What Florida Blue members in Broward should know about billing, ER and other care

For months now, ongoing contract disputes have prevented Florida Blue members from getting in-network care at Broward County’s two public hospital systems, Broward Health and Memorial, unless it’s an emergency situation.

That’s left tens of thousands of people with questions about how to get care and how to get it covered. What qualifies as an emergency? What if you get admitted to the hospital? And what about follow-up care?

Here are some things to know about how to navigate medical care and billing during the dispute:

ER or urgent care: Which one do you need?

Before getting into the details of what’s covered and what’s not, it’s important to consider what type of medical care you need. ERs are meant for life-threatening or potentially life-threatening symptoms and conditions, such as if you’re struggling to breathe, or have chest pain or numbness on one side of the body.

Urgent care is the place to start for everything else, like a cough, sore throat, runny nose or diarrhea. Urgent care visits are also cheaper.

It may help to review your insurance plan before something goes wrong to figure out which urgent care centers, ERs and standalone ERs are in-network. Remember, if it’s a medical emergency, go to your nearest ER, even if it’s out-of-network, or call 911.

TIP: If you don’t have a primary care doctor, you can also look for a nearby community health center for routine check-ups and other health needs.

Are ER visits at Memorial, Broward Health covered by Florida Blue?

The good news is that Florida Blue, like most health insurers, is required by law to cover emergency care at Memorial, Broward Health and other ERs at in-network rates, even if the emergency room is out-of-network.

It doesn’t matter if the patient is hospitalized or goes home the same day. If it’s an emergency, health insurance will cover it at in-network rates, according to Florida Blue, the hospitals and Patricia Kelmar, senior director of healthcare campaigns at PIRG, a nonprofit that advocates for consumer protections, public health and environmental sustainability.

TIP: Pay attention to the documents you sign, or ask a family member or friend to be your advocate and look over the paperwork before signing. Kelmar said out-of-network providers will sometimes ask you to sign a consent form that waives your protections under the federal No Surprises Act, leaving you responsible for surprise bills.

Providers are prohibited from asking you to waive your rights while providing emergency care, but it could pop up later on, according to Kelmar. She gave the example of going to an out-of-network ER for a dog bite. After the wound is sutured and you’re recovering, a plastic surgeon may come in to offer their services to help avoid scarring. That may be the moment you’re given a waiver for that part of the care.

Who decides if your situation is an emergency when it comes to billing?

This is where emergency care gets complicated.

ER doctors decide the necessary treatment. But it’s the health insurer that ultimately determines whether the provided services fall under emergency care for in-network rates, according to Kelmar and Broward Health.

What are examples of emergency symptoms or conditions, for billing purposes?

While Florida Blue responded to a list of emailed emergency-care related questions, it did not answer a Miami Herald question that asked for examples of conditions that would and would not be considered emergency care.

Broward Health and Memorial Health similarly did not respond to the question. Memorial, in its response, reiterated that federal law ensures patients can get “care when they believe they are experiencing a medical emergency, regardless of insurance coverage or ability to pay.” But Broward Health, in its response, said that health insurers don’t always agree with doctors on what is an emergency and recommended that patients contact their insurance provider for examples.

Kelmar, the patient health advocate expert, said it’s important to review your health insurance plan to know what is and is not covered. Everyone reiterated that people should go to their nearest ER if they feel like it’s an emergency.

What should you do if your emergency care claim is denied?

Always dispute the claim if your health insurer declines to cover the emergency care at in-network rates, Kelmar said. The patient care advocate recommends asking the provider to write you a letter of support.

Most people don’t appeal denials. But the few that do often win. Of the 850 million claims denied annually, less than 1% are appealed, according to the Wall Street Journal. Of those appeals, nearly three-quarters are approved.

For tips on how to appeal your health insurer’s denial, visit pirg.org/edfund/resources/did-your-insurance-deny-your-health-care-claim-how-to-appeal/

What about prescription medicine and physical therapy?

“For a member admitted to the hospital for emergency care, the medications and therapies prescribed are considered in-network,” Florida Blue told the Herald.

TIP: Make sure to get your prescription filled at an in-network pharmacy to avoid heftier costs. Physical therapy should be at in-network facilities, too. Physical therapy is important for recovery, but, it’s not considered an emergency service, according to Kelmar.

“If a member chooses to receive care from out-of-network providers, they may experience higher out-of-pocket costs, and under some benefit plans, may have no coverage at all,” Florida Blue said.

What if you’re admitted to the hospital from the ER?

Health insurers are typically required to cover emergency services at in-network rates at all U.S. hospitals, even if the facility is out-of-network.

“If you’re admitted to a Memorial Healthcare System hospital after a visit to their ER, even if the hospital is no longer in the network, the hospital stay for that emergency is covered at your in-network cost share,” Florida Blue states on a webpage dedicated to its ongoing contract dispute with the hospital.

The same is true for Broward Health hospitals and other out-of-network ERs. However, it’s important to know that not all admissions through the ER will qualify as an emergency for in-network billing, according to Broward Health.

“Generally, an emergency designation — under federal and state law — ends once a patient is stabilized. Hospitals provide emergency care and stabilizing treatment under EMTALA [the federal Emergency Medical Treatment and Labor Act] at in-network benefit,” the hospital said. “Once stabilized, insurance coverage and billing classifications for admissions, including the underlying diagnosis, are determined by the insurance provider.”

What if an ambulance takes you to the hospital? What if you drive yourself?

Kelmar said it doesn’t matter if you drive yourself to the ER or if you get there by rideshare or an ambulance. The federal No Surprises Act requires health insurers to give in-network rates for emergency services at all hospitals, even if the facilities are out-of-network, no matter how you got there.

But be careful. Many health insurances don’t cover non-emergency ground ambulance transportation.

If 911 sends an ambulance to take you to the nearest hospital, health insurers will generally consider it to be an emergency ride, Kelmar said. But insurers may consider other ambulance rides to be non-emergency — like if you yourself call an ambulance to take you to or from the hospital, or if a hospital orders an ambulance to take you to another facility — and may try to deny or limit coverage. Miami-Dade and Broward counties do have rules in place that limit how much ambulance services can charge.

Kelmar’s recommendation: Review your health insurance plan for coverage information. And if you get hit with a denial, or a hefty bill, appeal it.

Are follow-up appointments covered at out-of-network hospitals?

No. Only emergency care is covered at in-network rates. Once discharged, any follow-up care is no longer “considered emergency care but elective care,” according to Florida Blue.

What’s going on with Florida Blue and Cleveland Clinic?

Contract disputes had put Cleveland Clinic at risk of leaving Florida Blue’s network, similar to Broward Health and Memorial. But, after months of negotiations, a deal was made Friday, just shy of the deadline that would have left Florida Blue members locked out of in-network care with Cleveland Clinic.

Cleveland Clinic will continue to be in-network for Florida Blue members. That includes for patients with Florida Blue employer-sponsored plans, Health Insurance Marketplace coverage and Medicare Advantage plans.

Where can I go in Broward for in-network care right now?

Florida Blue told the Herald it still has many other in-network providers in Broward. Here are some options:

•HCA Florida told the Herald it accepts Florida Blue at its 14 hospitals across South Florida and its over 65 MD Now Urgent Care locations. All 12 of its freestanding ERs, including the one in Plantation, and its over 100 HCA Florida physician offices also accept the insurance, including Medicare Advantage, HMO and ACA plans associated with Florida Blue.

•Baptist Health South Florida, the region’s largest not-for-profit healthcare system, also has physician practices, urgent care centers and outpatient centers across South Florida, including in Broward County. It has 12 hospitals across South Florida, though none are in Broward County.

•Holy Cross Hospital in Fort Lauderdale and Cleveland Clinic’s hospital in Weston are also in-network with Florida Blue. Nicklaus Children’s doctors working at Broward Health facilities also remain in-network, according to Broward Health.

READ MORE: Do you have Florida Blue and need care? Here are some Broward options

How long could the disputes between Florida Blue and Broward Health and Memorial drag on?

It’s hard to say. All three have said that they’re committed to making a deal since negotiations began last year.

Could this happen in Miami-Dade hospitals?

Hospitals across Miami-Dade County, just like the rest of South Florida, accept many health insurance plans. All providers and health insurers eventually undergo contract negotiations, which can sometimes lead to changes in care.

That can lead to expanded coverage and the addition of new providers for patients, or changes that lead to certain providers or care no longer being in-network. Hospitals and health insurers usually notify patients of potential significant changes, such as if there’s a chance their hospital may go out-of-network.

Many times, negotiations stay behind closed doors. Sometimes, like in the case of Memorial, Broward Health and Cleveland Clinic, contract disputes spill out into the public.

If you have questions

Call your health insurance provider. Florida’s Division of Consumer Services, Florida SHINE and local advocacy groups like Catalyst Miami may be able to help answer your health insurance questions, too.

The U.S. Centers for Medicare and Medicaid Services also has information online on your rights as a health insurance customer.

Kelmar also recommends contacting the federal No Surprises help desk at 1-800-985-3059 if you have questions about your medical bill or want to file a complaint.

©2026 Miami Herald. Visit miamiherald.com. Distributed by Tribune Content Agency, LLC.