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Health Insurance Mandates
State 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
Autism Spectrum
Disorders
Description
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.
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
“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 Mandates
Bone Marrow Transplant
Procedures
Policies 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)
Cleft Lip/Cleft Palate
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.
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
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Health Insurance Mandates
benefits.
Dental 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
Enteral Formulas
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.
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
Jaw or Facial Procedures
Mammograms
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.
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.
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
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Health Insurance Mandates
based on the patient's physician's recommendation;

A mammogram every year for any woman who is 50 years of age
or older; and

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.
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Health Insurance Mandates
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,
outpatient 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
Out-of-Hospital Benefits
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.
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
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Health Insurance Mandates
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.
Reimbursement 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
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Health Insurance Mandates
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
Provider
Under the home health services benefit mandate, services may be
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, NurseMidwives 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 CourtOrdered 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.
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Health Insurance Mandates
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 fulltime 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:
Continuation Coverage

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.
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
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Health Insurance Mandates
date of termination of employment.
Conversion

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
offered 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.
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:
Handicapped Children
Newborn Children

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.
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.
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
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Health Insurance Mandates
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.
Additional Resources:
Florida statutes
Florida Office of Insurance Regulation
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