Section 627.6487, Florida Statutes 2004
627.6487 Guaranteed availability of individual health insurance coverage to eligible individuals.--
(1) Subject to the requirements of this section, each health insurance issuer that offers individual health insurance coverage in this state may not, with respect to an eligible individual who desires to enroll in individual health insurance coverage:
(a) Decline to offer such coverage to, or deny enrollment of, such individual; or
(b) Impose any preexisting condition exclusion with respect to such coverage. For purposes of this section, the term "preexisting condition" means, with respect to coverage, a limitation of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.
(2) For the purposes of this section:
(a) "Health insurance issuer" and "issuer" mean an authorized insurer or a health maintenance organization.
(b) "Individual health insurance" means health insurance, as defined in s. 627.6561(5)(a)2., which is offered to an individual, including certificates of coverage offered to individuals in this state as part of a group policy issued to an association outside this state, but the term does not include short-term limited duration insurance or excepted benefits specified in s. 627.6561(5)(b) or, if the benefits are provided under a separate policy, certificate, or contract, the term does not include excepted benefits specified in s. 627.6561(5)(c), (d), or (e).
(3) For the purposes of this section, the term "eligible individual" means an individual:
(a)1. For whom, as of the date on which the individual seeks coverage under this section, the aggregate of the periods of creditable coverage, as defined in s. 627.6561(5) and (6), is 18 or more months; and
2.a. Whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan, or health insurance coverage offered in connection with any such plan; or
b. Whose most recent prior creditable coverage was under an individual plan issued in this state by a health insurer or health maintenance organization, which coverage is terminated due to the insurer or health maintenance organization becoming insolvent or discontinuing the offering of all individual coverage in the State of Florida, or due to the insured no longer living in the service area in the State of Florida of the insurer or health maintenance organization that provides coverage through a network plan in the State of Florida;
(b) Who is not eligible for coverage under:
1. A group health plan, as defined in s. 2791 of the Public Health Service Act;
2. A conversion policy or contract issued by an authorized insurer or health maintenance organization under s. 627.6675 or s. 641.3921, respectively, offered to an individual who is no longer eligible for coverage under either an insured or self-insured employer plan;
3. Part A or part B of Title XVIII of the Social Security Act; or
4. A state plan under Title XIX of such act, or any successor program, and does not have other health insurance coverage;
(c) With respect to whom the most recent coverage within the coverage period described in paragraph (a) was not terminated based on a factor described in s. 627.6571(2)(a) or (b), relating to nonpayment of premiums or fraud, unless such nonpayment of premiums or fraud was due to acts of an employer or person other than the individual;
(d) Who, having been offered the option of continuation coverage under a COBRA continuation provision or under s. 627.6692, elected such coverage; and
(e) Who, if the individual elected such continuation provision, has exhausted such continuation coverage under such provision or program.
(4)(a) The health insurance issuer may elect to limit the coverage offered under subsection (1) if the issuer offers at least two different policy forms of health insurance coverage, both of which:
1. Are designed for, made generally available to, actively marketed to, and enroll both eligible and other individuals by the issuer; and
2. Meet the requirement of paragraph (b).
For purposes of this subsection, policy forms that have different cost-sharing arrangements or different riders are considered to be different policy forms.
(b) The requirement of this subsection is met for health insurance coverage policy forms offered by an issuer in the individual market if the issuer offers the policy forms for individual health insurance coverage with the largest, and next to largest, premium volume of all such policy forms offered by the issuer in this state or applicable marketing or service area, as prescribed in rules adopted by the commission, in the individual market in the period involved. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.
(5)(a) In the case of a health insurance issuer that offers individual health insurance coverage through a network plan, the issuer may:
1. Limit the individuals who may be enrolled under such coverage to those who live, reside, or work within the service area for such network plan; and
2. Within the service area of such plan, deny such coverage to such individuals if the issuer has demonstrated to the office that:
a. It will not have the capacity to deliver services adequately to additional individual enrollees because of its obligations to existing group contract holders and enrollees and individual enrollees; and
b. It is applying this paragraph uniformly to individuals without regard to any health-status-related factor of such individuals and without regard to whether the individuals are eligible individuals.
(b) An issuer, upon denying individual health insurance coverage in any service area in accordance with subparagraph (a)2., may not offer coverage in the individual market within such service area for a period of 180 days after such coverage is denied.
(6)(a) A health insurance issuer may deny individual health insurance coverage to an eligible individual if the issuer has demonstrated to the office that:
1. It does not have the financial reserves necessary to underwrite additional coverage; and
2. It is applying this paragraph uniformly to all individuals in the individual market in this state consistent with the laws of this state and without regard to any health-status-related factor of such individuals and without regard to whether the individuals are eligible individuals.
(b) An issuer, upon denying individual health insurance coverage in any service area in accordance with paragraph (a), may not offer such coverage in the individual market within such service area for a period of 180 days after the date such coverage is denied or until the issuer has demonstrated to the office that the issuer has sufficient financial reserves to underwrite additional coverage, whichever occurs later.
(7)(a) Subsection (1) does not require that a health insurance issuer that offers health insurance coverage only in connection with group health plans or through one or more bona fide associations, as defined in s. 627.6571(5), or both, offer such health insurance coverage in the individual market.
(b) A health insurance issuer that offers health insurance coverage in connection with group health plans is not deemed to be a health insurance issuer offering individual health insurance coverage solely because such issuer offers a conversion policy.
(8) This section does not:
(a) Restrict the amount of the premium rates that an issuer may charge an individual for individual health insurance coverage; or
(b) Prevent a health insurance issuer that offers individual health insurance coverage from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.
(9) Each health insurance issuer that offers individual health insurance coverage to an eligible individual shall elect to become a risk-assuming carrier or a reinsuring carrier, as provided by s. 627.6475.
(10) This section applies to individual health insurance coverage offered on or after January 1, 1998. An individual who would have been eligible for coverage on July 1, 1997, shall be eligible for coverage on January 1, 1998, and shall remain eligible for the same period of time after January 1, 1998, that the individual would have remained eligible for coverage after July 1, 1997.
History.--s. 4, ch. 97-179; s. 5, ch. 98-159; s. 4, ch. 2000-365; s. 59, ch. 2001-63; s. 1158, ch. 2003-261.