Florida Insurance Laws for EPO Direct Access Benefits

An exclusive provider organization, or EPO, is a type of managed health care plan. A medical provider or group of providers contracts with a medical insurance firm to provide health benefits under a medical insurance policy. EPO policy holders are usually required to see only these contracted providers to receive care covered by the policy and have a referral from their primary physician to see a specialist. However, Florida law allows these policy holders direct access to specialists and even noncontracted providers under certain circumstances.

Disclosures and Coverage

• Before a consumer purchases a policy that is an EPO plan, the insurance company must also offer the option of a health plan that is less restrictive regarding available medical providers. The consumer who chooses to purchase the EPO must be given written information in advance, including a detailed listing of the available medical providers and how to access them. Information regarding policy customer service, dispute resolution and emergency care must be provided to the consumer in advance. Florida law requires medical expense reimbursement for necessary medical services that are within the policy's benefit structure, but not made reasonably available by the existing contracted providers.

Emergency Care

• Florida law specifies that an EPO policy holder is allowed direct access to any necessary medical providers to treat an emergency medical situation. State law requires expense reimbursement in this situation if no appropriate contracted medical provider is reasonably accessible. Per the law, such an emergency entails the sudden or unexpected onset of a medical condition manifesting itself by acute symptoms, including injury caused by an accident, where the lack of immediate care could result in loss of life, serious impairment of bodily functions or permanent dysfunction of a bodily organ or part.

Dermatologists

• Florida insurance law specifically allows EPO policy holders direct access to dermatologists. This is applicable only if dermatological services are part of the insurance policy benefits. The dermatologist must also be a contracted provider of the EPO. Under these conditions, the policy holder is allowed to see the dermatologist without any kind of referral or prior authorization. Allowed services under this law are office visits, testing and minor procedures, up to five times in a 12-month period.

Obstetricians/Gynecologists

• Any female policy member of an EPO plan is entitled by state law to see an obstetrician or gynecologist once a year for an exam without a referral or prior authorization. Any medically necessary follow-up care resulting from that exam is also covered. Such medical services must be performed by a contracted provider of the EPO. The insurance company is allowed to require reasonable coordination for such medical services with the patient's primary care physician.