Florida Senate - 2016                                    SB 1442
       By Senator Garcia
       38-00445C-16                                          20161442__
    1                        A bill to be entitled                      
    2         An act relating to out-of-network health insurance
    3         coverage; amending s. 395.003, F.S.; requiring
    4         hospitals, ambulatory surgical centers, specialty
    5         hospitals, and urgent care centers to comply with
    6         certain provisions as a condition of licensure;
    7         amending s. 456.072, F.S.; adding a ground for
    8         discipline of referring health care providers by the
    9         Department of Health; creating s. 627.64194, F.S.;
   10         defining terms; specifying requirements for coverage
   11         provided by an insurer for emergency services;
   12         providing that an insurer is solely liable for payment
   13         of certain fees to a provider; providing limitations
   14         and requirements for reimbursements by an insurer to a
   15         nonparticipating provider; requiring a specified
   16         insurer to provide a disclosure to its insureds under
   17         certain circumstances; requiring a specified facility
   18         to provide a written disclosure and estimate to
   19         patients under certain circumstances; requiring a
   20         nonparticipating provider to provide a written
   21         disclosure to a patient under certain circumstances;
   22         providing that a patient is not liable for certain
   23         charges if a nonparticipating provider fails to
   24         provide such disclosure; amending s. 641.513, F.S.;
   25         revising the methodology for determining health
   26         maintenance organization reimbursement amounts for
   27         emergency services and care provided by certain
   28         providers; providing an effective date.
   30  Be It Enacted by the Legislature of the State of Florida:
   32         Section 1. Paragraph (d) is added to subsection (5) of
   33  section 395.003, Florida Statutes, to read:
   34         395.003 Licensure; denial, suspension, and revocation.—
   35         (5)
   36         (d) A hospital, ambulatory surgical center, specialty
   37  hospital, or urgent care center shall comply with the provisions
   38  of ss. 627.64194 and 641.513 as a condition of licensure.
   39         Section 2. Paragraph (oo) is added to subsection (1) of
   40  section 456.072, Florida Statutes, to read:
   41         456.072 Grounds for discipline; penalties; enforcement.—
   42         (1) The following acts shall constitute grounds for which
   43  the disciplinary actions specified in subsection (2) may be
   44  taken:
   45         (oo) Serving as an officer or director of a business
   46  entity, or group practice as defined in s. 456.053, and failing
   47  to comply with the provisions of s. 627.64194 or s. 641.513 with
   48  such frequency as to constitute a general business practice.
   49         Section 3. Section 627.64194, Florida Statutes, is created
   50  to read:
   51         627.64194 Coverage for out-of-network services.—
   52         (1) As used in this section, the term:
   53         (a) “Coverage for emergency services” means the coverage
   54  provided by a health insurance policy for “emergency services
   55  and care” as defined in s. 641.47.
   56         (b) “Participating provider” means a “preferred provider”
   57  as defined in s. 627.6471 and an “exclusive provider” as defined
   58  in s. 627.6472, including provider facilities.
   59         (2)An insurer must provide coverage for emergency services
   60  that:
   61         (a) May not require a prior authorization determination.
   62         (b) Must be provided regardless of whether the service is
   63  furnished by a participating or nonparticipating provider.
   64         (c) May impose a coinsurance amount, copayment, or
   65  limitation of benefits requirement for a nonparticipating
   66  provider only if the same requirement applies to a participating
   67  provider.
   68         (3)An insurer is solely liable for payment of fees to a
   69  provider and an insured is not liable for payment of fees to a
   70  provider, other than applicable copayments and deductibles, for
   71  medical services and care that are:
   72         (a) Not emergency services and care as defined in s.
   73  395.002;
   74         (b) Provided in a facility licensed under chapter 395 which
   75  has a contract with the insurer; and
   76         (c) Provided by a nonparticipating provider where the
   77  insured has no ability and opportunity to choose a participating
   78  provider at the facility.
   79         (4)A nonparticipating provider may not be reimbursed an
   80  amount greater than that provided under subsection (5) and may
   81  not collect or attempt to collect, directly or indirectly, any
   82  excess amount.
   83         (5) An insurer must reimburse a nonparticipating provider
   84  as provided in subsections (2) and (3) the greater of the
   85  following:
   86         (a)The amount negotiated with an in-network provider in
   87  the same community where the services were provided, excluding
   88  any in-network copayment or coinsurance imposed pursuant to the
   89  policy;
   90         (b) The usual and customary reimbursement received by a
   91  provider for the same service in the community where the service
   92  was provided, reduced only by any coinsurance amount or
   93  copayment that applies to the provider; or
   94         (c) The amount that would be paid under Medicare for the
   95  service, reduced only by any coinsurance amount or copayment
   96  that applies to the provider.
   97         (6)An insurer issuing a health insurance policy that
   98  provides coverage for medical and related services within a
   99  facility licensed under chapter 395 shall disclose to its
  100  insureds whether the facility contracts with nonparticipating
  101  providers. Such disclosure may be displayed on the insurer’s
  102  member website or directly distributed by the insurer to its
  103  insureds.
  104         (7)Upon scheduling services or admitting a patient for
  105  treatment of a condition other than an emergency medical
  106  condition, a facility licensed under chapter 395 shall disclose,
  107  in writing, to the patient all of the following information:
  108         (a) The names, office addresses, and telephone numbers of
  109  providers who will treat the patient, and which of those
  110  providers are nonparticipating providers. The facility shall
  111  identify only those providers who are reasonably expected to
  112  provide specific medical services and treatment scheduled to be
  113  received by the insured.
  114         (b) A statement that nonparticipating providers may
  115  directly bill patients with health insurance for services
  116  rendered within the facility, even after the nonparticipating
  117  provider has been reimbursed by the patient’s insurer.
  118         (8)A nonparticipating provider who treats a patient for a
  119  condition other than an emergency medical condition at a
  120  facility licensed under chapter 395 shall disclose, in writing,
  121  to the patient before providing medical services whether the
  122  patient will be billed directly for such services and shall
  123  provide a written estimate of the amount that will be billed
  124  directly to the patient. A patient is not liable for any
  125  charges, other than applicable copayments or deductibles, billed
  126  to the patient by a nonparticipating provider who fails to
  127  disclose such information and provide the required estimate.
  128         Section 4. Subsection (5) of section 641.513, Florida
  129  Statutes, is amended to read:
  130         641.513 Requirements for providing emergency services and
  131  care.—
  132         (5) Reimbursement for services pursuant to this section by
  133  a provider who does not have a contract with the health
  134  maintenance organization shall be the greater lesser of:
  135         (a) The Medicare allowable rate provider’s charges;
  136         (b) The usual and customary reimbursement received by a
  137  provider charges for the same service similar services in the
  138  community where the service was services were provided; or
  139         (c) The amount negotiated with a provider under a contract
  140  with the health maintenance organization in the same community
  141  where the emergency services were provided, excluding any
  142  copayment payable by the subscriber pursuant to the contract
  143  charge mutually agreed to by the health maintenance organization
  144  and the provider within 60 days of the submittal of the claim.
  146  Such reimbursement shall be net of any applicable copayment
  147  authorized pursuant to subsection (4).
  148         Section 5. This act shall take effect October 1, 2016.