Florida Senate - 2015                        COMMITTEE AMENDMENT
       Bill No. SB 516
       
       
       
       
       
       
                                Ì773678^Î773678                         
       
                              LEGISLATIVE ACTION                        
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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         627.42392Coverage 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.