Florida’s New PPO Balance Billing Prohibition: Outlook for Providers and Patients
By Maria D. Garcia
During the 2016 Florida Legislative Session, House Bill 221 was signed into law.1 House Bill 221 created Florida Statute 627.64194, which includes the state’s new preferred provider organization (PPO) balance billing prohibition, and provides new coverage and payment requirements that are important to both providers and patients.
Specifically, Florida Statute §627.64194(2)-(3) provides that the insurer is solely liable for payment of fees to a “nonparticipating provider” for (1) covered emergency services or (2) covered nonemergency services, respectively, provided to an insured in accordance with the coverage terms of the health insurance policy.2 Moreover, the insured patient is generally not liable for payment of fees for covered services, other than “applicable copayments, coinsurance, and deductibles.”3 Ultimately, a new balance billing prohibition has been codified into law pursuant to this new statute, which applies to Chapter 627 plans, such as fully insured PPO plans.
Providers should also be aware of the following. The new Florida Statute §627.64194 provides parameters for the type of “covered nonemergency services” to which its coverage and payment requirements apply. As to reimbursement to a “nonparticipating provider,” payment to said provider(s) under Florida Statute §627.64194(3) applies to “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.”4
Importantly, the provisions found in Florida Statute §627.64194(3) will likely have an effect on patients who are sometimes presented with unexpected bills and are balance billed for certain services provided by “nonparticipating providers.” For example, these new provisions may address instances where a patient has a procedure (such as a colonoscopy) completed at a facility, which is included in the patient’s health plan network, yet the anesthesiology services for the procedure are provided by a “nonparticipating provider.” Under this example, the patient that did not have the ability or opportunity to be treated by a “participating provider” at said facility, may invoke the new prohibition from balance billing under the new statute.
These new provisions in Florida Statute §627.64194(3) may be timely in an era of narrow network plans. Florida has enacted this statute at least in part as a patient protection measure. One may expect an increase in these types of measures in other areas of the country where narrow network plans have proliferated.
1 See 2016 Fla. HB 221.
2 See Florida Statute §627.64194(2)–(3) (2016), effective July 1, 2016.
4 See Florida Statute §627.64194(3)(a)-(b) (2016), effective July 1, 2016.