Florida Senate - 2015 COMMITTEE AMENDMENT Bill No. SB 516 Ì773678^Î773678 LEGISLATIVE ACTION Senate . House . . . . . ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— The Committee on Banking and Insurance (Lee) recommended the following: 1 Senate Amendment (with title amendment) 2 3 Delete everything after the enacting clause 4 and insert: 5 Section 1. Section 627.42392, Florida Statutes, is created 6 to read: 7 627.42392 Coverage for emergency services.— 8 (1) As used in this section, the term: 9 (a) “Coverage for emergency services” means the coverage 10 provided by a health insurance policy for emergency services. 11 (b) “Emergency services” means emergency services and care, 12 as defined in s. 641.47, which are provided within the emergency 13 department of a hospital with respect to an emergency medical 14 condition as defined in s. 641.47. 15 (c) “Participating provider” means a preferred provider as 16 defined in s. 627.6471 or an exclusive provider as defined in s. 17 627.6472. 18 (2) Coverage for emergency services: 19 (a) May not require a prior authorization determination. 20 (b) Must be provided regardless of whether the service is 21 furnished by a participating or nonparticipating provider. 22 (c) May impose a requirement for a coinsurance amount, a 23 copayment, or a limitation of benefits for a nonparticipating 24 provider only if the same requirement applies to a participating 25 provider. 26 (3) An insurer must reimburse a nonparticipating provider 27 of emergency services the greater of: 28 (a) The amount negotiated with a nonparticipating provider, 29 reduced only by a coinsurance amount or copayment that applies 30 to a participating provider. 31 (b) The usual and customary reimbursement amount received 32 by a participating provider for the same service in the same 33 geographic area of this state, reduced only by a coinsurance 34 amount or copayment that applies to a participating provider. 35 Evidence of the usual and customary reimbursement amount may 36 include the average amount reimbursed to the nonparticipating 37 provider for the same service in the same geographic region of 38 this state from other insurers with which such provider 39 participates. 40 (c) The amount that would be paid under Medicare for the 41 service, reduced only by a coinsurance amount or copayment that 42 applies to a participating provider. 43 44 A nonparticipating provider of emergency services may be 45 reimbursed only up to the amount of reimbursement required to be 46 paid by the insurer under this subsection and may not collect or 47 attempt to collect, directly or indirectly, from the insured or 48 insurer any excess amount. 49 (4) A provider of emergency services or a representative of 50 such provider, regardless of whether the provider is a 51 participating or nonparticipating provider, may not collect or 52 attempt to collect money from, maintain any action at law 53 against, or report to a credit agency an insured for payment of 54 services for which the insurer is liable, if the provider in 55 good faith knows or should know that the insurer is liable. This 56 prohibition applies during the pendency of a claim for payment 57 made by the provider to the insurer for payment of the services 58 and any legal proceeding or dispute resolution process to 59 determine whether the insurer is liable for the services if the 60 provider is informed that such proceeding is taking place. It is 61 presumed that a provider does not know and should not know that 62 an insurer is liable unless: 63 (a) The provider is informed by the insurer that the 64 insurer accepts liability; 65 (b) A court of competent jurisdiction determines that the 66 insurer is liable; or 67 (c) The office or Agency for Health Care Administration 68 makes a final determination that the insurer is required to pay 69 for such services. 70 (5) An insurer, the office, and the department shall report 71 any suspected violation of this section by a participating or 72 nonparticipating provider to the Department of Health and by a 73 facility to the Agency for Health Care Administration. Based on 74 the report, the Department of Health or the Agency for Health 75 Care Administration shall take action as authorized by law. 76 Section 2. This act shall take effect October 1, 2015. 77 78 ================= T I T L E A M E N D M E N T ================ 79 And the title is amended as follows: 80 Delete everything before the enacting clause 81 and insert: 82 A bill to be entitled 83 An act relating to health insurance coverage for 84 emergency services; creating s. 627.42392, F.S.; 85 defining terms; prohibiting coverage for emergency 86 services from requiring a prior authorization 87 determination; requiring such coverage to be provided 88 regardless of whether the emergency services are 89 furnished by a participating or nonparticipating 90 provider; specifying coinsurance, copayment, 91 limitation of benefits, and reimbursement requirements 92 for nonparticipating providers of emergency services; 93 prohibiting a nonparticipating provider of emergency 94 services from collecting or attempting to collect an 95 amount in excess of specified amounts; prohibiting 96 participating and nonparticipating providers of 97 emergency services from collecting or attempting to 98 collect money from, maintain an action at law against, 99 or report to a credit agency an insured if the 100 provider knows or should know that the insured is 101 liable; providing other circumstances under which such 102 prohibition applies; requiring an insurer, the Office 103 of Insurance Regulation, and the Department of 104 Financial Services to report suspected violations of 105 the act by a provider to the Department of Health or 106 by a facility to the Agency for Healthcare 107 Administration; requiring the Department of Health and 108 Agency for Healthcare Administration to take action as 109 authorized by law based on the reports; providing an 110 effective date.