Florida Senate - 2015 COMMITTEE AMENDMENT
Bill No. SB 516
Ì773678^Î773678
LEGISLATIVE ACTION
Senate . House
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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.