OVERVIEW HEALTH INSURANCE
Health insurance is an important coverage that helps protect you and your family from the
devastating financial effects of unexpected health problems or catastrophic illness.
Health coverage can be issued to individuals, to employees of an employer offering health
coverage, or to individuals that are members of association groups. Some health coverage is
provided by self insured funds, not regulated by the State of Florida. Although there are
other forms of health insurance, the three main categories of health insurance are:
• Policies that offer comprehensive coverage or coverage "medically
• Policies that provide managed care services;
• Policies that provide limited benefits.
POLICIES THAT PROVIDE COVERAGE OR COMPREHENSIVE MAJOR MEDICAL COVERAGE
Most group health insurance policies fall into the category of major medical policies. The
major medical policies are more expensive because they provide more benefits than basic
policies. A major medical policy usually pays a percentage of covered expenses (typically
80%), after you pay the deductible. Insurance companies use pricing programs to determine
the average cost of a procedure, however, this cost may differ from the actual cost that you
The disbursement ceilings restrict the amount of coinsurance you pay for. Not all policies
include such limits, but those that do include pay 100 percent of remaining covered
expenses after you pay the coinsurance amount established.
POLICIES TO PROVIDE MANAGED CARE SERVICES
The system combines managed care delivery and financing of health care services. This limits the choice
of doctors and hospitals. In return for this limited choice, you'll usually pay less for medical care (eg
doctor visits, prescriptions, surgery and other covered benefits) than we would pay with traditional
health insurance. The network of managed care controls health care services.
TYPES OF MANAGED HEALTH CARE ARE:
• Preferred Provider Organizations (PPO)
• Maintenance Organization (HMO)
• Plans under Point of Service (POS)
• Exclusive Provider Organizations (EPO)
PREFERRED PROVIDER ORGANIZATION (PPO)
PPOs offer a provider network to meet the healthcare needs of their policyholders. A traditional insurer
provides health benefits. An insurer contracts with a group of health care providers to control the cost
of providing benefits to policyholders.
These suppliers charge lower rates than usual because they require a rapid and serving a greater
number of patients. Policyholders usually choose who will provide their health services but pay less in
coinsurance with a preferred supplier to a non-preferred provider.
MAINTENANCE ORGANIZATION (HMO)
HMO members pay a monthly fixed dollar amount (similar to an insurance premium), which gives them
access to a wide range of health care services. In many cases, members also pay a predetermined
amount or copay for each doctor visit or emergency room and for prescription drugs instead of paying
all the supplier and get some money back later. Members must use the network of HMO providers may
include physicians, pharmacies and hospitals contracted by the specific HMO.
PLANS UNDER POINT OF SERVICES (POS)
In a Point of Service plan (POS, by its initials in English), the insured members can choose, at the point
of service, and receive care from a doctor that is within the plan network or leave the network to
receive the services.
The POS plan provides less coverage of medical expenses that is provided outside the network for costs
incurred within the network. In addition, the POS plan will generally require you to pay deductibles and
coinsurance costs for medical care received outside the network.
EXCLUSIVE PROVIDER ORGANIZATION (EPO)
In an array of type EPO, an insurance company contracts with hospitals or specific suppliers. The insured
members must use contracted providers or hospitals to receive the benefits of these plans.
POLICIES THAT PROVIDE LIMITED BENEFITS
Although there are others, better known policies that provide limited benefits are:
• Basic Hospital Expense
• Basic Surgical Expense
• Specific diseases such as cancer
• Hospital Indemnity Plans
HEALTH INSURANCE TIPS
Verify before you buy
Contact Florida Department of Financial Services to verify the license of the agent and the insurance
company before signing an application for a policy.
Guides to Helth Insurance
The guides are excellent tools if you are looking for a specific type of insurance and want to get a better
understanding of all aspects of the product before purchase.
List of Small Group Insurance
A list of companies offering health insurance to Small Business Owners of Florida.
List of Insurance for Private Persons
A list of companies marketing health insurance policies with guaranteed issue for eligible individuals as
defined in Section 627.6487 (3) of the Florida Statutes.
Cover Florida provides access to affordable health service and quality.
Plans are available for all applicants from 19 to 64 years, who have not had health insurance for at least
six months and who are not eligible for a program of public health insurance.
Read your policy carefully
Know your deductible and coinsurance provisions understands. Know your liability in case you need a
referral to see a specialist. Also, learn about their rights to file an appeal or grievance if a complaint
which you believe should be paid, is rejected.
HEALTH INSURANCE TIPS
Individual plans have a provision for review period of 10 days.
This allows you to return the policy and receive a full refund if you do not agree with the policy.
An individual policy should include provision of grace period.
The grace period is 7 to 31 days, depending on how much you pay in insurance premium. Individual
HMOs must grant a grace period of 10 days.
THERE ARE OTHER TYPES OF HEALTH – RELATED SERVICES THAH ARE NOT HEALTH INSURANCE PLANS
Medical Discount Plans, Discount Plans, Prescription Discount Plans Dental Discount Plans and Eye are
plans in which consumers pay a fee to join a plan and in return, the plan offers discounts on products
and certain services through participating providers. Often, members who adhere to this plan are
issued a card similar to an insurance card that identifies them as members. However, these plans do not
work as safe.
MEDICAL DISCOUNT PLANS. CONSIDERATIONS
Before joining a plan (Medical, Prescription, Dental, Vision, etc.) Note the following:
• Terminating health insurance while taking out a discount plan may limit your ability to purchase
insurance at a later date.
• If you leave a health insurance, you may lose coverage of preexisting conditions when making the
• Providers that are contracted by the plan can change without advance notice to the member.
• Some plans contain administrative costs and fees.
• The cancellation of the plan and reimbursement policies may be restrictive, be careful to pay all costs
upfront rather than monthly.
• Plans may provide little or no benefit if you move or when you travel outside the area.
• The discounts are advertised may change or may apply only to certain services or prescriptions.
For example, many savings plans to ensure a certain percentage, but "up to 40 percent" does not
guarantee savings of forty percent.
Discounts are sometimes exaggerated and often include various percentages, ie 15-60% for it is often
difficult to see and understand the savings.
• By using a discount plan with health insurance, most providers are not required to reduce rates with a
discount card because they have already agreed to reduce its rates with a health insurance plan.