During the Health Insurance open enrollment for 2022 coverage, more than 2.7 million Floridians enrolled in private individual-market plans through the Florida exchange. That is about 19% of the entire United States' exchange enrollments. There are 14 insurers currently offering insurance plans in Florida's marketplace.
Two types of Health Insurance are common in Florida:
Private companies typically offer private Health Insurance plans. A Health Insurance plan can be purchased as a group policy through an employer, an organization the individual is affiliated with, or by individual consumers directly from the insurance company or marketplace. The government offers public Health Insurance plans through Medicare, Medicaid, and CHIP programs.
Low-income earners and seniors can take advantage of State-funded programs and alternative health plans like Florida Medicaid, Florida Children's Health Insurance Program (CHIP), Limited Benefit, and Short-term Limited Duration Health Insurance.
Health Insurance in Florida can be purchased online or directly from insurers. However, it is best to purchase it from a Florida-licensed Health Insurance agent. Insurance agents are familiar with the Florida marketplace and can help you get an affordable policy that suits your needs.
The Office of Insurance Regulation (OIR) oversees all insurance companies and insurance-related entities licensed to do business in Florida. This regulation complies with the Florida Insurance Code and all federal laws and regulations relating to Health Insurance in the United States. The main federal laws that guide Health Insurance in Florida include:
Affordable Care Act (ACA compliant plans)
Health Insurance premiums in Florida vary depending on several factors like age, location, tobacco use, and whether the plan covers dependents. Health Insurance in Florida is categorized into policies that provide:
Managed care services: This system manages the delivery and financing of health care services. Individuals do not have many doctors and hospitals to choose from, but they pay less for medical care. You can enroll for managed care services if you are a U.S. citizen or national (or be lawfully resident) residing in the United States. The types of managed care services available in Florida include:
Preferred Provider Organization (PPO): This type of managed care service offers a network of providers to meet the insured's medical needs. The insurer contracts with a group of healthcare providers to regulate the price of providing benefits to its insureds. The fees charged by these providers are usually cheaper than the normal rate.
Health Maintenance Organization (HMO): Members of this organization pay fixed amounts monthly to access a wide range of medical services, depending on their HMO plans. They are only allowed to use doctors, pharmacies, and hospitals within the HMO's specific network of providers. There is coverage for emergency services regardless of the network status of the healthcare provider or facility.
Point of Service plans (POS): This type of HMO plan comes with an out-of-network option. At the point of service, the insured can choose whether to receive care from a healthcare provider within or outside the plan's network. The only issue is that health care expenses provided outside the network attract less coverage, a higher deductible, and coinsurance than expenses incurred within the network.
Exclusive Provider Organizations (EPOs): This is where insurers contract with hospitals or specific healthcare providers. Insured members can only receive benefits from this plan when they use the contracted hospitals or healthcare providers. Under the EPO plan, there is coverage for emergency services regardless of the network status of the medical provider or facility.
Traditional major medical plans: Covers hospitalization, serious illnesses, blood transfusion, drugs, injuries, and doctor visits. There are two types of traditional major medical coverage in Florida: individual and group health plans. To be eligible for traditional major medical coverage, you must be a U.S. citizen or national (or be lawfully resident) residing in the United States.
Limited benefits: These are health plans with reduced benefits intended to support comprehensive Health Insurance plans. Limited benefit health plans are designed for individuals who cannot afford comprehensive major health insurance.
For individual plans, Health Insurance is only available during the annual open enrollment period or a special enrollment period triggered by a qualifying event. There are 10 insurers and Health Maintenance Organizations (HMOs) in Florida that provide individual health plans to residents under the ACA. Individuals who just turned 26 years old, part-time workers, self-employed or unemployed, or are recent retirees are eligible for individual health insurance plans.
For group plans, there is no open enrollment period. Individuals can enroll anytime during the year if they are eligible. There are 14 insurers and Health Maintenance Organizations (HMOs) offering group plans to Florida residents under the Affordable Care Act. Businesses with at least one full-time equivalent employee and members of organizations are eligible for group health plans.
Florida law does not mandate residents to have Health Insurance in Florida. About 19% (approximately 4 million) of the Floridian adult population do not have Health Insurance. Statistics reveal that nearly 15% of Floridian adults are smokers, 19-20% suffer from poor health, over 27% (nearly 6 million) are obese, and nearly 11% have diabetes. Having Health Insurance would help individuals with any health conditions to cover their healthcare needs, provided the needs are within the limits of their Health Insurance plans. Florida health Insurance can be purchased:
Online through shopping sites like Health Insurance Marketplace
Through a licensed Florida Health Insurance agent in person or over the phone
Through membership association, union, or church
Directly from a Florida approved health insurance carrier
Through State-funded programs for low-income residents, including Florida Medicaid and Florida Children's Health Insurance Program (CHIP)
As part of parents' Health Insurance plan (this applies to individuals below 26 years old)
Through student plans offered by universities or colleges
In Florida, Individual Health Insurance covers one person or all family members under one policy. This type of insurance is for people who do not have employer-sponsored or government-run health coverage like Medicare, Medicaid, or CHIP. Self-employed individuals, family-only businesses, or people employed by a small business that doesn’t provide health benefits are eligible for this type of policy. Individual Health Insurance plans exclude dental treatment, self-inflicted injuries, alcohol or drug abuse, obesity treatment, infertility treatment, and cosmetic treatment. Instead, it covers:
Medical bills incurred by the insured when admitted to the hospital for more than 24 hours
Medical expenses incurred before admission and after leaving the hospital
Medical treatment received at home on the recommendation of a doctor
Medical emergency that involves the use of an ambulance
Individual Health Insurance premiums vary by insurance providers and are calculated based on age, occupation, and tobacco use. In Florida, an individual policy must include a grace period of 7 to 31 days based on the premium payment mode. It also comes with a 10-day free-look provision where insureds can return the policy and receive a full refund if they are not comfortable with it. This does not include the Individual Health Maintenance Organization (HMO). HMO plans must provide a minimum of 10 days grace period.
Alternative Health plans in Florida provide temporary and limited health care coverage for individuals. It is suitable for healthy individuals without pre-existing medical conditions and does not require regular health services or prescriptions. Alternative Health plans are majorly designed to meet emergency medical needs. They do not serve as a substitute for major Health Insurance plans. Instead, they are supposed to be a supplement because Alternative Health plans do not provide traditional major (ACA-compliant) medical coverage.
Short-term limited duration Health Insurance
Limited benefit plans
Direct primary care
Short-term Health Insurance is a temporary coverage that protects individuals from expensive medical bills due to emergency care. This type of insurance is right for individuals who are:
Changing jobs or waiting for health insurance benefits to begin at their new job
No longer enjoying employer-sponsored coverage
Unable to apply for the Affordable Care Act (ACA) because they missed Open Enrollment and do not qualify for Special Enrollment
Waiting for ACA compliant plans to start
Searching for coverage that can bridge them to Medicare
Turning 26 and no longer eligible to be part of their parent's insurance
Healthy and below 65 years old
Florida Short-term Limited Duration Health Insurance plans provide healthcare coverage for less than 12 months with the opportunity for renewals of up to three years. Note that there is no guaranteed renewal for Short-term plans. Hence, individuals whose health worsen during the policy may be unable to renew their insurance, or their health condition may be excluded from their policy when they renew it. Always check your Short-term Limited Duration Health Insurance plan details to learn more about exclusions or coverage of pre-existing conditions.
Short-term plans benefit individuals who do not need regular medical care like frequent doctor visits or expensive prescriptions. This plan may make you ineligible for any guaranteed issue individual health plans in Florida.
Limited Benefit health plans are medical plans with reduced premiums but fewer and more restricted benefits than major medical insurance. The Affordable Care Act (ACA) does not regulate these types of plans. Limited Benefit health plans are not designed to be a primary form of insurance but rather to supplement or support your current major Health Insurance plans. The most common policies providing Limited Benefits in Florida are:
Basic hospital expense: This type of limited insurance covers hospital confinement expenses. In Florida, coverage must be provided for a minimum of 31 days during any one period of confinement. Basic hospital policies cover:
Daily room and board costs: These policies vary by the amount payable daily and the duration the benefits are payable. For example, some policies pay in-hospital benefits for as long as a year, while others pay benefits for only 1 or 3 months. Some policies can offer a fixed rate approach where insureds are reimbursed for the daily room and board charge up to a specified limit. Others provide a reimbursement approach that involves paying an amount similar to the hospital's daily charge for a semi-private room.
Miscellaneous Expenses: Aside from room and board, basic hospital expense policies also cover extra hospital charges up to a specific dollar amount. This can include dressings, drugs, anesthesia, X-rays, lab fees, use of the operating room, and supplies.
Basic surgical expense: These policies cover the cost of surgery done by the insured regardless of where the surgery was performed (within or outside the hospital). Basic surgical expenses cover the fees of the surgeon, the anesthesiologist, and any postoperative care.
Specified disease plans: These are also known as critical illness, dreaded disease, and limited risk because they provide medical expense coverage for specific types of sicknesses. This plan comes into force only when the insured is diagnosed with certain illnesses covered under the policy, like cancer, heart disease, and Alzheimer's disease. In Florida, specified disease plans cannot have a higher deductible than $250. They must provide a benefit of at least $2,500 and a period of benefit of at least 24 months.
Hospital indemnity plans: A hospital indemnity (fixed-rate) policy provides periodic (daily, weekly or monthly) payment of a specific amount for each day the insured is hospitalized. Benefits are paid directly to the insured instead of the medical provider and may be used for any purpose. In Florida, a minimum benefit of $10 per day must be provided to the insured for a minimum of 31 days during any one period of confinement. No elimination period is allowed unless the benefit period is a year or more (for such, three days elimination period is permitted).
Florida Subscription Health plans are designed in such a way that patients will be required to pay fixed installment fees regularly (monthly, quarterly, or annually), which covers the visits and services provided by their doctor. The number of visits that can be scheduled may be limited. Patients who require any care, not within the Subscription Health plan coverage may have to pay out of their pockets.
Although Discount Health plans are less expensive than Health Insurance, they do not provide similar coverage as Health Insurance policies. Discount Health plans only give members reduced costs for medical services. Discount plans usually cover vision, hearing, or pharmaceutical services. Individuals must pay monthly fees to qualify for discounts within a network of doctors, dentists, hospitals, and pharmacies. The types of Discount Health plans available in Florida are Medical Discount Plans, Prescription Discount Plans, Dental Discount Plans, and Vision Discount Plans. Before joining any of these Discount Health plans, consider the following:
Terminating Health Insurance while purchasing a discount plan may affect your ability to get insurance later.
Plan providers can change without giving any prior notice to the members.
Some Discount Health plans include extra charges like administrative costs and fees.
Plan cancellation and refund policies may be limited. Hence, it is better to opt for a regular premium payment option than to pay all costs upfront.
The plans may not benefit you when you move or travel out of your locality.
Association Health Plans (AHPs) are Health Insurance plans designed for individuals with common interests. Plan members typically come from the same industry or profession. Some AHPs are set up by member-based associations, while others are set up by employers. The combined membership with AHPs allows employers to negotiate better terms with insurers to have comprehensive insurance policies at affordable prices.
Direct Primary Care (DPC) is a financial agreement between a doctor and a patient. The patient pays a fee periodically (monthly, quarterly, or annually) to the doctor in exchange for some basic medical care services. These services can include routine care, regular checkups, consultation, and preventive care.
Telehealth is when healthcare practitioners use synchronous (real-time information sharing) or asynchronous (relay of information with lag time) telecommunications technology to provide health care services to patients. These services include:
The assessment, diagnosis, consultation, treatment, and monitoring of a patient
Transfer of medical data
Patient and professional health-related education
Public health services
Health care services that require audio-only telephone calls, e-mail messages, or fax transmissions are excluded from Telehealth. Out-of-state Telehealth providers must be registered with the Florida Department of Health to perform Telehealth services for patients in Florida.
Group Health Insurance is typically common among employees or members of a company or organization. Group Health Insurance premiums are usually split between an employer and their employees, and coverage can even extend to employees’ family members or dependents. Group Health Insurance is cheaper than individual plans because it involves more people. To be eligible for Group Health Insurance in Florida, a business must:
Have at least one qualified full-time or full-time equivalent employee (someone who works at least 30 hours per week) other than the business owner or their spouse.
Be considered a legal business entity.
Businesses like sole proprietorships and family businesses with a spouse as the only employee do not qualify for Group Insurance plans. There are two types of Group Insurance plans in Florida:
Small Group Health plans: Cover employers with one to 50 full-time employees in Florida. Small Group Health plans cover all of the Affordable Care Act’s 10 essential health benefits (EHB) and exclude vision or dental care for adults.
Large Group Health plans: They are for employers or associations with 51 or more employees. They are not required to cover ACA’s essential health benefits.
Many Group Health Insurance carriers in the marketplace offer various coverage plans with different deductibles and copays. This makes shopping for Group Health Insurance a seemingly difficult task. However, shopping for Group Health Insurance is easier if you involve a Florida-licensed insurance agent. A state-licensed insurance agent can help you get quotes from different insurers and provide an affordable plan for your employee.
Commercial Health Insurance is a type of insurance coverage that is not provided by government agencies like Medicaid, Medicare, or the Florida Children's Health Insurance Program (CHIP). Instead, it is managed by nongovernmental private or public companies. It generally covers the insured's medical bills and disability income. Individuals and employers who want a group plan for their employees are eligible for Commercial Health Insurance. Commercial Health Insurance is typically divided into two categories:
Group health plans
Non-group health plans
Group health plans are usually offered by employers, while non-group health plans are purchased by individuals directly from the Florida Health Insurance marketplace carriers. The common types of Commercial Health Insurance in Florida are:
Health Maintenance Organizations (HMOs)
Preferred Provider Organizations (PPOs)
Point-of-Service (POS) plans
Health Reimbursement Accounts (HRAs)
Long Term Care (LTC) plans
Florida Disability Income (DI) Insurance provides income to people incapable of working due to a disability. This insurance policy pays wage replacement benefits to employees who are unable to work because of non-job-related accidents or illnesses that prevent them from meeting up with the demands of their occupations. These benefits tend to be tax-free. DI premiums are calculated based on age and occupation. For example, individuals who have high-risk jobs like construction should expect to pay higher premiums than those whose jobs have lower risks. The types of Disability Income Insurance available in Florida are:
Short-term disability: It provides coverage for periods where employees are absent from work (due to illnesses, accidents, or injuries) for a short period. The affected employee is expected to return to work after a few weeks, months, or a year. The waiting period of short-term disability policy benefits falls between zero and two weeks, and it may only be paid for a maximum of two years.
Long-term disability: It provides coverage for employees who have disabilities that would require them to spend a long time away from work. The waiting period for long-term disability benefits ranges from one week to several months.
Florida Workers' Compensation Insurance provides coverage for employee's job-related injuries. This type of insurance covers medical bills, disabilities, and death. In Florida, the Office of Insurance Regulation (OIR) regulates the rate, financial solvency, and forms of Workers' Compensation Insurance coverage. The Division of Workers' Compensation within the Department of Financial Services (DFS) is solely responsible for ensuring employees receive adequate benefits under this coverage. A typical Workers' Compensation Insurance does not cover:
Injuries sustained while an employee is not doing a work-related duty
Injuries sustained by employees due to:
Intentional acts or self-inflicted injuries
Company policy violation
Employers in Florida must purchase Workers' Compensation Insurance for their employees. Operating a business in Florida without this policy can lead to the issuance of a Stop-Work Order. This order requires that the business ends operations until it complies with Florida Insurance Law and pays a penalty. Several factors like industry and the number of employees determine the coverage requirements for specific employers. For instance:
Construction industry: Trades in the construction industry with one or more employees, including the business owner, are required to purchase Workers' Compensation Insurance for all employees.
Non-construction industry:Businesses with more than four employees in Florida must purchase Workers' Compensation Insurance coverage for their employees.
Agricultural industry: Agricultural businesses with a minimum of six regular workers and/or at least 12 seasonal workers must have Workers' Compensation Insurance.
Out-of-state employers: Their insurers must be aware that they are working in Florida. They may be required to obtain Florida Workers’ Compensation Insurance policies that meet the requirements of the Florida Insurance Code and Florida law.
Contractors: They must ensure that all subcontractors have the required Workers' Compensation Insurance before they commence work on a project. If not, the contractor will shoulder the responsibility for any work-related injuries sustained by the sub-contractors.
Sole proprietorships: This type of business is excluded from purchasing Workers' Compensation Insurance.
There are over 250 insurance providers that offer Workers' Compensation Insurance in Florida. This makes it easy for employers to compare quotes from multiple insurers to get the best policy at an affordable price. With a Workers' Compensation Insurance policy, employers will be protected against liability claims filed by employees due to job-related injuries. In Florida, the cost of Workers' Compensation Insurance is based on three factors:
The type of work performed by the employees
The individual employer's claims history
Employers are responsible for paying Workers' Compensation Insurance premiums and may be eligible for premium discounts. For instance, a 2% discount is usually given when employers provide a workplace safety program and a 5% discount for a drug-free workplace program.
Medicare is a federal program that subsidizes healthcare services for individuals 65 years old or older or specific young people with disabilities. About 2.4 million people in Florida are currently enjoying Medicare coverage. To be eligible for Health Insurance through Medicare, you must be a United States citizen or a legal resident who has lived in the country for a minimum of five years and fulfill at least one of the following:
Be 65 years of age
Have a disability based on the Social Security's definition of disability
Have amyotrophic lateral sclerosis (ALS)
Have end-stage renal disease (ESRD) (permanent kidney failure requiring dialysis or transplant)
Have worked and paid Medicare taxes for a minimum of 10 years
There are multiple Medicare plans options in Florida that residents can choose from. These plans are designed to help Floridians find the best health insurance coverage option that suits their lifestyles and medical needs. Medicare is divided into:
Original Medicare (Parts A and B): Original Medicare has two parts, which are Part A (Hospital Insurance) and Part B (Medical Insurance). Part A covers hospitalization, hospice care, inpatient care in a skilled nursing facility, and lab tests an individual has performed. Part B covers doctor's office visits and home health care services. It can also provide coverage for some preventive care services like screenings for cancers and mental illnesses, including depression. Original Medicare is a good choice for individuals who want flexibility in choosing and accessing Medicare providers anywhere in the United States.
Part C (Medicare Advantage): These plans are sold by Medicare-approved private insurers. They include Original Medicare coverage, excluding hospice care. Medicare Advantage offers additional coverage for important needs like prescription drugs, dental care, and vision care. It can also cover gym memberships and transportation to and from medical appointments. Medicare Advantage is a good choice for individuals who want to bundle health care and drug benefits in one plan and are okay with the restriction on the choice of providers to save on costs. There are four types of plans available in Florida's Medicare Advantage program:
Health maintenance organization (HMO)
Preferred provider organization (PPO)
Private fee-for-service (PFFS)
Special needs plan (SNP)
Part D (Prescription Drug): These plans are offered to all Medicare enrollees, but eligible individuals who wait to enroll may be penalized. All Part D plans may not cover the same drugs or have similar costs. Medicare-approved private insurers offer standalone Part D coverage, and most plans have deductibles and copay for each prescription drug. Part D is a good choice for individuals who have Original Medicare or Medicare Advantage Plan (excluding health maintenance organization (HMO) or preferred provider organization (PPO) that does not include prescription drug coverage).
Medicaid is a Health Insurance program funded by both state and federal governments that provides health coverage for a selected group of people (like pregnant women, children, seniors, and disabled adults) in the state that earn low wages. This type of policy aims to improve the health of individuals who cannot afford medical care for themselves and their kids. The Agency for Health Care Administration is responsible for administering Medicaid services in Florida. To qualify for Medicaid in Florida, you must be living in Florida and a U.S. national, citizen, permanent resident, or legal alien, requiring health care/insurance assistance, with low income. In addition, you must meet any of the following requirements:
Have an 18-year-old old or younger child
Have a disability or a family member with a disability
Be 65 years old or above
In Florida, individuals on Medicaid are enrolled in the Statewide Medicaid Managed Care program, which has three parts:
Managed Medical Assistance (MMA) plan: It covers medical services like hospital care, prescribed drugs, doctor visits, mental health care, and the cost of going for these services
Long-Term Care (LTC): It covers care in a nursing facility, assisted living, or at home. You must be at least 18 years old and meet the nursing home or hospital level of care to qualify for this plan
Dental plan: It covers dental services for children and adults and is compulsory for everyone on Medicaid
Medigap, also known as Medicare Supplement Insurance policy, covers medical coverage while overseas, Part A and Part B copays, and excess Part B charge. Medigap is designed to complement the benefits provided by an Original Medicare plan and not Medicare Advantage. Individuals cannot bundle a Medigap plan and a Medicare Advantage Plan. Medigap does not cover prescription drugs, dental care, and vision care. Individuals will be required to pay monthly premiums, and most copayments and coinsurance costs are covered. Medigap is a good choice for individuals who:
Have Original Medicare
Want help paying for out-of-pocket bills incurred when accessing Original Medicare benefits
Have significant health care needs
Want the freedom to see any Medicare provider without restrictions of network providers
Individuals with physical illnesses or disabilities often need help with activities of daily living (ADLs). Additionally, people with cognitive impairments usually need supervision, protection, or verbal reminders to do daily activities. Individuals with these impediments need skilled care and custodial care, making Long-term Care Insurance very important.
Long-term Care (LTC) Insurance provides services to assist individuals with chronic conditions to overcome limitations that make them dependent on others. With LTC, individuals' current level of functioning is maintained instead of improving or correcting their medical conditions. Long-term Care Insurance is designed to help pay for part or all of the individual's long-term care expenses. To be eligible for LTC, you must be unable to perform at least three of the following activities of daily living (ADLs):
Transferring (ability to move into or out of a bed, chair, or wheelchair)
Additional or stand-alone Health Insurance options are also called supplemental Health Insurance. They help to cover healthcare costs (like copayments, coinsurance, and deductibles) that are not covered by basic Health Insurance plans. The common types of supplemental Health Insurance in Florida are:
Long-term care insurance
Medicare supplemental plans
Accidental death and dismemberment insurance (AD&D)
Additional or Stand-alone Health Insurance plans are also available for specific conditions like cancer, stroke, or kidney failure. Some additional or stand-alone Health Insurance policies may cover food, medicine, transportation, and other expenses related to an illness or injury.
Below are some of the Health Insurance rights you have in Florida:
No insurer can deny your application because of pre-existing conditions.
Your premiums can not increase after enrollment solely due to health purposes.
You have a right to receive preventive care without costs from a doctor who participates in your health plans.
You have a right to stay on your parent's health plan if you are below 26 years old, even if you are married or living alone.
You have the right to receive a copy of the insurance policy or certificate governing your coverage.
You can appeal any denied claim.
Before purchasing any Health Insurance plan in Florida, ensure you verify the license of the agent and the insurance company. Also, take time to review your policy and understand your deductible and coinsurance provisions. Seek the help of a Florida-licensed Health Insurance agent to compare quotes from various insurance providers. If you need further information or you want to file an insurance complaint, contact the Florida Department of Financial Services (FL DFS) Division of Consumer Services via Consumer.Services@myfloridacfo.com, call (877) 693-5236, or online on the FL DFS website.