409.9128 Requirements for providing emergency services and care.—
(1) In providing for emergency services and care as a covered service, neither a managed care plan nor the MediPass program may:
(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 enrollee’s or the hospital’s failure to notify the managed care plan or MediPass primary care provider in advance 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 an enrollee of a managed care plan or the MediPass program as required under ss. 395.1041, 395.4045, and 401.45.
(3)(a) When an enrollee is present at a hospital seeking emergency services and care, the determination as to whether an emergency medical condition, as defined in s. 409.901, 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 managed care plan or the Medicaid program on behalf of MediPass patients 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 managed care plan or the Medicaid program on behalf of MediPass patients 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 managed care plan’s contract with the agency.
(b) If a determination has been made that an emergency medical condition exists and the enrollee has notified the hospital, or the hospital emergency personnel otherwise has knowledge that the patient is an enrollee of the managed care plan or the MediPass program, the hospital must make a reasonable attempt to notify the enrollee’s primary care physician, if known, or the managed care plan, if the managed care plan had previously requested in writing that the notification be made directly to the managed care plan, 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 managed care plan or the MediPass provider as soon as possible prior to discharge of the enrollee from the emergency care area; or
2. Notify the managed care plan or the MediPass provider within 24 hours or on the next business day after admission of the enrollee as an inpatient to the hospital.
If notification required by this paragraph is not accomplished, the hospital must document its attempts to notify the managed care plan or the MediPass provider or the circumstances that precluded attempts to notify the managed care plan or the MediPass provider. Neither a managed care plan nor the Medicaid program on behalf of MediPass patients may deny payment for emergency services and care based on a hospital’s failure to comply with the notification requirements of this paragraph.
(c) If the enrollee’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 enrollee. The managed care plan may have a member of the hospital staff with whom it has a contract participate in the treatment of the enrollee within the scope of the physician’s hospital staff privileges. The enrollee may be transferred, in accordance with state and federal law, to a hospital that has a contract with the managed care plan and has the service capability to treat the enrollee’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 an enrollee of a managed care plan or the MediPass program, if emergency services and care are not delayed.
(4) 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 provided to an enrollee of a managed care plan under this section by a provider who does not have a contract with the managed care plan 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, as provided in s. 409.967(2)(b).
