Senate Bill 1638
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Florida Senate - 1998 SB 1638
By Senator Campbell
33-336A-98
1 A bill to be entitled
2 An act relating to health care; amending ss.
3 408.706, 627.419, F.S.; creating s. 641.3151,
4 F.S.; deleting provisions governing recruitment
5 and retention of health care providers in a
6 community health purchasing alliance district;
7 providing free choice to subscribers to certain
8 health care plans, and to persons covered under
9 certain health insurance policies or contracts,
10 in the selection of specified health care
11 providers; prohibiting coercion of provider
12 selection; specifying conditions under which
13 any health care provider must be permitted to
14 provide services under a health care plan or
15 health insurance policy or contract; amending
16 s. 627.6577, F.S.; creating ss. 636.0165,
17 641.3155, F.S.; providing for freedom of choice
18 for dental patients; providing limitations;
19 providing for civil penalties; providing
20 applicability; creating the "Access to
21 Emergency Medical Services Act"; providing
22 findings and purpose; requiring a health plan
23 that provides coverage for emergency services
24 to cover emergency services furnished to an
25 enrollee under specified circumstances;
26 requiring the health plan to promptly pay for
27 services; prohibiting a health plan from
28 imposing certain types of cost-sharing;
29 providing that a health plan may impose a
30 reasonable copayment; providing requirements
31 for a health plan with respect to providing
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1 prior authorization; specifying circumstances
2 under which a health plan is deemed to have
3 approved a request for prior authorization for
4 certain services; prohibiting a health plan
5 from subsequently denying or reducing payment
6 for items or services; requiring that a health
7 plan include certain information in educational
8 materials; providing civil penalties; requiring
9 that the Director of Health Care Administration
10 take certain factors into consideration in
11 imposing a civil penalty; requiring the Agency
12 for Health Care Administration to adopt rules;
13 providing definitions; repealing s. 641.513,
14 F.S., relating to requirements for providing
15 emergency services and care; providing an
16 effective date.
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18 Be It Enacted by the Legislature of the State of Florida:
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20 Section 1. Subsection (11) of section 408.706, Florida
21 Statutes, is amended to read:
22 408.706 Community health purchasing alliances;
23 accountable health partnerships.--
24 (11)(a) Notwithstanding any other provision of law to
25 the contrary, any subscriber to a health plan offered by or
26 through a health maintenance organization, managed care
27 organization, prepaid health plan, or accountable health
28 partnership is entitled at all times to free, full, and
29 absolute choice in the selection of a provider or facility
30 licensed or permitted under chapter 458, chapter 459, chapter
31 460, chapter 461, chapter 463, chapter 465, or chapter 466.
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1 It is expressly forbidden for any health plan to contain any
2 provision that would require or coerce a subscriber to the
3 plan to use any provider other than the provider selected by
4 the subscriber. Health maintenance organizations, managed
5 care provider organizations, prepaid health plans, and
6 accountable health partnerships must allow any health care
7 provider to participate as a service provider under a health
8 plan offered by the health maintenance organization, managed
9 care organization, prepaid health plan, or accountable health
10 partnership, if the health care provider agrees to:
11 1. Accept the reimbursement rates negotiated by the
12 health maintenance organization, managed care provider
13 organization, prepaid health plan, or accountable health
14 partnership with other health care providers that provide the
15 same service under the health plan; and
16 2. Comply with all guidelines relating to quality of
17 care and utilization criteria which must be met by other
18 employee or nonemployee providers.
19 (b) A health maintenance organization, managed care
20 provider organization, prepaid health plan, or accountable
21 health partnership that violates paragraph (a) is subject to a
22 civil fine in the amount of:
23 1. Up to $25,000 for each violation, or
24 2. If the Director of the Agency for Health Care
25 Administration determines that the entity has engaged in a
26 pattern of violations of paragraph (a), up to $100,000 for
27 each violation. The ability to recruit and retain alliance
28 district health care providers in its provider network. For
29 provider networks initially formed in an alliance district
30 after July 1, 1993, an accountable health partnership shall
31 make offers as to provider participation in its provider
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1 network to relevant alliance district health care providers
2 for at least 60 percent of the available provider positions. A
3 provider who is made an offer may participate in an
4 accountable health partnership as long as the provider abides
5 by the terms and conditions of the provider network contract,
6 provides services at a rate or price equal to the rate or
7 price negotiated by the accountable health partnership, and
8 meets all of the accountable health partnership's
9 qualifications for participation in its provider networks
10 including, but not limited to, network adequacy criteria. For
11 purposes of this subsection, "alliance district health care
12 provider" means a health care provider who is licensed under
13 chapter 458, chapter 459, chapter 460, chapter 461, chapter
14 464, or chapter 465 who has practiced in Florida for more than
15 1 year within the alliance district served by the accountable
16 health partnership.
17 Section 2. Subsection (9) is added to section 627.419,
18 Florida Statutes, to read:
19 627.419 Construction of policies.--
20 (9)(a) Notwithstanding any other provision of law to
21 the contrary, any person covered under any health insurance
22 policy, health care services plan, or other contract that
23 provides for payment for medical expense benefits or
24 procedures is entitled at all times to free, full, and
25 absolute choice in the selection of a provider or facility
26 licensed or permitted under chapter 458, chapter 459, chapter
27 460, chapter 461, chapter 463, chapter 465, or chapter 466.
28 It is expressly forbidden for any health plan to contain any
29 provision that would require or coerce a person covered by the
30 plan to use any provider other than the provider selected by
31 the subscriber. Any health insurance policy, health care
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1 services plan, or other contract that provides for payment for
2 medical expense benefits or procedures must allow any health
3 care provider to participate as a service provider under a
4 health plan offered by the health insurance policy, health
5 care services plan, or other contract that provides for
6 payment for medical expense benefits or procedures, if the
7 health care provider agrees to:
8 1. Accept the reimbursement rates negotiated by the
9 health insurance policy, health care services plan, or other
10 contract that provides for payment for medical expense
11 benefits or procedures with other health care providers that
12 provide the same service under the health plan; and
13 2. Comply with all guidelines relating to quality of
14 care and utilization criteria which must be met by other
15 providers with whom the health insurance policy, health care
16 services plan, or other contract that provides for payment for
17 medical expense benefits or procedures has contractual
18 arrangements for those services.
19 (b) The provider of any health insurance policy,
20 health care services plan, or other contract that violates
21 paragraph (a) is subject to a civil fine in the amount of:
22 1. Up to $25,000 for each violation, or
23 2. If the Insurance Commissioner determines that the
24 provider has engaged in a pattern of violations of paragraph
25 (a), up to $100,000 for each violation.
26 Section 3. Section 641.3151, Florida Statutes, is
27 created to read:
28 641.3151 Subscriber freedom of choice.--
29 (1) Notwithstanding any other provision of law to the
30 contrary, any subscriber to a health plan offered by or
31 through a health maintenance organization or managed care
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1 organization is entitled at all times to free, full, and
2 absolute choice in the selection of a provider or facility
3 licensed or permitted under chapter 458, chapter 459, chapter
4 460, chapter 461, chapter 463, chapter 465, or chapter 466. It
5 is expressly forbidden for any health plan to contain any
6 provision that would require or coerce a subscriber to the
7 plan to use any provider other than the provider selected by
8 the subscriber. Health maintenance organizations and managed
9 care provider organizations must allow any health care
10 provider to participate as a service provider under a health
11 plan offered by the health maintenance organization or managed
12 care organization, if the health care provider agrees to:
13 (a) Accept the reimbursement rates negotiated by the
14 health maintenance organization or managed care provider
15 organization with other health care providers that provide the
16 same service under the health plan; and
17 (b) Comply with all guidelines relating to quality of
18 care and utilization criteria which must be met by other
19 employee or nonemployee providers.
20 Section 4. Section 627.6577, Florida Statutes, is
21 amended to read:
22 (Substantial rewording of section. See
23 s. 627.6577, F.S., for present text.)
24 627.6577 Freedom of choice for dental patients.--
25 (1) A dental insurance policy that is delivered,
26 renewed, or issued for delivery, or otherwise contracted for
27 in this state by a health insurer or dental service plan
28 corporation may not:
29 (a) Prohibit any person who is a party to or
30 beneficiary of the policy from selecting the dentist of his or
31 her choice, nor interfere with such selection.
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1 (b) Deny any dentist the right to participate as a
2 contracting provider for the policy or plan if the dentist
3 agrees to comply with the terms set forth in the insurer's
4 standard provider document and to accept the corresponding
5 reimbursement rates applicable to the provider document.
6 (2) An insurer dental service plan corporation must
7 make payment or reimbursement to a noncontracting provider
8 dentist in the same amounts and according to the same
9 procedures as the insurer makes payment or reimbursement to a
10 contracting dentist for the same services.
11 (3) A health insurer or dental service plan
12 corporation that violates subsection (1) or subsection (2) is
13 subject to a civil fine in the amount of:
14 (a) Up to $25,000 for each violation, or
15 (b) If the Insurance Commissioner determines that the
16 provider has engaged in a pattern of violations of subsection
17 (1) or subsection (2), up to $100,000 for each violation.
18 Section 5. Section 636.0165, Florida Statutes, is
19 created to read:
20 636.0165 Freedom of choice for dental patients.--
21 (1) A dental insurance policy that is delivered,
22 renewed, or issued for delivery, or otherwise contracted for
23 in this state by a health insurer or dental service plan
24 corporation may not:
25 (a) Prohibit any person who is a party to or
26 beneficiary of such policy from selecting the dentist of his
27 or her choice, nor interfere with such selection.
28 (b) Deny any dentist the right to participate as a
29 contracting provider for such policy or plan if the dentist
30 agrees to comply with the terms set forth in the insurer's
31 standard provider document and agrees to accept the
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1 corresponding reimbursement rates applicable to the provider
2 document.
3 (2) A prepaid limited health services organization
4 must make payment or reimbursement to a noncontracting
5 provider dentist in the same amounts and according to the same
6 procedures as the insurer makes payment or reimbursement to a
7 contracting dentist for the same services.
8 (3) A health insurer or dental service plan
9 corporation that violates subsection (1) or subsection (2) is
10 subject to a civil fine in the amount of:
11 (a) Up to $25,000 for each violation, or
12 (b) If the Insurance Commissioner determines that the
13 provider has engaged in a pattern of violations of subsection
14 (1) or subsection (2), up to $100,000 for each violation.
15 Section 6. Section 641.3155, Florida Statutes, is
16 created to read:
17 641.3155 Freedom of choice for dental patients.--
18 (1) A dental insurance policy that is delivered,
19 renewed, or issued for delivery, or otherwise contracted for
20 in this state by a health insurer or dental service plan
21 corporation may not:
22 (a) Prohibit any person who is a party to or
23 beneficiary of such policy from selecting the dentist of his
24 or her choice, nor interfere with such selection.
25 (b) Deny any dentist the right to participate as a
26 contracting provider for the policy or plan if the dentist
27 agrees to comply with the terms set forth in the insurer's
28 standard provider document and to accept the corresponding
29 reimbursement rates applicable to the provider document.
30 (2) A health maintenance organization or managed care
31 organization must make payment or reimbursement to a
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1 noncontracting provider dentist in the same amounts and
2 according to the same procedures as the insurer makes payment
3 or reimbursement to a contracting dentist for the same
4 services.
5 Section 7. This act does not apply to any health
6 insurance policy that is in force before the effective date of
7 this act but does apply to each such policy commencing with
8 its next renewal period immediately following the effective
9 date of this act.
10 Section 8. (1) SHORT TITLE.--This section may be
11 cited as the "Access to Emergency Medical Services Act."
12 (2) FINDINGS; PURPOSE.--
13 (a)1. State law requires emergency physicians and
14 other providers to evaluate, treat, and stabilize any
15 individual who seeks treatment in a hospital emergency
16 department.
17 2. An emergency physician is specifically prohibited
18 from delaying any treatment needed to evaluate or stabilize an
19 individual in order to determine the status of the
20 individual's health insurance.
21 3. Many health plans routinely deny payment for
22 required emergency services furnished to their enrollees,
23 basing such denials on:
24 a. Failure to obtain prior approval for such services
25 from the plan; or
26 b. An after-the-fact determination that the medical
27 condition identified through the required evaluation was not
28 an emergency medical condition.
29 4. Such denials by health plans impose significant
30 financial burdens on:
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1 a. Enrollees who, based on symptoms that reasonably
2 suggest a medical emergency, prudently seek care in a hospital
3 emergency department; and
4 b. Emergency physicians, the hospital emergency
5 departments, and others who furnish emergency services to
6 enrollees.
7 5. These burdens discourage enrollees from seeking
8 emergency care in cases where it is appropriate and,
9 ultimately, threaten the financial livelihood of hospital
10 emergency departments that provide emergency services to the
11 entire population, including beneficiaries of the Medicare and
12 Medicaid programs and of other health care programs.
13 6. Health plans have engaged in practices that
14 discourage the appropriate use of the 911 emergency telephone
15 number and that adversely impact the health of enrollees.
16 (b) The purpose of this section is to:
17 1. Require health plans to cover and pay for their
18 fair share for emergency services that hospital emergency
19 departments are required to provide.
20 2. Protect health plan enrollees by establishing a
21 uniform definition of the term "emergency medical condition,"
22 which is based on the average knowledge of a prudent
23 layperson.
24 3. Prohibit health plans from requiring prior approval
25 for required emergency services.
26 4. Assure that health plans promote the appropriate
27 use of the 911 emergency telephone number.
28 (3) EQUITABLE HEALTH PLAN COVERAGE WITH RESPECT TO
29 EMERGENCY SERVICES.--
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1 (a) A health plan that provides any coverage with
2 respect to emergency services must cover emergency services
3 furnished to an enrollee of the plan without regard to:
4 1. Whether or not the provider that furnishes the
5 emergency services has a contractual or other arrangement with
6 the plan for the provision of such services to the enrollee;
7 and
8 2. Prior authorization.
9 (b)1. A health plan that provides any coverage with
10 respect to emergency services:
11 a. Shall determine and make prompt payment in a
12 reasonable and appropriate amount for such services.
13 b. Except as provided in subparagraph 2., may not
14 impose cost-sharing for services furnished in a hospital
15 emergency department which is calculated in a manner that
16 imposes a greater percentage of cost-sharing with respect to
17 such services when compared to comparable services furnished
18 in other settings.
19 2. A health plan may impose a reasonable copayment in
20 lieu of coinsurance to deter inappropriate use of services of
21 a hospital emergency department.
22 (c)1. If an enrollee of a health plan receives
23 emergency services from an emergency department pursuant to a
24 screening evaluation conducted by a treating physician or
25 other emergency department personnel and, pursuant to the
26 evaluation by such physician or personnel, identifies items
27 and services, other than emergency services, promptly needed
28 by the enrollee, the health plan shall provide access 24 hours
29 a day, 7 days a week, to such persons as are authorized to
30 make any prior authorization determinations with respect to
31 coverage of such promptly needed items and services.
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1 2. A health plan is deemed to have approved a request
2 for a prior authorization for such promptly needed items and
3 services if the physician or other personnel:
4 a. Has attempted to contact such a person for
5 authorization to provide:
6 (I) An appropriate referral for the items and
7 services; or
8 (II) The items and services or access to the person
9 has not been provided, as required under subparagraph 1.; or
10 b. Has requested such authorization and the
11 authorization is not denied within 30 minutes after the time
12 the request was made.
13 3. If a physician or, in the case of a managed care
14 plan, a participating physician or other person authorized to
15 make prior authorization determinations for the plan, refers
16 an enrollee to a hospital emergency department for evaluation
17 or treatment, a request for prior authorization of the items
18 and services reasonably furnished the enrollee pursuant to
19 such referral shall be deemed to have been made and approved.
20 4.a. Approval of a request for a prior authorization
21 determination, including a deemed approval under subparagraph
22 2. or subparagraph 3., shall be treated as approval of any
23 health care items and services required to treat the medical
24 condition identified pursuant to a screening evaluation under
25 subparagraph 1.
26 b. A health plan may not subsequently deny or reduce
27 payment for an item or service furnished pursuant to such an
28 approval unless the approval was based on fraudulent
29 information about the medical condition of an enrollee.
30 (d) A health plan:
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1 1. Must include, in any educational materials the plan
2 makes available to its enrollees on the procedures for
3 obtaining emergency services:
4 a. A statement that it is appropriate for an enrollee
5 to use the 911 emergency telephone number for an emergency
6 medical condition; and
7 b. An explanation of what constitutes an emergency
8 medical condition.
9 2. May not discourage appropriate use of the 911
10 emergency telephone number by an enrollee with an emergency
11 medical condition.
12 3. May not deny coverage or payment for an item or
13 service solely on the basis that an enrollee used the 911
14 emergency telephone number to summon treatment for an
15 emergency medical condition.
16 (4) ENFORCEMENT.--
17 (a) A health plan that violates a requirement of
18 subsection (3) is subject to a civil penalty of not more than
19 the greater of:
20 1. Ten thousand dollars for each such violation.
21 2. Three times the amount that the health plan would
22 have paid for items and services if the plan had not violated
23 subsection (3).
24 3. In the case of a pattern of repeated and
25 substantial violations, $1 million.
26 (b) In determining the amount of any civil penalty
27 under this section, the Director of Health Care Administration
28 shall take into account whether a health plan has taken
29 corrective action, such as:
30 1. Paying for items and services for which coverage or
31 payment has been denied in violation of subsection (3); or
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1 2. Establishing policies and procedures to prevent the
2 same type of violation from occurring in the future.
3 (c) The Director of Health Care Administration may,
4 out of any civil penalty collected under this section, pay an
5 enrollee or provider, as appropriate, an amount equal to the
6 amount the health plan would have paid for an item or service,
7 if any, if the plan had not denied coverage or payment for
8 such item or service in violation of subsection (3).
9 (d) For purposes of paragraph (a), the Director of
10 Health Care Administration shall consider at least the
11 following acts or omissions as violations of subsection (3).
12 1. Failing to cover emergency services in violation of
13 paragraph (3)(a).
14 2. Failing to provide for payment for emergency
15 services in violation of sub-subparagraph (3)(b)1.a.
16 3. Imposing cost-sharing in violation of
17 sub-subparagraph (3)(b)1.b.
18 4. Failing to provide access to prior authorization
19 determinations in violation of subparagraph (3)(c)1.
20 5. Failing to pay for services that are deemed to be
21 approved under subparagraph (3)(c)2.
22 6. Failing to include educational materials as
23 required by subparagraph (3)(d)1.
24 7. Discouraging the appropriate use of the 911
25 emergency telephone number, or denying payment if the enrollee
26 uses the 911 emergency telephone number, in violation of
27 subparagraph (3)(d)2., or subparagraph (3)(d)3.
28 (5) RULES.--The Agency for Health Care Administration
29 shall adopt rules to administer this section.
30 (6) DEFINITIONS.--As used in this section, the term:
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1 (a) "Cost-sharing" means any deductible, coinsurance
2 amount, copayment, or other out-of-pocket payment that an
3 enrollee is responsible for paying with respect to a health
4 care item or service covered under a health plan.
5 (b) "Emergency department" includes a trauma center.
6 (c) "Emergency medical condition" means a medical
7 condition, the onset of which is sudden, which manifests
8 itself by symptoms of sufficient severity, including severe
9 pain, which a prudent layperson, who possesses an average
10 knowledge of health and medicine, could reasonably expect that
11 the absence of immediate medical attention would result in:
12 1. Placing the person's health in serious jeopardy.
13 2. Serious impairment to bodily functions.
14 3. Serious dysfunction of any bodily organ or part.
15 (d) "Emergency services" means:
16 1. Health care items and services furnished in the
17 emergency department of a hospital; and
18 2. Ancillary services routinely available to such
19 department,
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21 to the extent that the items and services are required to
22 evaluate and treat an emergency medical condition until the
23 condition is stabilized.
24 (e) "Enrollee" means an individual enrolled with a
25 health plan.
26 (f) "Health plan" means any plan or arrangement that
27 provides, or pays the cost of, health benefits, whether
28 through insurance, reimbursement, or otherwise. The term does
29 not include:
30 1. Coverage only for accidental death or
31 dismemberment.
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1 2. Coverage that provides wages or payments in lieu of
2 wages for any period during which the employee is absent from
3 work due to sickness or injury.
4 3. A Medicare supplemental policy, as defined in
5 section 1882(g)(1) of the Social Security Act.
6 4. Coverage issued as a supplement to liability
7 insurance.
8 5. Workers' compensation or similar insurance.
9 6. Automobile medical-payment insurance.
10 7. Coverage for a specified disease or illness.
11 8. A long-term care policy.
12 9. A federally funded health care program, unless such
13 a program contracts with a health plan to provide items and
14 services to individuals eligible for benefits under the
15 program.
16 (g) "Managed care plan" means a health plan that
17 provides or arranges for the provision of health care items
18 and services to enrollees primarily through participating
19 physicians and providers.
20 (h) "Participating" means, with respect to a physician
21 or provider, a physician or provider that furnishes health
22 care items and services to enrollees of a managed care plan
23 under an agreement with the plan.
24 (i) "Prior authorization determination" means a
25 determination, before the provision of the items and services
26 and as a condition of coverage of the items and services under
27 the plan, that coverage will be provided for the items and
28 services under the plan.
29 (j) "Stabilized" means that no material deterioration
30 of an emergency medical condition is likely, within reasonable
31 medical probability, to result or occur before an individual
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1 can be transferred in compliance with the requirements of
2 section 1867 of the Social Security Act.
3 (k) "911 emergency telephone number" includes, in the
4 case of a geographic area where 911 is not in use for
5 emergencies, any other telephone number that is in use for
6 emergencies.
7 Section 9. Section 641.513, Florida Statutes, as
8 created by section 33 of chapter 96-199, Laws of Florida, and
9 section 9 of chapter 96-223, Laws of Florida, is repealed.
10 Section 10. This act shall take effect October 1,
11 1998.
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2 SENATE SUMMARY
3 Repeals current provisions governing the recruitment and
retention of health care providers in a community health
4 purchasing alliance district. Provides that subscribers
to a health plan offered through a health maintenance
5 organization, managed care organization, prepaid health
plan, or accountable health partnership, and persons
6 covered under a health insurance policy or contract, are
entitled to free, full, and absolute choice of providers
7 offering physician, chiropractic, podiatry, optometry,
pharmacy, or dental services, and prohibits coercion or
8 coercive requirements relating to subscriber selection.
Provides that such service providers must be permitted to
9 offer services under the health plan of a health
maintenance organization, managed care organization,
10 prepaid health plan, or accountable health partnership,
or under the health insurance policy or contract, if they
11 agree to the negotiated reimbursement rates and comply
with certain guidelines relating to quality of care and
12 utilization. Prohibits dental insurance policies from
restricting a subscriber's choice or refusing payment to
13 noncontracting dental service providers who meet certain
requirements. Provides for civil fines for violations.
14
15 Creates the "Access to Emergency Medical Services Act."
Requires that if a health plan provides coverage for
16 emergency services, the health plan must pay for
emergency services without regard to whether the health
17 plan has a contract with the provider that furnished the
emergency services and without regard to prior
18 authorization. Authorizes a health plan to impose a
copayment for emergency services. Requires that a health
19 plan inform enrollees of the appropriate use of the 911
emergency telephone number and what constitutes an
20 emergency medical condition. Provides for civil penalties
to be imposed for violation of the act. Requires the
21 Agency for Health Care Administration to adopt rules to
administer the act.
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