Self-Employed Florida Health Insurance Plans

In Addition to Major Medical Plans, There Are Self-Employed Plans.

Traditional health insurance and managed-care plans form major parts of the American health care system. However, employers may select an alternative to cover health expenses and meet employees' needs. This is known as a single-employer plan.

Single-employer plans

These plans fall under the guidelines of the federal Employee Retirement Income Security Act (ERISA). Employers establish these plans to provide health care and/or other employment benefits to employees, their families and dependents. An insurance carrier may fully insure a plan of this type or the employer may opt for self-insurance.

Employers participating in a self-insured plan assume the financial risks involved, rather than transferring this risk to an insurance carrier. The employer pays for claims filed by employees covered by the plan. Your employer might hire an insurance company to administer the plan, but this company does not take responsibility for paying claims. DFS does not regulate self-insured, single-employer plans. In addition, the Florida Guaranty Fund, which pays losses to policyholders when certain insurance companies become insolvent, does not cover such plans.

An insurance company's name or logo may appear on the forms and paperwork you receive from your single-employer, but this should not fool you. Many of these plans hire an insurance company to handle paperwork. The insurance company acts as a third-party administrator, but does not assume any legal obligation to pay claims.

You should determine whether your coverage comes from a self-insured plan. An insurance company may appear to underwrite a plan without actually doing so. You should also check the history of the group offering the plan, and talk to current members to see if they have experienced any trouble getting claims paid.

Facts to Consider

Group and individual health insurance plans usually offer coverage for family members. Family policies generally pay benefits for your spouse and your dependent children up to the age specified in the policy. However, your insurance company cannot terminate coverage for dependent children who lack other means of support due to mental or physical handicaps. Both group and individual plans may include several kinds of coverage, such as "hospital," "medical/surgical" and "major medical."

Consumer Alert

By statute, applications for medical coverage not governed by Florida law must contain a disclosure statement in contrasting color near the signature block declaring what state governs the coverage and the ramifications of not purchasing coverage governed by Florida's consumer protections. Furthermore, certificates issued under a policy approved by another state must contain the following statement, generally found on the front page: "The benefits of the policy providing your coverage are governed primarily by the laws of a state other than Florida." These disclosures should prompt you to ask further questions about the laws governing this coverage and the resulting suitability of this coverage for your needs.