(1) In providing for emergency services and care as a covered service, a health maintenance organization may not:(a) Require prior authorization for the receipt of prehospital transport or treatment or for emergency services and care.
(b) Indicate that emergencies are covered only if care is secured within a certain period of time.
(c) Use terms such as “life threatening” or “bona fide” to qualify the kind of emergency that is covered.
(d) Deny payment based on the subscriber’s failure to notify the health maintenance organization in advance of seeking treatment or within a certain period of time after the care is given.
(2) Prehospital and hospital-based trauma services and emergency services and care must be provided to a subscriber of a health maintenance organization as required under ss. 395.1041, 395.4045, and 401.45. (3)(a) When a subscriber is present at a hospital seeking emergency services and care, the determination as to whether an emergency medical condition, as defined in s. 641.47 exists shall be made, for the purposes of treatment, by a physician of the hospital or, to the extent permitted by applicable law, by other appropriate licensed professional hospital personnel under the supervision of the hospital physician. The physician or the appropriate personnel shall indicate in the patient’s chart the results of the screening, examination, and evaluation. The health maintenance organization shall compensate the provider for the screening, evaluation, and examination that is reasonably calculated to assist the health care provider in arriving at a determination as to whether the patient’s condition is an emergency medical condition. The health maintenance organization shall compensate the provider for emergency services and care. If a determination is made that an emergency medical condition does not exist, payment for services rendered subsequent to that determination is governed by the contract under which the subscriber is covered. (b) If a determination has been made that an emergency medical condition exists and the subscriber has notified the hospital, or the hospital emergency personnel otherwise have knowledge that the patient is a subscriber of the health maintenance organization, the hospital must make a reasonable attempt to notify the subscriber’s primary care physician, if known, or the health maintenance organization, if the health maintenance organization had previously requested in writing that the notification be made directly to the health maintenance organization, of the existence of the emergency medical condition. If the primary care physician is not known, or has not been contacted, the hospital must:1. Notify the health maintenance organization as soon as possible prior to discharge of the subscriber from the emergency care area; or
2. Notify the health maintenance organization within 24 hours or on the next business day after admission of the subscriber as an inpatient to the hospital.
If notification required by this paragraph is not accomplished, the hospital must document its attempts to notify the health maintenance organization of the circumstances that precluded attempts to notify the health maintenance organization. A health maintenance organization may not deny payment for emergency services and care based on a hospital’s failure to comply with the notification requirements of this paragraph. Nothing in this paragraph shall alter any contractual responsibility of a subscriber to make contact with the health maintenance organization, subsequent to receiving treatment for the emergency medical condition.
(c) If the subscriber’s primary care physician responds to the notification, the hospital physician and the primary care physician may discuss the appropriate care and treatment of the subscriber. The health maintenance organization may have a member of the hospital staff with whom it has a contract participate in the treatment of the subscriber within the scope of the physician’s hospital staff privileges. The subscriber may be transferred, in accordance with state and federal law, to a hospital that has a contract with the health maintenance organization and has the service capability to treat the subscriber’s emergency medical condition. Notwithstanding any other state law, a hospital may request and collect insurance or financial information from a patient in accordance with federal law, which is necessary to determine if the patient is a subscriber of a health maintenance organization, if emergency services and care are not delayed.
1(4) A subscriber may be charged a reasonable copayment, as provided in s. 641.31(12), for the use of an emergency room. 1(5) Reimbursement for services pursuant to this section by a provider who does not have a contract with the health maintenance organization shall be the lesser of:(a) The provider’s charges;
(b) The usual and customary provider charges for similar services in the community where the services were provided; or
(c) The charge mutually agreed to by the health maintenance organization and the provider within 60 days of the submittal of the claim.
Such reimbursement shall be net of any applicable copayment authorized pursuant to subsection (4).
(6) Reimbursement for services under this section provided to subscribers who are Medicaid recipients by a provider for whom no contract exists between the provider and the health maintenance organization shall be determined under chapter 409.
(7) Reimbursement for services under this section provided to subscribers who are enrolled in a health maintenance organization pursuant to s. 624.91 by a provider for whom no contract exists between the provider and the health maintenance organization shall be the lesser of:(a) The provider’s charges;
(b) The usual and customary provider charges for similar services in the community where the services were provided;
(c) The charge mutually agreed to by the entity and the provider within 60 days after submittal of the claim; or
(d) The Medicaid rate.
1Note.—As created by s. 33, ch. 96-199. As created by s. 9, ch. 96-223, s. 641.513(4) and (5) read:(4) A subscriber may be charged a reasonable copayment, as provided in s. 641.31(12), for the use of an emergency room, except for Medicaid recipients. Nothing in this section is intended to prohibit or limit application of a nominal copayment as provided in s. 409.9081 for the use of an emergency room for services other than emergency services and care.
(5) Reimbursement for services under this section provided to subscribers who are not Medicaid recipients by a provider for whom no contract exists between the provider and the health maintenance organization shall be the lesser of:
(a) The provider’s charges;
(b) The usual and customary provider charges for similar services in the community where the services were provided; or
(c) The charge mutually agreed to by the health maintenance organization and the provider within 60 days after the submittal of the claim.
Such reimbursement shall be net of any applicable copayment authorized pursuant to subsection (4).
