Florida's Health Insurance Plans Tailored to Our One-Size-Does-Not-Fit-All Populace

With daily reports of new information and proposed changes on comprehensive health- care insurance reform, it may be time to look at what is already available to Floridians. Florida is a large and diverse state, and one size does not fit all when it comes to health-care coverage and costs. The state of Florida and insurance carriers have recognized this and designed a wide array of group, individual, Medicaid, and Medicare health insurance plans to serve the needs of all. Listings of various plans and their health insurance carriers are available at www.floridahealthfinder.gov.

Group Plans

Businesses with one life or more have access to guaranteed issue group plans. The group plans for employers with less than 100 employees are available to businesses regardless of health claims experience. Carriers and benefit plans vary from county to county; some counties have regional HMO carriers that do excellent jobs in meeting the specific needs of the county population. The coverage for a one-life group (self-employed person with no other eligible employees) is only available for enrollment in August of each year for an effective date of October 1st.

While traditional health insurance and managed care plans are a major part of our health care system, the larger employer may elect a single employer, self-funded or partially self-funded plan. These plans fall under the guidelines of the federal Employee Retirement Income Security Act (ERISA).

Employers participating in a self-insured plan assume the financial risks, rather than transferring the risk to an insurance carrier. The employer pays the covered claims filed by the employees as specified in the plan. The employer generally hires a third party administrator to administer the plan; however, the employer is responsible for the claims.

Individual Plans

There are many reasons why a client may choose an individual plan, whether it is coverage for one person or all members of a family. Many buy these plans because an insurance plan may not be available through their employer, they want to supplement their current coverage, they are unemployed, or they have a life style change such as a death or divorce. Some insurance carriers offer individual plans on a county-by-county basis and usually include an HMO, PPO or HSA. While all individual plans are medically underwritten and an applicant may be rejected, the underwriting has become simpler and easier to complete.

If a client is not medically eligible for an individual plan and does not qualify for a group plan, an alternative resource is the Cover Florida Health Access Program. The Cover Florida plans are available to Floridians between the ages of 19-64 who have been without health insurance for six months and may have pre-existing health conditions. Coverage is available in all 67 counties. More information on Cover Florida is available at www.coverfloridaheathcare.com

Coverage for Children, Medicaid

Florida has three health-care programs for children through Florida KidCare: Medikids for children ages 1-4; Healthy Kids for children 5-18; and Medicaid for children birth-18 for families. Also, Children's Medical Services Network is a program for children from birth to age 18 who have special medical needs.

The eligibility for Florida KidCare depends primarily on household size and family income. Coverage is offered for any child in Florida through the full-pay option for families who are over-income for the MediKids and Healthy Kids programs. Subsidized coverage is offered for child up to 200 percent of the federal poverty level. More information on Florida Kidcare is available at www.floridakidcare.org

Medicare Plans and Supplements

The Centers for Medicare and Medicaid (CMS) is part of the U.S. Department of Health and Human Services; 46 contractors administer the Medicare program. Originally the Medicare program had two parts — A & B — known as the hospital insurance program and the medical insurance program. Today, Medicare also has Part C and Part D. Part C is the Medicare Advantage or managed care plans, and Part D is the prescription drug benefits program. These plans are offered by private insurance companies and approved by Medicare.

Medicare supplements are available to offset deductibles and out-of-pocket expenses not covered by Medicare Parts A & B. The plans E-J vary in pricing by county, but are standardized in the benefits offered.

Offering Medicare to potential clients is a detailed, time-consuming process. Because of the rules, reporting, and enrollment processes involved, many carriers require that agents representing their products obtain special training and certifications.

Timelines, materials and guidelines are strictly enforced by CMS. On October 1, approved marketing may begin. The annual election period is November 15-December 31. New plan or continuation of current plan enrollment starts January 1. Medicare Advantage Open Enrollment is January 1-March 31. During open enrollment, enrollees may join a new plan, switch plans, or return to original Medicare. Changes made during this period will be effective the first day of the month after the plan gets the person's enrollment form. This enrollment time may be used to switch to a different type of Medicare plan, but it cannot be used to change whether or not a person is enrolled in Medicare prescription drug coverage. April 1 is the lock-in date — whichever plan the person has elected is locked in for the rest of the year. More information on Medicare is available at www.medicare.gov.

Kimberly Auclair of Pineapple Financial Services, LLC, in Melbourne, also is president-elect of the Florida Association of Health Underwriters. She may be reached at 321-259-8088 or knvauclair@bellsouth.net.