Florida Statute 627.64194 - Full Text and Legal Analysis

The 2025 Florida Statutes

Title XXXVII
INSURANCE

Chapter 627
INSURANCE RATES AND CONTRACTS

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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.

(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.

History.—s. 12, ch. 2016-222; s. 107, ch. 2018-24; s. 13, ch. 2021-112.

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Amendments to 627.64194

Annotations, Discussions, Cases:

Cases Citing Statute 627.64194

Total Results: 4 | Sort by: Relevance | Newest First

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Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 371 F. Supp. 3d 1056 (M.D. Fla. 2019).

Cited 2 times | Published | District Court, M.D. Florida

...43) On July 18, 2018, the Court granted Plaintiff's Motion, allowing withdrawal of Count II of the Complaint and an amendment of Count I. (Dkt. 54) The resulting complaint (hereinafter, "Amended Complaint") alleges one count of breach of implied-in-law contract, alleging a violation of both Fla. Stat. §§ 641.513 (5) and 627.64194....

...Florida Law Overview Florida law requires HMOs, such as Defendant, to reimburse out-of-network emergency medical service providers, such as Plaintiff, within certain time parameters and at specified rates for emergency services medical treatment. See Fla. Stat. §§ 641.513 (5), 641.3155(3), 627.6131(4)(b), and 627.64194....

...In each of the Pinellas County Complaints, Plaintiff seeks to recoup the outstanding balance for its billed emergency medical services, citing three Florida statutes as the bases for its allegations. (Dkt. 2) Additionally, in several of the Hillsborough County Complaints, Plaintiff cites a fourth *1070 Florida statute, § 627.64194....

...at (4)(c). Likewise, § 627.6131(5) parrots § 641.3155(5)'s mandate concerning the procedure for nonelectronically submitted claims. Id. at (5). *1071 Lastly, in several of the Hillsborough County Complaints, Plaintiff cites a fourth Florida statute, § 627.64194. E.g. , Hillsborough County First-Filed Case , Docket No. 2. Section 627.64194 of the Florida Insurance Code also establishes coverage requirements for non-participating provider services and sets payment collection limitations. See Fla. Stat. § 627.64194 . The applicable section of the statute, § 627.64194(4), requires an insurer to "reimburse a non-participating provider of services ... 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." Id. at (4). Moreover, § 627.64194(6) provides that "any dispute with regard to the reimbursement to the non-participating provider ......

...2; see also Premier Inpatient Partners, LLC, (D.A.Z.) , 8:19-cv-00242-MSS-AAS, Docket No. 1-1. In seventeen of the twenty-two Hillsborough County Cases, the Complaints assert two additional counts, "declaratory judgment" and "unjust enrichment/quantum merit," and reference an additional Florida statute, § 627.64194....

..., Premier Inpatient Partners, LLC, (E.A.) , 8:18-cv-01818-MSS-AAS, Docket No. 2 at 5-10. In the 5 last-filed cases, including (1) 8:19-cv-00074; (2) 8:19-cv-00075; (3) 8:19-cv-00076; (4) 8:19-cv-00241; and (5) 8:19-cv-00242, the operative Complaints assert claims pursuant to only two Florida statutes, §§ 641.513(5) and 627.64194, and do not include any claims pursuant to § 3155 of Florida's Prompt Payment Act....

...Fla. 2006), aff'd sub nom. Shane v. Humana, Inc. , 228 F. App'x 927 (11th Cir. 2007) (unpublished). 591 F.3d at 1342 . As previously noted, in seventeen of the twenty-two Hillsborough County Cases, Plaintiff references an additional Florida statute, § 627.64194....

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Premier Inpatient Partners LLC v. Aetna Health & Life Ins. Co., 362 F. Supp. 3d 1217 (M.D. Fla. 2019).

Cited 2 times | Published | District Court, M.D. Florida

...32) On July 18, 2018, the Court granted Plaintiff's Motion, allowing withdrawal of Count II of the Complaint and an amendment of Count I. (Dkt. 42) The resulting Amended Complaint alleges one count of breach of implied-in-law contract, alleging a violation of both Fla. Stat. §§ 641.513 (5) and 627.64194....

...volving the administration of the program.") The Court notes that in the Hillsborough County Cases, Plaintiff cites four (4) Florida Statutes in each of the initial Complaints-(i) § 641.3155(6) ; (ii) § 627.6131(7) ; (iii) § 641.513(5) ; and (iv) § 627.64194....

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Hialeah Anesthesia Specialists, LLC v. Coventry Health Care of Florida, Inc., 258 F. Supp. 3d 1323 (S.D. Fla. 2017).

Cited 1 times | Published | District Court, S.D. Florida

...Their argument in favor of this recognition is supported by a recently enacted Florida statutory provision (taking effect July 1, 2016), which creates an obligation for insurers to pay fees to an out-of-network “provider of covered «««emergency services provided to an’ insured.” Fla. Stat. § 627.64194 (3) (emphasis added); see also Pis.’ Reply at 4 n.2....

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North Shore Med. Ctr., Inc. v. Cigna Health & Life Ins. Co. (11th Cir. 2023).

Published | Court of Appeals for the Eleventh Circuit

Argued: Apr 18, 2023

portion of their ER costs. Fla. Stat. § 627.64194(4). As relevant here, the measure of what the

This Florida statute resource is curated by Graham W. Syfert, Esq., a Jacksonville, Florida personal injury and workers' compensation attorney. Attorney Syfert regularly works with Chapter 627 in the context of insurance coverage law and represents clients throughout Northeast Florida. For legal consultation, call 904-383-7448.