Florida Statutes
Fla. Stat. § 627.64194 (2025)
Coverage requirements for services provided by nonparticipating providers; payment collection limitations.
✓ 2025 Florida Statutes — current through the 2025 Regular Session
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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.
(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.
Notes of Decisions
Cited in 12
cases (8 in the last 5 years), 2017–2026 · leading case: Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 371 F. Supp. 3d 1056 (M.D. Fla. 2019).
Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 371 F. Supp. 3d 1056 (M.D. Fla. 2019). “See Fla. Stat. § 627.64194 . The applicable section of the statute, § 627.”
Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 362 F. Supp. 3d 1217 (M.D. Fla. 2019). “513(5) ; and (iv) § 627.64194. See n. 1; see also, e.g. , Premier Inpatient Partners, LLC, (J.”
Hialeah Anesthesia Specialists, LLC v. Coventry Health Care of Florida, Inc., 258 F. Supp. 3d 1323 (S.D. Fla. 2017). “” Fla. Stat. § 627.64194 (3) (emphasis added); see also Pis.”
North Shore Med. Ctr., Inc. v. Cigna Health & Life Ins. Co., 68 F.4th 1241 (11th Cir. 2023). “And they rely on Fla. Stat. § 627.64194 (4), which incorporates the reimbursement standard set out in Fla.”
AMISUB (SFH), Inc. v. Cigna Health & Life Ins. Co., 142 F.4th 403 (6th Cir. 2025). “Fla. Stat. §§ 627.64194 , 641.513. Tennessee had no such statutory scheme during the events of this case.”
Sarasota Cnty. Pub. Hosp. Bd. v. Blue Cross & Blue Shield of Florida, Inc. (M.D. Fla. 2021). “513, Florida Statutes, and Section 627.64194, Florida Statutes. In Counts III and IV, the plaintiff alleges that the defendants breached the “anti- steerage” provisions of the Provider Agreements by “advising, steering, and providing incentives to [plan] members to seek hospital…”
Surgery Ctr. of Viera, LLC v. Cigna Health & Life Ins. Co., Inc. (M.D. Fla. 2020). “” Fla. Stat. § 627.64194 (3) (emphasis added).”
Benjamin J. Cousins, M.D., P.A. v. Blue Cross & Blue Shield of Florida, Inc., et al. (S.D. Fla. 2026). “Section 627.64194 states that “[a]n 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 “must reimburse a nonparticipating…”
Worldwide Aircraft Servs., Inc. v. Anthem Ins. Companies, Inc. (M.D. Fla. 2022). “As a result of Jet ICU’s status as an out-of-network out-of-plan provider, the reimbursement methodology, under the Certificate, requires the claim to be priced as required by state or federal law – in this case Fla. Stat. § 627.64194 . Id. ¶ 34 . Further, the Certificate also…”
Vanguard Plastic Surgery, PLLC v. UnitedHealthcare Ins. Co. (S.D. Fla. 2023). “513 and § 627.64194, as well as the common law causes of action under which Plaintiffs bring their state law claims all have force and operate independently of the existence of any ERISA plans.”
Neurosurgical Consultants of South Florida, L.L.C. v. Blue Cross & Blue Shield of Rhode Island (S.D. Fla. 2025). “Now, in the operative Second Amended Complaint (the “Complaint”), Plaintiff brings three claims against Defendant: • Count I: Violation of Fla. Stat. § 627.64194 (Coverage requirements for services provided by nonparticipating providers; payment collection limitations) • Count…”
B. Rai Gupta, M.D., P.A. v. Cigna Health & Life Ins. Co. & Allegiance Benefit Plan Mgmt., Inc. (M.D. Fla. 2025). “asserts nineteen counts, collectively alleging 1) causes of action brought under Florida Statute § 627.64194, and 2) breach of contract implied in fact.”
— 627.64194(3) — 1 case
Surgery Ctr. of Viera, LLC v. Cigna Health & Life Ins. Co., Inc. (M.D. Fla. 2020). “” Fla. Stat. § 627.64194 (3) (emphasis added).”
— 627.64194(4) — 3 cases
Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 371 F. Supp. 3d 1056 (M.D. Fla. 2019). “See Fla. Stat. § 627.64194 . The applicable section of the statute, § 627.”
Benjamin J. Cousins, M.D., P.A. v. Blue Cross & Blue Shield of Florida, Inc., et al. (S.D. Fla. 2026). “Section 627.64194 states that “[a]n 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 “must reimburse a nonparticipating…”
Vanguard Plastic Surgery, PLLC v. UnitedHealthcare Ins. Co. (S.D. Fla. 2023). “513 and § 627.64194, as well as the common law causes of action under which Plaintiffs bring their state law claims all have force and operate independently of the existence of any ERISA plans.”
— 627.64194(6) — 1 case
Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 371 F. Supp. 3d 1056 (M.D. Fla. 2019). “See Fla. Stat. § 627.64194 . The applicable section of the statute, § 627.”
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