Florida § 627.64194 - Coverage requirements for services provided by nonparticipating providers; payment collection limitations.

§ 627.64194. Coverage requirements for services provided by nonparticipating providers; payment collection limitations.

(1) As used in this section, the term: (a) “Emergency services” means emergency services and care, as defined in s. 641.47(8), which are provided in a facility. (b) “Facility” means a licensed facility as defined in s. 395.002(17) and an urgent care center as defined in s. 395.002. (c) “Insured” means a person who is covered under an individual or group health insurance policy delivered or issued for delivery in this state by an insurer authorized to transact business in this state. (d) “Nonemergency services” means the services and care that are not emergency services. (e) “Nonparticipating provider” means a provider who is not a preferred provider as defined in s. 627.6471 or a provider who is not an exclusive provider as defined in s. 627.6472. For purposes of covered emergency services under this section, a facility licensed under chapter 395 or an urgent care center defined in s. 395.002 is a nonparticipating provider if the facility has not contracted with an insurer to provide emergency services to its insureds at a specified rate. (f) “Participating provider” means, for purposes of this section, a preferred provider as defined in s. 627.6471 or an exclusive provider as defined in s. 627.6472. (2) An insurer is solely liable for payment of fees to a nonparticipating provider of covered emergency services provided to an insured in accordance with the coverage terms of the health insurance policy, and such insured is not liable for payment of fees for covered services to a nonparticipating provider of emergency services, other than applicable copayments, coinsurance, and deductibles. An insurer must provide coverage for emergency services that: (a) May not require prior authorization. (b) Must be provided regardless of whether the services are furnished by a participating provider or a nonparticipating provider. (c) May impose a coinsurance amount, copayment, or limitation of benefits requirement for a nonparticipating provider only if the same requirement applies to a participating provider. The provisions of s. 627.638 apply to this subsection. (3) An insurer is solely liable for payment of fees to a nonparticipating provider of covered nonemergency services provided to an insured in accordance with the coverage terms of the health insurance policy, and such insured is not liable for payment of fees to a nonparticipating provider, other than applicable copayments, coinsurance, and deductibles, for covered nonemergency services that are: (a) Provided in a facility that has a contract for the nonemergency services with the insurer which the facility would be otherwise obligated to provide under contract with the insurer; and (b) Provided when the insured does not have the ability and opportunity to choose a participating provider at the facility who is available to treat the insured. The provisions of s. 627.638 apply to this subsection. (4) An insurer must reimburse a nonparticipating provider of services under subsections (2) and (3) as specified in s. 641.513(5), reduced only by insured cost share responsibilities as specified in the health insurance policy, within the applicable timeframe provided in s. 627.6131. (5) A nonparticipating provider of emergency services as provided in subsection (2) or a nonparticipating provider of nonemergency services as provided in subsection (3) may not be reimbursed an amount greater than the amount provided in subsection (4) and may not collect or attempt to collect from the insured, directly or indirectly, any excess amount, other than copayments, coinsurance, and deductibles. This section does not prohibit a nonparticipating provider from collecting or attempting to collect from the insured an amount due for the provision of noncovered services. (6) Any dispute with regard to the reimbursement to the nonparticipating provider of emergency or nonemergency services as provided in subsection (4) shall be resolved in a court of competent jurisdiction or through the voluntary dispute resolution process in s. 408.7057.