HB 1041

1	A bill to be entitled
2	An act relating to emergency services provided by Medicaid
3	managed care plans; amending s. 409.9128, F.S.; providing
4	conditions for provision of services to enrollees of
5	managed care plans by certain hospitals; amending s.
6	641.3155, F.S.; providing time limits and rate structures
7	for payment of claims to certain hospitals for services or
8	goods by a provider; amending s. 641.513, F.S.; revising
9	requirements for reimbursement for provision of emergency
10	services and care under a health maintenance contract;
11	providing for construction; providing applicability;
12	providing an effective date.
13
14	Be It Enacted by the Legislature of the State of Florida:
15
16	Section 1.  Subsection (6) is added to section 409.9128,
17	Florida Statutes, to read:
18	409.9128  Requirements for providing emergency services and
19	care.--
20	(6)  When services are provided to an enrollee of a managed
21	care plan under this section by a hospital that does not have a
22	contract with the managed care plan:
23	(a)  The agency may seek to facilitate contract terms
24	between a specific hospital and a specific managed care plan
25	related to emergency services and care, if:
26	1.  The agency receives a written request for such
27	facilitation from either party based on a belief that the
28	provision of emergency services and care on a noncontracted
29	basis has become excessive; and
30	2.  After receiving such a written request, the agency
31	determines, at its own discretion, that the provision of
32	emergency services and care on a noncontracted basis has become
33	excessive.
34	(b)  The agency is not authorized under paragraph (a) to
35	require either party to agree to specific contract terms or
36	specific payment amounts.
37	(c)  In the interest of patient safety:
38	1.  Under no circumstances may a managed care plan allow
39	the provisions of this subsection or subsection (5) or the
40	absence of a hospital contract to influence decisions regarding
41	the provision of care or case management for its Medicaid
42	members, including, but not limited to, whether members should
43	be transferred from one hospital to another.
44	2.  Under no circumstances may a hospital allow the
45	provisions of this subsection or subsection (5) or the absence
46	of a managed care plan contract to influence its treatment,
47	care, or procedures concerning an individual who seeks emergency
48	services, including, but not limited to, the procedures to
49	determine whether an emergency medical condition exists or
50	whether to transfer a patient to another hospital.
51	Section 2.  Subsections (16) and (17) of section 641.3155,
52	Florida Statutes, are renumbered as subsections (17) and (18),
53	respectively, and a new subsection (16) is added to that
54	section, to read:
55	641.3155  Prompt payment of claims.--
56	(16)  When a hospital provides emergency services and care
57	under s. 409.9128 to a Medicaid subscriber of a health
58	maintenance organization and the hospital is not under contract
59	with the health maintenance organization for Medicaid services:
60	(a)  Notwithstanding s. 409.9128(5), for a hospital that is
61	exempt from Medicaid reimbursement ceilings pursuant to chapter
62	409 or the General Appropriations Act:
63	1.  If the health maintenance organization pays a claim
64	submitted electronically pursuant to subsection (3) within 10
65	days after receipt of the claim, or if the claim is not
66	submitted electronically pursuant to subsection (3), the amount
67	paid by the health maintenance organization shall be 70 percent
68	of the Medicaid rate normally paid directly to the hospital on a
69	fee-for-service basis by the agency for providing the services
70	in question to a Medicaid recipient.
71	2.  If the health maintenance organization pays a claim
72	submitted electronically pursuant to subsection (3) later than
73	10 days after receipt of the claim, the amount paid by the
74	health maintenance organization shall be the Medicaid rate
75	normally paid directly to the hospital on a fee-for-service
76	basis by the agency for providing the services in question to a
77	Medicaid recipient.
78	3.  This paragraph does not prevent the hospital and the
79	health maintenance organization from mutually agreeing to a
80	payment that differs from the amounts specified in subparagraph
81	1. or subparagraph 2.
82	(b)  For a hospital that is not exempt from Medicaid
83	reimbursement ceilings pursuant to chapter 409 or the General
84	Appropriations Act, s. 409.9128(5) applies.
85	Section 3.  Subsection (6) of section 641.513, Florida
86	Statutes, is amended to read:
87	641.513  Requirements for providing emergency services and
88	care.--
89	(6)  Reimbursement for services under this section provided
90	to subscribers who are Medicaid recipients by a provider for
91	whom no contract exists between the provider and the health
92	maintenance organization shall be governed by ss. 409.9128(5)
93	and 641.3155(16). the lesser of:
94	(a)  The provider's charges;
95	(b)  The usual and customary provider charges for similar
96	services in the community where the services were provided;
97	(c)  The charge mutually agreed to by the entity and the
98	provider within 60 days after submittal of the claim; or
99	(d)  The Medicaid rate.
100	Section 4.  It is the intent of the Legislature that this
101	act represents a material change in law and may not be construed
102	in any way as a clarification of existing law. This act shall
103	only apply prospectively for hospital emergency services and
104	care rendered on or after the effective date of this act.
105	Section 5.  This act shall take effect July 1, 2009.

CODING: Words stricken are deletions; words underlined are additions.