech therapy, audiology and nutrition services if the services are prescribed by the treating physician or surgeon and the physician or surgeon certifies that the services are medically necessary and resulting from treatment of the cleft lip or cleft palate.This coverage may be subject to terms and conditions applicable to other benefits.

2

Health Insurance MandatesDental Treatment –

General Anesthesia and Hospitalization

Policies providing coverage for general anesthesia and hospitalization services must also provide this coverage to assure the safe delivery of necessary dental care provided to a covered person who:

Is under eight years of age and determined by a licensed dentist and the child's licensed physician to require necessary dental treatment in a hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or

Has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center.

All terms and conditions of the covered person's health insurance policy apply to the services. This mandate does not require coverage for the diagnosis or treatment of dental disease.

Diabetes Treatment Coverage for all medically appropriate and necessary equipment, supplies and diabetes outpatient self-management training and educational services used to treat diabetes, if the patient's treating physician or a physician who specializes in the treatment of diabetes certifies that the services are necessary.

Enteral Formulas Must offer coverage (for an additional premium) for prescription and nonprescription enteral formulas for home use. The enteral formulas must be physician-prescribed as medically necessary for the treatment of inherited diseases of amino acid, organic acid, carbohydrate or fat metabolism, as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. Coverage for inherited diseases of amino acids and organic acids must include food products modified to be low protein, in an amount not to exceed $2,500 annually for any insured individual, through the age of 24.

Home Health Services Coverage for home health care by a licensed home health care agency. This benefit may be subject to a maximum length of care for any policy year, but in no event can reimbursement be limited to less than $1,000 per year.

Jaw or Facial Procedures Policies providing coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton cannot discriminate against coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region. This coverage is required only if, under accepted medical standards, the procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease or injury.

Mammograms Coverage for mammograms as follows: A baseline mammogram for any woman who is 35 years of age or

older, but younger than 40 years of age; A mammogram every 2 years for any woman who is 40 years of

age or older, but younger than 50 years of age, or more frequently based on the patient's physician's recommendation;

A mammogram every year for any woman who is 50 years of age or older; and

3

Health Insurance Mandates One or more mammograms a year, based upon a physician's

recommendation, for any woman who is at risk for breast cancer because:

o She has personal or family history of breast cancer; o She has a history of biopsy-proven benign breast disease;o She has a mother, sister or daughter with breast cancer or a

history of breast cancer; or o She has not given birth before the age of 30.

In addition, the health insurer must offer, for an appropriate additional premium, the mammogram coverage described above without application of the policy’s deductible or coinsurance provisions.

Mastectomy – Inpatient Stay and Postsurgical

Care

Policies that provide coverage for breast cancer treatment may not limit inpatient hospital coverage for mastectomies to any period that is less than that determined by the treating physician to be medically necessary in accordance with prevailing medical standards and after consultation with the insured patient.Policies that provide coverage for mastectomies must also provide coverage for outpatient postsurgical follow-up care in keeping with prevailing medical standards by a licensed health care professional qualified to provide postsurgical mastectomy care. The treating physician, after consultation with the insured patient, may choose that the outpatient care be provided at the most medically appropriate setting, which may include the hospital, treating physician's office, outpatient center or home of the insured patient.Policies may impose deductibles, coinsurance or other cost-sharing, except that this cost-sharing may not exceed cost-sharing for other benefits.

Mastectomy – Prosthetic Devices and

Reconstructive Surgery

Policies that cover mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy.

Maternity Care Policies providing maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for follow-up care outside of a hospital to any time period that is less than that determined to be medically necessary by the treating obstetrical care provider or the pediatric care provider.These policies must also provide coverage for post-delivery care for a mother and her newborn infant. The post-delivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician's office, at an outpatient maternity center or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards.This mandate does not apply to any health insurance coverage that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant.

Mental Health Must offer coverage (for an appropriate additional premium) for the necessary care and treatment of mental and nervous disorders, as described below. The plan sponsor may select any alternative benefits or level of benefits offered by the insurer. However, if alternate inpatient,

4

Health Insurance Mandatesoutpatient or partial hospitalization benefits are selected, the benefits cannot be less than the level of benefits described below.Inpatient benefits may be limited to not less than 30 days per year. Outpatient benefits may be limited to $1,000 for consultations with a licensed physician, a licensed psychologist, a licensed mental health counselor, a licensed marriage and family therapist and a licensed clinical social worker. Partial hospitalization benefits must be provided under the direction of a licensed physician. Alcohol rehabilitation programs accredited by an accrediting organization whose standards are comparable to the state’s standards or approved by the state and licensed drug abuse rehabilitation programs are also qualified providers for partial hospitalization benefits. In any benefit year, if partial hospitalization services (or a combination of inpatient and partial hospitalization services) are utilized, the total benefits paid for these services may not exceed the cost of 30 days after inpatient hospitalization for psychiatric services, including physician fees, which prevail in the community in which the partial hospitalization services are rendered.Inpatient hospital benefits, partial hospitalization benefits and outpatient benefits consisting of durational limits, dollar amounts, deductibles and coinsurance factors may not be less favorable than for physical illness generally, except to the extent that the policy provides benefits in excess of the minimum limits described above. The federal Mental Health Parity and Addiction Equity Act (MHPAEA) creates additional parity requirements for employers with more than 50 employees that offer mental health or substance use disorder benefits in their group health plans. Depending on a plan’s design, the MHPAEA may require stricter parity requirements than state law mandates. Also, beginning in 2014, the ACA requires non-grandfathered health plans in the individual and small group markets to cover mental health and substance use disorder services and comply with the federal parity law.

Osteoporosis Coverage for the medically necessary diagnosis and treatment of osteoporosis for high-risk individuals, including, but not limited to:

Estrogen-deficient individuals who are at clinical risk for osteoporosis;

Individuals who have vertebral abnormalities; Individuals who are receiving long-term glucocorticoid (steroid)

therapy; Individuals who have primary hyperparathyroidism; and Individuals who have a family history of osteoporosis.

Out-of-Hospital Benefits Coverage for treatment performed outside of a hospital for any accident or illness as defined in the policy, provided that the treatment:

Would be covered on an inpatient basis; Is provided by a health care provider whose services would be

covered under the policy if the treatment were performed in a hospital; and

Is medically necessary and is provided as an alternative to inpatient treatment in a hospital.

5

Health Insurance MandatesReimbursement may be limited to amounts that are reasonable for the treatment or services provided and may be limited by any deductible and coinsurance provisions of the policy.

Substance Abuse Must offer coverage for the benefits described below for the necessary care and treatment of substance abuse impaired persons. The plan sponsor may select any alternative benefits or level of benefits as may be offered by the insurer. Inpatient benefits or outpatient benefits must consist of an intensive treatment program for the treatment of substance abuse impaired persons, subject to the following:

A minimum lifetime benefit of $2,000; A maximum of 44 outpatient visits; and A maximum benefit of $35 for an outpatient visit.

Detoxification is not considered a benefit under the outpatient program.

Well Child Care Policies providing family coverage must provide coverage for child health supervision services from the moment of birth to age 16 years. The services cannot be subject to the policy’s deductible. Child health supervision services must include periodic visits involving a history, physical examination, developmental assessment and anticipatory guidance and appropriate immunizations and laboratory tests. The services and periodic visits must be provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics.

Provider Mandate Description

Acupuncturist Any policy of group health insurance that provides coverage for acupuncture must cover the services of a certified acupuncturist under the same conditions that apply to services of a licensed physician. Nondiscrimination mandate. (Nondiscrimination mandates require coverage if the health plan reimburses services within the scope of the health care professional’s practice.)

Ambulatory Surgical Center

Coverage must be provided for any service performed in an ambulatory surgical center if the service would have been covered under the terms of the policy as an eligible inpatient service. Nondiscrimination mandate.

Chiropractor When a policy provides for the payment of medical expense benefits or procedures, the policy must be construed to include payment to a chiropractic physician who provides the medical service benefits or procedures that are within the scope of a chiropractic physician's license. Nondiscrimination mandate.

Dentist The word “physician” or “medical doctor,” when used in any health insurance policy providing for the payment of surgical procedures that are specified in the policy or are performed in an accredited hospital in consultation with a licensed physician and are within the scope of a dentist's professional license, must be construed to include a dentist who performs these specified procedures. Nondiscrimination mandate.

Home Health Care Under the home health services benefit mandate, services may be

6

Health Insurance MandatesProvider performed by a registered graduate nurse, licensed practical nurse,

physical therapist, speech therapist, occupational therapist or home health aide.

Massage Therapists Policies that cover massage must also cover the services of persons licensed to practice massage where the massage has been prescribed by a licensed physician as being medically necessary and the prescription specifies the number of treatments. Nondiscrimination mandate.

Midwives, Nurse-Midwives and Birth

Centers

Policies that cover maternity care must also cover the services of certified nurse-midwives and licensed midwives and the services of licensed birth centers. Nondiscrimination mandate.

Optometrist Policies that cover procedures that are within the scope of an optometrist's professional license must include payment to an optometrist who performs the procedures. Nondiscrimination mandate.

Physician Any limitation or condition placed upon payment to, or upon services, diagnosis or treatment by, any licensed physician must apply equally to all licensed physicians without unfair discrimination to the usual and customary treatment procedures of any class of physicians. Nondiscrimination mandate.

Physician Assistant or Registered Nurse First

Assistant

Policies that cover surgical first assisting benefits or services must include payment to a registered nurse first assistant or employers of a physician assistant or nurse first assistant who performs these services that are within the scope of a physician assistant's or registered nurse first assistant's professional license. This nondiscrimination mandate applies only if reimbursement for a licensed assisting physician would be covered and a physician assistant or a registered nurse first assistant who performs the services is used as a substitute.

Podiatrist Policies that cover procedures that are within the scope of a podiatric physician's professional license must include payment to a podiatric physician who performs the procedures. In the case of podiatric services, payments must be made in accordance with the coverage provided for medical and surgical benefits. Nondiscrimination mandate.

Person Mandate Description

Adopted/Foster Children and Children in Court-

Ordered Custody

Policies that provide family coverage must provide that benefits applicable to children of the insured also apply to an adopted child or a foster child of the insured, from the moment of placement in the residence of the insured. In the case of a newborn child, coverage begins at the moment of birth if a written agreement to adopt the child has been entered into by the insured prior to the birth of the child, whether or not the agreement is enforceable. This coverage mandate also applies to a child placed court-ordered temporary or other custody of the insured.

Adult Dependent Children

Policies that provide family coverage must cover a dependent child at least until the end of the calendar year in which the child reaches the age of 25, if the child meets both of the following:

The child is dependent upon the insured for support; and The child is living in the insured’s household or the child is a full-

7

Health Insurance Mandatestime or part-time student.

In addition, the insured must be offered the option to insure his or her child at least until the end of the calendar year in which the child reaches the age of 30, if the child is:

Unmarried and does not have a dependent of his or her own; A resident of this state or a full-time or part-time student; and Not provided coverage as a named subscriber, insured, enrollee, or

covered person under any other group, blanket, or franchise health insurance policy or individual health benefits plan, or is not entitled to benefits under Medicare.

Continuation Coverage A group health plan issued to a small employer (less than 20 employees) must provide that each qualified beneficiary who would lose coverage under the group health plan because of a qualifying event is entitled, without evidence of insurability, to elect continuation coverage.“Qualified beneficiary” means any individual who, on the day before the qualifying event is covered under the plan as an employee, a spouse or a dependent child. “Qualifying event” means any of the following events which, but for the election of continuation coverage, would result in a loss of coverage to a qualified beneficiary:

Employee’s death; Employee’s termination of employment (except for termination due

to gross misconduct) or reduction in hours; Divorce or legal separation from the employee's spouse; Employee's entitlement to Medicare benefits; Dependent child's ceasing to qualify as a dependent under the

plan’s terms; or A retiree or the spouse or child of a retiree losing coverage within

one year before or after the employer’s commencement of a federal bankruptcy proceeding.

The maximum period of state continuation coverage is 18 months (29 months if the qualified beneficiary is eligible for an 11-month disability extension). Special continuation coverage rules apply to employees in the military Reserves or National Guard.

If an employee’s employment is terminated either after or during the active duty period, the termination is a separate qualifying event from the qualifying event that may have occurred when the employee was called to active duty, and the employee and other qualified beneficiaries are eligible for a new 18-month benefit period beginning on the later of the date active duty ends or the date of termination of employment.

If the employee dies during the period of active duty, there is a divorce or separation or a dependent child no longer qualifies as a dependent child under the plan’s terms, the event is a qualifying event separate from the qualifying event that may have occurred when the employee was called to active duty.

If a period of continuation coverage is terminated because the qualified beneficiary becomes eligible for the health program

8

Health Insurance Mandatesoffered by the U.S. Defense Department (TRICARE), the maximum continuation period is tolled during the time he or she is eligible for TRICARE. Within 63 days after TRICARE coverage terminates, the qualified beneficiary may elect to continue coverage under the group health plan, retroactively to the date coverage terminated under TRICARE, for the remainder of the maximum coverage period.

Conversion Policies must provide a conversion option for employees who have been continuously covered for at least three months and whose insurance terminates for any reason, except nonpayment of premiums by the employee. The converted policy must be issued without evidence of insurability. The conversion requirement does not apply to any person eligible for Medicare or certain other health coverage. The conversion privilege also applies to:

A covered surviving spouse and/or children at the death of the employee;

A former spouse whose coverage would terminate because of annulment or dissolution of marriage, if the former spouse is dependent for financial support;

A spouse and children whose coverage would terminate, while the employee remains insured under the group policy, because the spouse is no longer a qualified family member under the group policy.

A covered child who ceases to meet the plan’s definition of dependent child.

Handicapped Children Policies providing family coverage that have an age limit for dependent eligibility must provide that attaining the limiting age does not terminate the coverage of the child while the child continues to be both:

Incapable of self-sustaining employment by reason of an intellectual or physical disability; and

Chiefly dependent upon the employee or member for support and maintenance.

Newborn Children Policies providing family coverage must provide that the health insurance benefits applicable for children will be payable with respect to a newborn child of the insured, or covered family member from the moment of birth. However, the coverage for a newborn child of a covered family member of the insured terminates 18 months after the birth of the newborn child.The newborn coverage must include coverage for injury or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities or prematurity. It must also include transportation costs of the newborn to and from the nearest available facility appropriately staffed and equipped to treat the newborn's condition, if the transportation is certified by the attending physician as necessary to protect the health and safety of the newborn child. The coverage of transportation costs may not exceed the usual and customary charges, up to $1,000.

*While many of the mandates described in the above chart are applicable to health maintenance organizations (HMOs) and preferred provider plans (PPPs), HMOs and PPPs may be subject to additional requirements under Florida statutes and regulations that are not specifically addressed in the above chart. In addition, the chart focuses on mandates applicable to health insurance plans sponsored by private employers, and does not address mandates specifically applicable to the health benefits provided by government employers.

9

Health Insurance MandatesAdditional Resources:Florida statutesFlorida Office of Insurance Regulation

10