House Bill hb0589

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    Florida House of Representatives - 2002                 HB 589

        By Representative Murman






  1                      A bill to be entitled

  2         An act relating to health care; amending s.

  3         395.002, F.S.; revising definitions relating to

  4         emergency services and care provided by

  5         hospitals and related facilities; amending s.

  6         395.1041, F.S.; revising provisions relating to

  7         hospital service capability and access to

  8         emergency services and care; directing the

  9         Agency for Health Care Administration to

10         convene a workgroup to report to the

11         Legislature regarding hospital service

12         capability requirements; creating s. 395.1042,

13         F.S.; establishing a program under the agency

14         to reimburse health care facilities and

15         practitioners for the cost of uncompensated

16         emergency services and care; amending ss.

17         383.50, 394.4787, 395.602, 395.701, 400.051,

18         409.905, 468.505, and 812.014, F.S.; correcting

19         cross references; amending s. 401.23, F.S.;

20         revising definitions relating to emergency

21         medical transportation services; amending s.

22         409.901, F.S.; revising definitions relating to

23         emergency services and care for purposes of

24         Medicaid coverage; amending s. 409.9128, F.S.;

25         revising requirements for providing emergency

26         services and care under Medicaid managed care

27         plans and MediPass; creating s. 627.6053, F.S.;

28         providing requirements for health insurance

29         policy coverage of hospital emergency services

30         and care; amending ss. 641.19, 641.47, and

31         641.513, F.S.; revising definitions and

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  1         requirements relating to the provision of

  2         emergency services and care by health

  3         maintenance organizations and prepaid health

  4         clinics; providing an appropriation; providing

  5         an effective date.

  6

  7  Be It Enacted by the Legislature of the State of Florida:

  8

  9         Section 1.  Subsection (4) of section 383.50, Florida

10  Statutes, is amended to read:

11         383.50  Treatment of abandoned newborn infant.--

12         (4)  Each hospital of this state subject to s. 395.1041

13  shall, and any other hospital may, admit and provide all

14  necessary emergency services and care, as defined in s.

15  395.002(11)(10), to any newborn infant left with the hospital

16  in accordance with this section. The hospital or any of its

17  licensed health care professionals shall consider these

18  actions as implied consent for treatment, and a hospital

19  accepting physical custody of a newborn infant has implied

20  consent to perform all necessary emergency services and care.

21  The hospital or any of its licensed health care professionals

22  is immune from criminal or civil liability for acting in good

23  faith in accordance with this section. Nothing in this

24  subsection limits liability for negligence.

25         Section 2.  Subsection (7) of section 394.4787, Florida

26  Statutes, is amended to read:

27         394.4787  Definitions; ss. 394.4786, 394.4787,

28  394.4788, and 394.4789.--As used in this section and ss.

29  394.4786, 394.4788, and 394.4789:

30

31

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  1         (7)  "Specialty psychiatric hospital" means a hospital

  2  licensed by the agency pursuant to s. 395.002(31)(29) as a

  3  specialty psychiatric hospital.

  4         Section 3.  Present subsections (9), (10), (26), and

  5  (30) of section 395.002, Florida Statutes, are amended,

  6  present subsections (10) through (21) and (22) through (33)

  7  are renumbered as subsections (11) through (22) and (24)

  8  through (35), respectively, and new subsections (10) and (23)

  9  are added to said section, to read:

10         395.002  Definitions.--As used in this chapter:

11         (9)  "Emergency medical condition" means:

12         (a)  A medical condition manifesting itself by acute

13  symptoms of sufficient severity, which may include severe

14  pain, psychiatric disturbances, symptoms of substance abuse,

15  or other acute symptoms, such that the absence of immediate

16  medical attention could reasonably be expected to result in

17  any of the following:

18         1.  Serious jeopardy to patient health, including a

19  pregnant woman or fetus.

20         2.  Serious impairment to bodily functions.

21         3.  Serious dysfunction of any bodily organ or part.

22         (b)  With respect to a pregnant woman:

23         1.  That there is inadequate time to effect safe

24  transfer to another hospital prior to delivery;

25         2.  That a transfer may pose a threat to the health and

26  safety of the patient or fetus; or

27         3.  That there is evidence of the onset and persistence

28  of uterine contractions or rupture of the membranes.

29         (c)  With respect to a person exhibiting acute

30  psychiatric disturbance or substance abuse, or taken into

31  custody and delivered to a hospital under a court ex parte

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  1  order for examination or placed by an authorized party for

  2  involuntary examination in accordance with chapter 394 or

  3  chapter 397, that the absence of immediate medical attention

  4  could reasonably be expected to result in:

  5         1.  Serious jeopardy to the health of a patient; or

  6         2.  Serious jeopardy to the health of others.

  7         (10)  "Emergency medical services provider" means a

  8  provider licensed pursuant to chapter 401.

  9         (11)(10)  "Emergency services and care" means medical

10  screening, examination, and evaluation by a physician, or, to

11  the extent permitted by applicable law, by other appropriate

12  personnel under the supervision of a physician, to determine

13  if an emergency medical condition exists and, if it does, the

14  care, treatment, or surgery by a physician necessary to

15  stabilize relieve or eliminate the emergency medical

16  condition, within the service capability of the facility.

17         (23)  "Medically unnecessary procedure" means a

18  surgical or other invasive procedure that no reasonable

19  physician, in light of the patient's history and available

20  diagnostic information, would deem to be indicated in order to

21  treat, cure, or palliate the patient's condition or disease.

22         (28)(26)  "Service capability" means the physical

23  space, equipment, supplies, and services that the hospital

24  provides and the level of care that the medical staff can

25  provide within the training and scope of their professional

26  licenses and hospital privileges all services offered by the

27  facility where identification of services offered is evidenced

28  by the appearance of the service in a patient's medical record

29  or itemized bill.

30         (32)(30)  "Stabilized" means, with respect to an

31  emergency medical condition, that no material deterioration of

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  1  the condition is likely, within reasonable medical

  2  probability, to result from the transfer or discharge of the

  3  patient from a hospital.

  4         Section 4.  Subsections (1) and (2) and paragraphs (c)

  5  and (d) of subsection (3) of section 395.1041, Florida

  6  Statutes, are amended to read:

  7         395.1041  Access to emergency services and care.--

  8         (1)  LEGISLATIVE INTENT.--The Legislature finds and

  9  declares it to be of vital importance that emergency services

10  and care be provided by hospitals and physicians to every

11  person in need of such care.  The Legislature finds that

12  persons have been denied emergency services and care by

13  hospitals.  It is the intent of the Legislature that the

14  agency vigorously enforce the ability of persons to receive

15  all necessary and appropriate emergency services and care and

16  that the agency act in a thorough and timely manner against

17  hospitals and physicians which deny persons emergency services

18  and care.  It is further the intent of the Legislature that

19  hospitals, emergency medical services providers, and other

20  health care providers work together in their local communities

21  to enter into agreements or arrangements to ensure access to

22  emergency services and care.  The Legislature further

23  recognizes that appropriate emergency services and care often

24  require followup consultation and treatment in order to

25  effectively care for emergency medical conditions.

26         (2)  INVENTORY OF HOSPITAL EMERGENCY SERVICES.--The

27  agency shall establish and maintain an inventory of hospitals

28  with emergency services.  The inventory shall list all

29  services within the service capability of the hospital, and

30  such services shall appear on the face of the hospital

31  license.  Each hospital having emergency services shall notify

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  1  the agency of its service capability in the manner and form

  2  prescribed by the agency.  The agency, in cooperation with the

  3  Department of Health shall provide use the inventory to assist

  4  emergency medical services providers and shall make the

  5  inventory available to others to assist in locating

  6  appropriate emergency medical care.  The inventory shall also

  7  be made available to the general public.  On or before August

  8  1, 1992, the agency shall request that each hospital identify

  9  the services which are within its service capability.  On or

10  before November 1, 1992, the agency shall notify each hospital

11  of the service capability to be included in the inventory.

12  The hospital has 15 days from the date of receipt to respond

13  to the notice.  By December 1, 1992, the agency shall publish

14  a final inventory. Each hospital shall reaffirm its service

15  capability when its license is renewed and shall notify the

16  agency of the addition of a new service or the termination of

17  a service prior to a change in its service capability.

18         (3)  EMERGENCY SERVICES; DISCRIMINATION; LIABILITY OF

19  FACILITY OR HEALTH CARE PERSONNEL.--

20         (c)  A patient that has not been stabilized, whether

21  stabilized or not, may be transferred to another hospital

22  which has the requisite service capability or is not at

23  service capacity, if:

24         1.  The patient, or a person who is legally responsible

25  for the patient and acting on the patient's behalf, after

26  being informed of the hospital's obligation under this section

27  and of the risk of transfer, requests that the transfer be

28  effected;

29         2.  A physician has signed a certification that, based

30  upon the reasonable risks and benefits to the patient, and

31  based upon the information available at the time of transfer,

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  1  the medical benefits reasonably expected from the provision of

  2  appropriate medical treatment at another hospital outweigh the

  3  increased risks to the individual's medical condition from

  4  effecting the transfer; or

  5         3.  A physician is not physically present in the

  6  emergency services area at the time an individual is

  7  transferred and a qualified medical person signs a

  8  certification that a physician, in consultation with

  9  personnel, has determined that the medical benefits reasonably

10  expected from the provision of appropriate medical treatment

11  at another medical facility outweigh the increased risks to

12  the individual's medical condition from effecting the

13  transfer.  The consulting physician must countersign the

14  certification;

15

16  provided that this paragraph shall not be construed to require

17  acceptance of a transfer that is not medically necessary.

18         (d)1.  Every hospital shall ensure the provision of

19  services within the service capability of the hospital, at all

20  times, either directly or indirectly through an arrangement

21  with another hospital, through an arrangement with one or more

22  physicians, or as otherwise made through prior arrangements.

23  A hospital may enter into an agreement with another hospital

24  for purposes of meeting its service capability requirement,

25  and appropriate compensation or other reasonable conditions

26  may be negotiated for these backup services.

27         2.  If any arrangement requires the provision of

28  emergency medical transportation, such arrangement must be

29  made in consultation with the applicable emergency medical

30  service provider and may not require the emergency medical

31  service provider to provide transportation that is outside the

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  1  routine service area of that emergency medical service

  2  provider or in a manner that impairs the ability of the

  3  emergency medical service provider to timely respond to

  4  prehospital emergency calls.

  5         3.  A hospital shall not be required to ensure service

  6  capability at all times as required in subparagraph 1. if,

  7  prior to the receiving of any patient needing such service

  8  capability, such hospital has demonstrated to the agency that

  9  it lacks the ability to ensure such capability and it has

10  exhausted all reasonable efforts to ensure such capability

11  through backup arrangements.  In reviewing a hospital's

12  demonstration of lack of ability to ensure service capability,

13  the agency shall consider factors relevant to the particular

14  case, including the following:

15         a.  Number and proximity of hospitals with the same

16  service capability.

17         b.  Number, type, credentials, and privileges of

18  specialists.

19         c.  Frequency of procedures.

20         d.  Size of hospital.

21         4.  The agency shall publish proposed rules

22  implementing a reasonable exemption procedure by November 1,

23  1992.  Subparagraph 1. shall become effective upon the

24  effective date of said rules or January 31, 1993, whichever is

25  earlier.  For a period not to exceed 1 year from the effective

26  date of subparagraph 1., a hospital requesting an exemption

27  shall be deemed to be exempt from offering the service until

28  the agency initially acts to deny or grant the original

29  request.  The agency has 45 days from the date of receipt of

30  the request for exemption to approve or deny the request.

31  After the first year from the effective date of subparagraph

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  1  1., If the agency fails to initially act within the time

  2  period, the hospital is deemed to be exempt from offering the

  3  service until the agency initially acts to deny the request.

  4         5.  The agency shall convene a workgroup consisting of

  5  representatives from the Florida Hospital Association, the

  6  Florida Medical Association, and the Florida College of

  7  Emergency Physicians to make recommendations to the

  8  Legislature for changes to this paragraph regarding:

  9         a.  Services performed on an infrequent basis that

10  would not be considered to be within the service capability of

11  the hospital.

12         b.  Situations in which hospitals would be deemed

13  exempt from providing services at all times that are within

14  their service capability.

15         Section 5.  Section 395.1042, Florida Statutes, is

16  created to read:

17         395.1042  Uncompensated Emergency Services and Care

18  Reimbursement Program.--

19         (1)  There is established the Uncompensated Emergency

20  Services and Care Reimbursement Program for the purpose of

21  reimbursing health care facilities and health care

22  practitioners for the cost of uncompensated emergency services

23  and care provided as required by s. 395.1041. The Agency for

24  Health Care Administration shall reimburse providers for

25  services at the Medicaid rate in an amount equal to the

26  provider's pro rata share of uncompensated emergency services

27  and care provided in the prior fiscal year.

28         (2)  Any funds appropriated in the General

29  Appropriations Act for the implementation of s. 395.1041, and

30  any other funds that become available for the implementation

31  of s. 395.1041, shall be used exclusively to compensate

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  1  providers under the Uncompensated Emergency Services and Care

  2  Reimbursement Program.

  3         Section 6.  Paragraph (c) of subsection (2) of section

  4  395.602, Florida Statutes, is amended to read:

  5         395.602  Rural hospitals.--

  6         (2)  DEFINITIONS.--As used in this part:

  7         (c)  "Inactive rural hospital bed" means a licensed

  8  acute care hospital bed, as defined in s. 395.002(15)(14),

  9  that is inactive in that it cannot be occupied by acute care

10  inpatients.

11         Section 7.  Paragraph (c) of subsection (1) of section

12  395.701, Florida Statutes, is amended to read:

13         395.701  Annual assessments on net operating revenues

14  for inpatient and outpatient services to fund public medical

15  assistance; administrative fines for failure to pay

16  assessments when due; exemption.--

17         (1)  For the purposes of this section, the term:

18         (c)  "Hospital" means a health care institution as

19  defined in s. 395.002(14)(13), but does not include any

20  hospital operated by the agency or the Department of

21  Corrections.

22         Section 8.  Paragraph (b) of subsection (1) of section

23  400.051, Florida Statutes, is amended to read:

24         400.051  Homes or institutions exempt from the

25  provisions of this part.--

26         (1)  The following shall be exempt from the provisions

27  of this part:

28         (b)  Any hospital, as defined in s. 395.002(12)(11),

29  that is licensed under chapter 395.

30         Section 9.  Subsections (1) and (7) of section 401.23,

31  Florida Statutes, are amended to read:

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  1         401.23  Definitions.--As used in this part, the term:

  2         (1)  "Advanced life support" means assessment,

  3  monitoring, or treatment of medical conditions, through use of

  4  techniques described in the Paramedic Basic Training Course

  5  Curriculum of the United States Department of Transportation,

  6  by a paramedic under the supervision of a medical director of

  7  a licensee, pursuant to rules of the department.  The term

  8  "advanced life support" also includes techniques provided to

  9  persons with psychiatric disturbances, symptoms of substance

10  abuse, or emergency medical conditions, as defined in 42

11  U.S.C. 1395dd treatment of life-threatening medical

12  emergencies through the use of techniques such as endotracheal

13  intubation, the administration of drugs or intravenous fluids,

14  telemetry, cardiac monitoring, and cardiac defibrillation by a

15  qualified person, pursuant to rules of the department.

16         (7)  "Basic life support" means assessment, monitoring,

17  or treatment of medical conditions treatment of medical

18  emergencies by a qualified person through the use of

19  techniques such as patient assessment, cardiopulmonary

20  resuscitation (CPR), splinting, obstetrical assistance,

21  bandaging, administration of oxygen, application of medical

22  antishock trousers, administration of a subcutaneous injection

23  using a premeasured autoinjector of epinephrine to a person

24  suffering an anaphylactic reaction, and other techniques

25  described in the Emergency Medical Technician Basic Training

26  Course Curriculum of the United States Department of

27  Transportation, by an emergency medical technician or

28  paramedic under the supervision of a medical director, as

29  required by the department.  The term "basic life support"

30  also includes other techniques provided to persons with

31  psychiatric disturbances, symptoms of substance abuse, or

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  1  emergency medical conditions as defined in 42 U.S.C. 1395dd;

  2  and other techniques which have been approved and are

  3  performed under conditions specified by rules of the

  4  department.

  5         Section 10.  Subsections (9) and (10) of section

  6  409.901, Florida Statutes, are amended to read:

  7         409.901  Definitions; ss. 409.901-409.920.--As used in

  8  ss. 409.901-409.920, except as otherwise specifically

  9  provided, the term:

10         (9)  "Emergency medical condition" means:

11         (a)  A medical condition manifesting itself by acute

12  symptoms of sufficient severity, which may include severe

13  pain, psychiatric disturbances, symptoms of substance abuse,

14  or other acute symptoms, such that the absence of immediate

15  medical attention could reasonably be expected to result in

16  any of the following:

17         1.  Serious jeopardy to the health of a patient,

18  including a pregnant woman or a fetus.

19         2.  Serious impairment to bodily functions.

20         3.  Serious dysfunction of any bodily organ or part.

21         (b)  With respect to a pregnant woman:

22         1.  That there is inadequate time to effect safe

23  transfer to another hospital prior to delivery.

24         2.  That a transfer may pose a threat to the health and

25  safety of the patient or fetus.

26         3.  That there is evidence of the onset and persistence

27  of uterine contractions or rupture of the membranes.

28         (c)  With respect to a person exhibiting acute

29  psychiatric disturbance or substance abuse, or taken into

30  custody and delivered to a hospital under a court ex parte

31  order for examination or placed by an authorized party for

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  1  involuntary examination in accordance with chapter 394 or

  2  chapter 397, that the absence of immediate medical attention

  3  could reasonably be expected to result in:

  4         1.  Serious jeopardy to the health of a patient; or

  5         2.  Serious jeopardy to the health of others.

  6         (10)  "Emergency services and care" means medical

  7  screening, examination, and evaluation by a physician, or, to

  8  the extent permitted by applicable laws, by other appropriate

  9  personnel under the supervision of a physician, to determine

10  whether an emergency medical condition exists and, if it does,

11  the care, treatment, or surgery for a covered service by a

12  physician which is necessary to stabilize relieve or eliminate

13  the emergency medical condition, within the service capability

14  of a hospital.

15         Section 11.  Subsection (8) of section 409.905, Florida

16  Statutes, is amended to read:

17         409.905  Mandatory Medicaid services.--The agency may

18  make payments for the following services, which are required

19  of the state by Title XIX of the Social Security Act,

20  furnished by Medicaid providers to recipients who are

21  determined to be eligible on the dates on which the services

22  were provided. Any service under this section shall be

23  provided only when medically necessary and in accordance with

24  state and federal law. Mandatory services rendered by

25  providers in mobile units to Medicaid recipients may be

26  restricted by the agency. Nothing in this section shall be

27  construed to prevent or limit the agency from adjusting fees,

28  reimbursement rates, lengths of stay, number of visits, number

29  of services, or any other adjustments necessary to comply with

30  the availability of moneys and any limitations or directions

31  provided for in the General Appropriations Act or chapter 216.

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  1         (8)  NURSING FACILITY SERVICES.--The agency shall pay

  2  for 24-hour-a-day nursing and rehabilitative services for a

  3  recipient in a nursing facility licensed under part II of

  4  chapter 400 or in a rural hospital, as defined in s. 395.602,

  5  or in a Medicare certified skilled nursing facility operated

  6  by a hospital, as defined by s. 395.002(12)(11), that is

  7  licensed under part I of chapter 395, and in accordance with

  8  provisions set forth in s. 409.908(2)(a), which services are

  9  ordered by and provided under the direction of a licensed

10  physician.  However, if a nursing facility has been destroyed

11  or otherwise made uninhabitable by natural disaster or other

12  emergency and another nursing facility is not available, the

13  agency must pay for similar services temporarily in a hospital

14  licensed under part I of chapter 395 provided federal funding

15  is approved and available.

16         Section 12.  Section 409.9128, Florida Statutes, is

17  amended to read:

18         409.9128  Requirements for providing emergency services

19  and care.--

20         (1)  Emergency services and care is a covered service.

21  In providing for emergency services and care as a covered

22  service, neither a managed care plan nor the MediPass program

23  may:

24         (a)  Require prior authorization for the receipt of

25  prehospital transport or treatment or for the provision of

26  emergency services and care.

27         (b)  Indicate that emergencies are covered only if care

28  is secured within a certain period of time or from a health

29  care provider that has a contract with the managed care plan

30  or MediPass program.

31

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  1         (c)  Use terms such as "life threatening" or "bona

  2  fide" to qualify the kind of emergency that is covered.

  3         (d)  Deny payment based on the enrollee's or the

  4  hospital's failure to notify the managed care plan or MediPass

  5  primary care provider in advance or within a certain period of

  6  time after the care is given or to obtain care from a health

  7  care provider that has a contract with the managed care plan.

  8         (2)  Prehospital and hospital-based trauma services and

  9  emergency services and care must be provided as a covered

10  service to an enrollee of a managed care plan or the MediPass

11  program as required under ss. 395.1041, 395.4045, and 401.45.

12         (3)(a)  When an enrollee is present at a hospital

13  seeking emergency services and care, the determination as to

14  whether an emergency medical condition, as defined in s.

15  409.901, exists shall be made, for the purposes of treatment,

16  by a physician of the hospital or, to the extent permitted by

17  applicable law, by other appropriate licensed professional

18  hospital personnel under the supervision of the hospital

19  physician.  The physician or the appropriate personnel shall

20  indicate in the patient's chart the results of the screening,

21  examination, and evaluation.  The managed care plan or the

22  Medicaid program on behalf of MediPass patients shall

23  compensate the provider for the screening, evaluation, and

24  examination that is required by law to determine reasonably

25  calculated to assist the health care provider in arriving at a

26  determination as to whether the patient's condition is an

27  emergency medical condition and shall not deny payment if an

28  emergency medical condition is not found to exist. When an

29  emergency medical condition does exist, the managed care plan

30  or the Medicaid program on behalf of MediPass patients shall

31  compensate the provider for all emergency services and care

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  1  and any medically necessary followup care provided in

  2  accordance with this subsection.  If a determination is made

  3  that an emergency medical condition does not exist, payment

  4  for services rendered subsequent to that determination is

  5  governed by the managed care plan's contract with the agency.

  6         (b)  If a determination has been made that an emergency

  7  medical condition exists and the enrollee has notified the

  8  hospital, or the hospital emergency personnel otherwise has

  9  knowledge that the patient is an enrollee of the managed care

10  plan or the MediPass program, the hospital must make a

11  reasonable attempt to notify the enrollee's primary care

12  physician, if known, or the managed care plan, if the managed

13  care plan had previously requested in writing that the

14  notification be made directly to the managed care plan, of the

15  existence of the emergency medical condition.  If the primary

16  care physician is not known, or has not been contacted, the

17  hospital must:

18         1.  Notify the managed care plan or the MediPass

19  provider as soon as possible prior to discharge of the

20  enrollee from the emergency care area; or

21         2.  Notify the managed care plan or the MediPass

22  provider within 24 hours or on the next business day after

23  admission of the enrollee as an inpatient to the hospital.

24

25  If notification required by this paragraph is not

26  accomplished, the hospital must document its attempts to

27  notify the managed care plan or the MediPass provider or the

28  circumstances that precluded attempts to notify the managed

29  care plan or the MediPass provider.  Neither a managed care

30  plan nor the Medicaid program on behalf of MediPass patients

31  may deny payment for emergency services and care based on a

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  1  hospital's failure to comply with the notification

  2  requirements of this paragraph.

  3         (c)  The physician who provides the care, treatment, or

  4  surgery necessary to stabilize the emergency medical condition

  5  may, at his or her sole discretion, continue to care for the

  6  patient for the duration of the patient's hospital stay and

  7  for any medically necessary followup or may transfer care of

  8  the patient, in accordance with state and federal laws, to a

  9  provider that has a contract with the managed care plan or

10  MediPass provider. If the enrollee's primary care physician

11  responds to the notification, the hospital physician and the

12  primary care physician may discuss the appropriate care and

13  treatment of the enrollee.  The managed care plan may have a

14  member of the hospital staff with whom it has a contract

15  participate in the treatment of the enrollee within the scope

16  of the physician's hospital staff privileges.  The enrollee

17  may be transferred, in accordance with state and federal law,

18  to a hospital that has a contract with the managed care plan

19  and has the service capability to treat the enrollee's

20  emergency medical condition.  Notwithstanding any other state

21  law, a hospital may request and collect insurance or financial

22  information from a patient in accordance with federal law,

23  which is necessary to determine if the patient is an enrollee

24  of a managed care plan or the MediPass program, if emergency

25  services and care are not delayed.

26         (4)  Nothing in this section is intended to prohibit or

27  limit application of a nominal copayment as provided in s.

28  409.9081 for the use of an emergency room for services other

29  than emergency services and care.

30         (5)  Reimbursement amounts for services provided to an

31  enrollee of a managed care plan under this section shall be

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  1  governed by the terms of the contract with the provider if

  2  such contract exists. Reimbursement amounts for services under

  3  this section by a provider that who does not have a contract

  4  with the managed care plan shall be the lesser of:

  5         (a)  The provider's charges;

  6         (b)  For noninstitutional providers, the usual and

  7  customary provider charges for similar services in the

  8  community where the services were provided;

  9         (c)  The charge mutually agreed to by the entity and

10  the provider within 35 60 days after submittal of the claim;

11  or

12         (d)  The Medicaid rate.

13         (6)  The provisions of this section may not be waived,

14  voided, or nullified by contract.

15         Section 13.  Paragraph (l) of subsection (1) of section

16  468.505, Florida Statutes, is amended to read:

17         468.505  Exemptions; exceptions.--

18         (1)  Nothing in this part may be construed as

19  prohibiting or restricting the practice, services, or

20  activities of:

21         (l)  A person employed by a nursing facility exempt

22  from licensing under s. 395.002(14)(13), or a person exempt

23  from licensing under s. 464.022.

24         Section 14.  Section 627.6053, Florida Statutes, is

25  created to read:

26         627.6053  Requirements for providing emergency services

27  and care.--

28         (1)  An individual, group, blanket, or franchise health

29  insurance policy governed by this chapter, including a health

30  benefit plan issued pursuant to s. 627.6699, must provide

31

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  1  coverage for hospital emergency services and care pursuant to

  2  this section.

  3         (2)  As used in this section, the term:

  4         (a)  "Emergency medical condition" means:

  5         1.  A medical condition manifesting itself by acute

  6  symptoms of sufficient severity, which may include severe

  7  pain, psychiatric disturbances, symptoms of substance abuse,

  8  or other acute symptoms, such that the absence of immediate

  9  medical attention could reasonably be expected to result in

10  any of the following:

11         a.  Serious jeopardy to the health of a patient,

12  including a pregnant woman or a fetus.

13         b.  Serious impairment to bodily functions.

14         c.  Serious dysfunction of any bodily organ or part.

15         2.  With respect to a pregnant woman:

16         a.  That there is inadequate time to effect safe

17  transfer to another hospital prior to delivery;

18         b.  That a transfer may pose a threat to the health and

19  safety of the patient or fetus; or

20         c.  That there is evidence of the onset and persistence

21  of uterine contractions or rupture of the membranes.

22         3.  With respect to a person exhibiting acute

23  psychiatric disturbance or substance abuse, or taken into

24  custody and delivered to a hospital under a court ex parte

25  order for examination or placed by an authorized party for

26  involuntary examination in accordance with chapter 394 or

27  chapter 397, that the absence of immediate medical attention

28  could reasonably be expected to result in:

29         a.  Serious jeopardy to the health of a patient; or

30         b.  Serious jeopardy to the health of others.

31

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  1         (b)  "Emergency services and care" means medical

  2  screening, examination, and evaluation by a physician, or, to

  3  the extent permitted by applicable law, by other appropriate

  4  personnel under the supervision of a physician, to determine

  5  if an emergency medical condition exists and, if it does, the

  6  care, treatment, or surgery for a covered service by a

  7  physician necessary to stabilize the emergency medical

  8  condition, within the service capability of a hospital.

  9         (c)  "Provider" means any physician, hospital, or other

10  institution, organization, or person that furnishes health

11  care services and is licensed or otherwise authorized to

12  practice in the state.

13         (3)  Emergency services and care is a covered service.

14  In providing for emergency services and care as a covered

15  service, a health insurer may not:

16         (a)  Require prior authorization for the receipt of

17  prehospital transport or treatment or for the provision of

18  emergency services and care.

19         (b)  Indicate that emergencies are covered only if care

20  is secured within a certain period of time or from a health

21  care provider who has a contract with the health insurer.

22         (c)  Use terms such as "life threatening" or "bona

23  fide" to qualify the kind of emergency that is covered.

24         (d)  Deny payment based on the insured's failure to

25  notify the health insurer in advance of seeking treatment or

26  within a certain period after the care is given or to obtain

27  care from a health care provider that has a contract with the

28  health insurer.

29         (4)  Prehospital and hospital-based trauma services and

30  emergency services and care must be provided as a covered

31

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  1  service to an insured as required under ss. 395.1041,

  2  395.4045, and 401.45.

  3         (5)(a)  When an insured is present at a hospital

  4  seeking emergency services and care, the determination as to

  5  whether an emergency medical condition exists shall be made,

  6  for the purposes of treatment, by a physician of the hospital

  7  or, to the extent permitted by applicable law, by other

  8  appropriate licensed professional hospital personnel under the

  9  supervision of the hospital physician. The physician or the

10  appropriate personnel shall indicate in the patient's chart

11  the results of the screening, examination, and evaluation.

12  The health insurer shall compensate the provider for the

13  screening, evaluation, and examination that is required by law

14  to determine whether the patient's condition is an emergency

15  medical condition and shall not deny payment if an emergency

16  medical condition is not found to exist.  When an emergency

17  medical condition does exist, the health insurer shall

18  compensate the provider for all emergency services and care

19  and any medically necessary followup care provided in

20  accordance with this subsection.

21         (b)  If a determination has been made that an emergency

22  medical condition exists and the insured has notified the

23  hospital, or the hospital emergency personnel otherwise has

24  knowledge that the patient has health insurance, the hospital

25  must make a reasonable attempt to notify the insurer of the

26  existence of the emergency medical condition. The hospital

27  must:

28         1.  Notify the health insurer as soon as possible prior

29  to discharge of the insured from the emergency care area; or

30

31

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  1         2.  Notify the health insurer within 24 hours or on the

  2  next business day after admission of the insured as an

  3  inpatient to the hospital.

  4

  5  If notification required by this paragraph is not

  6  accomplished, the hospital must document its attempts to

  7  notify the health insurer of the circumstances that precluded

  8  attempts to notify the health insurer. A health insurer may

  9  not deny payment for emergency services and care based on a

10  hospital's failure to comply with the notification

11  requirements of this paragraph. This paragraph does not alter

12  any contractual responsibility of an insured to make contact

13  with a health insurer, subsequent to receiving treatment for

14  the emergency medical condition.

15         (c)  The physician who provides the care, treatment, or

16  surgery necessary to stabilize the emergency medical condition

17  may, at his or her sole discretion, continue to provide care

18  to the patient for the duration of the patient's hospital stay

19  and for any medically necessary followup or may transfer care

20  of the patient, in accordance with state and federal laws, to

21  a provider that has a contract with the health insurer.

22         (6)  Reimbursement amounts for services under this

23  section shall be governed by the terms of the contract with

24  the provider if such contract exists.  Reimbursement amounts

25  for services under this section by a provider that does not

26  have a contract with the health insurer shall be the lesser

27  of:

28         (a)  The provider's charges;

29         (b)  For noninstitutional providers, the usual and

30  customary provider charges for similar services in the

31  community where the services were provided; or

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  1         (c)  The charge mutually agreed to by the health

  2  insurer and the provider within 35 days after the submittal of

  3  the claim.

  4         (7)  This section shall govern the provision of

  5  emergency services and care pursuant to a policy subject to s.

  6  627.6471 or s. 627.6472.

  7         (8)  The provisions of this section may not be waived,

  8  voided, or nullified by contract.

  9         Section 15.  Subsection (7) of section 641.19, Florida

10  Statutes, is amended to read:

11         641.19  Definitions.--As used in this part, the term:

12         (7)  "Emergency medical condition" means:

13         (a)  A medical condition manifesting itself by acute

14  symptoms of sufficient severity, which may include severe

15  pain, psychiatric disturbances, symptoms of substance abuse,

16  or other acute symptoms, such that the absence of immediate

17  medical attention could reasonably be expected to result in

18  any of the following:

19         1.  Serious jeopardy to the health of a patient,

20  including a pregnant woman or a fetus.

21         2.  Serious impairment to bodily functions.

22         3.  Serious dysfunction of any bodily organ or part.

23         (b)  With respect to a pregnant woman:

24         1.  That there is inadequate time to effect safe

25  transfer to another hospital prior to delivery;

26         2.  That a transfer may pose a threat to the health and

27  safety of the patient or fetus; or

28         3.  That there is evidence of the onset and persistence

29  of uterine contractions or rupture of the membranes.

30         (c)  With respect to a person exhibiting acute

31  psychiatric disturbance or substance abuse, or taken into

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  1  custody and delivered to a hospital under a court ex parte

  2  order for examination or placed by an authorized party for

  3  involuntary examination in accordance with chapter 394 or

  4  chapter 397, that the absence of immediate medical attention

  5  could reasonably be expected to result in:

  6         1.  Serious jeopardy to the health of a patient; or

  7         2.  Serious jeopardy to the health of others.

  8         Section 16.  Subsection (7) of section 641.47, Florida

  9  Statutes, is amended to read:

10         641.47  Definitions.--As used in this part, the term:

11         (7)  "Emergency medical condition" means:

12         (a)  A medical condition manifesting itself by acute

13  symptoms of sufficient severity, which may include severe

14  pain, psychiatric disturbances, symptoms of substance abuse,

15  or other acute symptoms, such that the absence of immediate

16  medical attention could reasonably be expected to result in

17  any of the following:

18         1.  Serious jeopardy to the health of a patient,

19  including a pregnant woman or a fetus.

20         2.  Serious impairment to bodily functions.

21         3.  Serious dysfunction of any bodily organ or part.

22         (b)  With respect to a pregnant woman:

23         1.  That there is inadequate time to effect safe

24  transfer to another hospital prior to delivery;

25         2.  That a transfer may pose a threat to the health and

26  safety of the patient or fetus; or

27         3.  That there is evidence of the onset and persistence

28  of uterine contractions or rupture of the membranes.

29         (c)  With respect to a person exhibiting acute

30  psychiatric disturbance or substance abuse, or taken into

31  custody and delivered to a hospital under a court ex parte

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  1  order for examination or placed by authorized party for

  2  involuntary examination in accordance with chapter 394 or

  3  chapter 397, that the absence of immediate medical attention

  4  could reasonably be expected to result in:

  5         1.  Serious jeopardy to the health of a patient; or

  6         2.  Serious jeopardy to the health of others.

  7         Section 17.  Section 641.513, Florida Statutes, is

  8  amended to read:

  9         641.513  Requirements for providing emergency services

10  and care.--

11         (1)  Emergency services and care is a covered service.

12  In providing for emergency services and care as a covered

13  service, a health maintenance organization may not:

14         (a)  Require prior authorization for the receipt of

15  prehospital transport or treatment or for the provision of

16  emergency services and care.

17         (b)  Indicate that emergencies are covered only if care

18  is secured within a certain period of time or from a health

19  care provider that has a contract with the health maintenance

20  organization.

21         (c)  Use terms such as "life threatening" or "bona

22  fide" to qualify the kind of emergency that is covered.

23         (d)  Deny payment based on the subscriber's failure to

24  notify the health maintenance organization in advance of

25  seeking treatment or within a certain period of time after the

26  care is given or to obtain care from a health care provider

27  that does not have a contract with the health maintenance

28  organization.

29         (2)  Prehospital and hospital-based trauma services and

30  emergency services and care must be provided as a covered

31

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  1  service to a subscriber of a health maintenance organization

  2  as required under ss. 395.1041, 395.4045, and 401.45.

  3         (3)(a)  When a subscriber is present at a hospital

  4  seeking emergency services and care, the determination as to

  5  whether an emergency medical condition, as defined in s.

  6  641.47, exists shall be made, for the purposes of treatment,

  7  by a physician of the hospital or, to the extent permitted by

  8  applicable law, by other appropriate licensed professional

  9  hospital personnel under the supervision of the hospital

10  physician.  The physician or the appropriate personnel shall

11  indicate in the patient's chart the results of the screening,

12  examination, and evaluation.  The health maintenance

13  organization shall compensate the provider for the screening,

14  evaluation, and examination that is required by law to

15  determine reasonably calculated to assist the health care

16  provider in arriving at a determination as to whether the

17  patient's condition is an emergency medical condition and

18  shall not deny payment if an emergency medical condition is

19  not found to exist. When an emergency medical condition does

20  exist, the health maintenance organization shall compensate

21  the provider for all emergency services and care and any

22  medically necessary followup care provided in accordance with

23  this subsection. If a determination is made that an emergency

24  medical condition does not exist, payment for services

25  rendered subsequent to that determination is governed by the

26  contract under which the subscriber is covered.

27         (b)  If a determination has been made that an emergency

28  medical condition exists and the subscriber has notified the

29  hospital, or the hospital emergency personnel otherwise have

30  knowledge that the patient is a subscriber of the health

31  maintenance organization, the hospital must make a reasonable

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  1  attempt to notify the subscriber's primary care physician, if

  2  known, or the health maintenance organization, if the health

  3  maintenance organization had previously requested in writing

  4  that the notification be made directly to the health

  5  maintenance organization, of the existence of the emergency

  6  medical condition.  If the primary care physician is not

  7  known, or has not been contacted, the hospital must:

  8         1.  Notify the health maintenance organization as soon

  9  as possible prior to discharge of the subscriber from the

10  emergency care area; or

11         2.  Notify the health maintenance organization within

12  24 hours or on the next business day after admission of the

13  subscriber as an inpatient to the hospital.

14

15  If notification required by this paragraph is not

16  accomplished, the hospital must document its attempts to

17  notify the health maintenance organization of the

18  circumstances that precluded attempts to notify the health

19  maintenance organization.  A health maintenance organization

20  may not deny payment for emergency services and care based on

21  a hospital's failure to comply with the notification

22  requirements of this paragraph. Nothing in this paragraph

23  shall alter any contractual responsibility of a subscriber to

24  make contact with the health maintenance organization,

25  subsequent to receiving treatment for the emergency medical

26  condition.

27         (c)  The physician who provides the care, treatment, or

28  surgery necessary to stabilize the emergency medical condition

29  may, at his or her sole discretion, continue to provide care

30  to the patient for the duration of the patient's hospital stay

31  and for any medically necessary followup, or may transfer care

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  1  of the patient, in accordance with state and federal law, to a

  2  provider that has a contract with the health maintenance

  3  organization. If the subscriber's primary care physician

  4  responds to the notification, the hospital physician and the

  5  primary care physician may discuss the appropriate care and

  6  treatment of the subscriber.  The health maintenance

  7  organization may have a member of the hospital staff with whom

  8  it has a contract participate in the treatment of the

  9  subscriber within the scope of the physician's hospital staff

10  privileges.  The subscriber may be transferred, in accordance

11  with state and federal law, to a hospital that has a contract

12  with the health maintenance organization and has the service

13  capability to treat the subscriber's emergency medical

14  condition. Notwithstanding any other state law, a hospital may

15  request and collect insurance or financial information from a

16  patient in accordance with federal law, which is necessary to

17  determine if the patient is a subscriber of a health

18  maintenance organization, if emergency services and care are

19  not delayed.

20         (4)  A subscriber may be charged a reasonable

21  copayment, as provided in s. 641.31(12), for the use of an

22  emergency room.

23         (5)  Reimbursement amounts for services pursuant to

24  this section shall be governed by the terms of the contract

25  with the provider if such contract exists. Reimbursement

26  amounts for services pursuant to this section by a provider

27  that who does not have a contract with the health maintenance

28  organization shall be the lesser of:

29         (a)  The provider's charges;

30

31

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  1         (b)  For noninstitutional providers, the usual and

  2  customary provider charges for similar services in the

  3  community where the services were provided; or

  4         (c)  The charge mutually agreed to by the health

  5  maintenance organization and the provider within 35 60 days

  6  after of the submittal of the claim.

  7

  8  Such reimbursement shall be net of any applicable copayment

  9  authorized pursuant to subsection (4).

10         (6)  Reimbursement amounts for services under this

11  section provided to subscribers who are Medicaid recipients

12  shall be governed by the terms of the contract with the

13  provider. Reimbursement amounts for services under this

14  section by a provider when for whom no contract exists between

15  the provider and the health maintenance organization shall be

16  the lesser of:

17         (a)  The provider's charges;

18         (b)  For noninstitutional providers, the usual and

19  customary provider charges for similar services in the

20  community where the services were provided;

21         (c)  The charge mutually agreed to by the entity and

22  the provider within 35 60 days after submittal of the claim;

23  or

24         (d)  The Medicaid rate.

25         (7)  The provisions of this section may not be waived,

26  voided, or nullified by contract.

27         Section 18.  Paragraph (b) of subsection (2) of section

28  812.014, Florida Statutes, is amended to read:

29         812.014  Theft.--

30         (2)

31

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  1         (b)1.  If the property stolen is valued at $20,000 or

  2  more, but less than $100,000;

  3         2.  The property stolen is cargo valued at less than

  4  $50,000 that has entered the stream of interstate or

  5  intrastate commerce from the shipper's loading platform to the

  6  consignee's receiving dock; or

  7         3.  The property stolen is emergency medical equipment,

  8  valued at $300 or more, that is taken from a facility licensed

  9  under chapter 395 or from an aircraft or vehicle permitted

10  under chapter 401,

11

12  the offender commits grand theft in the second degree,

13  punishable as a felony of the second degree, as provided in s.

14  775.082, s. 775.083, or s. 775.084. Emergency medical

15  equipment means mechanical or electronic apparatus used to

16  provide emergency services and care as defined in s.

17  395.002(11)(10) or to treat medical emergencies.

18         Section 19.  There is appropriated from the General

19  Revenue Fund to the Agency for Health Care Administration the

20  sum of $50 million for the Uncompensated Emergency Services

21  and Care Reimbursement Program.

22         Section 20.  This act shall take effect July 1, 2002.

23

24

25

26

27

28

29

30

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  1            *****************************************

  2                          HOUSE SUMMARY

  3
      Revises and conforms definitions relating to emergency
  4    services and care provided by hospitals, Health
      Maintenance Organizations, and prepaid health clinics and
  5    covered by Medicaid. Revises definitions relating to
      emergency medical transportation services. Revises
  6    provisions relating to inventory of hospital service
      capability and access to hospital emergency services and
  7    care. Directs the Agency for Health Care Administration
      to convene a workgroup to make recommendations to the
  8    Legislature regarding hospital service capability
      requirements. Establishes a program under the agency to
  9    reimburse health care facilities and practitioners for
      the cost of uncompensated emergency services and care,
10    and provides an appropriation therefor. Revises
      requirements for the provision of emergency services and
11    care by Health Maintenance Organizations and prepaid
      health clinics, and under Medicaid managed care plans and
12    MediPass, and provides requirements for health insurance
      policy coverage of hospital emergency services and care.
13    See bill for details.

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

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