FLORIDA

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The Florida SBL became effective in 2016. The relevant provisions include:

The Types of State Plans Subject to the Law. In Florida, the law applies to Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans.

Emergency and Inadvertent. Florida’s law applies to emergency services, as well as non-emergency services performed by an out-of-network provider at an in-network facility.

Arbitration is Voluntary. In case of a payment dispute, Florida case law has determined that the “baseball-style” arbitration process is voluntary for both the carriers and the medical providers. So, if a medical provider brings an arbitration, the carrier can opt-out, forcing the provider to pursue a judicial remedy.

Reimbursement is at UCR Rates. Carriers are required to reimburse the medical provider at essentially UCR rates. The law requires carriers to pay the lesser of 1) billed charges, 2) UCR, or 3) agreed-upon reimbursement.

Timeline for Filing. A medical provider has 12 months to file for arbitration and under Florida regulations most providers have to object to a payment within 12 months. So, though there is a 4-year statute of limitations for statutory causes of action, 12 months is essentially the operative timeline for action by the medical provider, especially since objecting to the payment within 12 months is a condition precedent to the medical provider bringing the action..

Regarding bifurcation, according to CMS,

Florida does not have an applicable All-Payer Model Agreement that would determine the OON rate. Based on the survey response and CMS communications with the Florida Office of Insurance Regulation staff, CMS understands that Sections 408.7057, 627.42397, 627.64194(4), 627.64194(6), 641.513(5), and 641.514, F.S. and rule 59A-12.030, Florida Administrative Code are specified state laws that will apply for purposes of determining the OON rate with respect to items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Florida, as well as claim dispute payment amounts pertaining to health maintenance organizations (HMO) that are above the claims payment thresholds described in the paragraph below, and by nonparticipating providers or nonparticipating emergency facilities.

Letter from CMS to Governor of Florida, dated January 28, 2022.