Florida PIP Fee Schedule: 14-Day Rule, Caps, and 80/20 Split

The Florida PIP fee schedule caps what your auto insurer pays for medical treatment after a crash by tying most reimbursements to Medicare rates. For physician and outpatient care, the ceiling is 200 percent of the Medicare Part B rate for that service, and the insurer then pays 80 percent of that ceiling.¹ Total benefits are capped at $10,000 when an emergency medical condition is diagnosed and $2,500 when it is not. The schedule only matters, though, if you clear a threshold most people underestimate: getting treated in time, by the right kind of provider.

You Have 14 Days to See Someone

Initial medical services must be received within 14 days of the accident. Miss that window and you lose PIP benefits entirely.¹ It is a hard rule, not a guideline. The 14 days apply to your first visit, not the entire course of care. Once a qualified provider has seen you inside the window, follow-up treatment can continue beyond it.

Who Can Provide That First Visit

Not every licensed professional qualifies. The statute limits initial services to:²

Physicians (MD or DO)
Dentists, for injuries to the mouth, jaw, or teeth
Chiropractic physicians
Advanced practice registered nurses registered under the PIP statute
Hospitals and emergency departments, including facilities owned by a hospital
Licensed ambulance services

After one of these providers refers you, physical therapists, physician assistants, and certain licensed health care clinics can take over ongoing care. Massage therapy and acupuncture are excluded from PIP coverage entirely, regardless of who provides them.³

How the Reimbursement Ceilings Work

The fee schedule is not one rate. It sets different ceilings for different categories of care, and the insurer pays 80 percent of whichever ceiling applies to the specific service billed.¹

Physician and Outpatient Services

For most doctor visits, lab work, and outpatient care, the ceiling is 200 percent of the allowable amount under the Medicare Part B participating physicians fee schedule for the year the services were provided. Ambulatory surgical centers and clinical laboratories use the broader Medicare Part B rates. Durable medical equipment follows the Medicare Part B DME fee schedule.

Because the ceiling is tied to Medicare, it shifts whenever Medicare adjusts its conversion factor. The 2026 Medicare Part B conversion factor is $33.40 per relative value unit for most physicians.⁴ Under PIP, the ceiling per unit would be double that figure, and the insurer would pay 80 percent of the doubled amount.

Hospital Services

Hospital reimbursement depends on whether the care was emergent and whether it was inpatient or outpatient:

Emergency hospital services: 75 percent of the hospital’s usual and customary charges. A physician or dentist providing emergency care inside a hospital is reimbursed at the usual and customary charges in the community.
Non-emergency inpatient stays: 200 percent of the Medicare Part A prospective payment for that specific hospital.
Non-emergency outpatient services: 200 percent of the Medicare Part A Ambulatory Payment Classification for that hospital.
Emergency ambulance transport: 200 percent of Medicare.⁵

A patient admitted through the ER who later transitions to inpatient care may have two line items on the same bill governed by entirely different formulas: the ER portion against the hospital’s own charges, the inpatient portion against Medicare.

Services With No Medicare Equivalent

If Medicare does not reimburse a particular service, the insurer can cap payment at 80 percent of the maximum allowable amount under Florida’s workers’ compensation fee schedule. If the service is covered by neither Medicare nor workers’ compensation, the insurer is not required to reimburse it at all. Specialized therapies and newer treatment modalities sometimes fall into that gap.

The 80 Percent You Get, the 20 Percent You Owe

Across every category, PIP pays 80 percent of the ceiling. The remaining 20 percent is yours to cover, through out-of-pocket payment, your health plan, or Medical Payments (MedPay) coverage if your auto policy includes it.¹ That 20 percent is calculated on the capped amount, not the provider’s full bill. On a $500 service with a $400 fee schedule ceiling, PIP pays $320 and you owe $80.

The $10,000 vs. $2,500 Benefit Cap

Even with the fee schedule applied correctly, total PIP benefits are hard-capped based on the severity of your injuries. A qualifying provider has to determine that you have an emergency medical condition for the full benefit to be available.

Emergency medical condition diagnosed: up to $10,000 in combined medical and disability benefits. The determination must come from a physician, dentist, physician assistant, or advanced practice registered nurse.
No emergency medical condition: medical benefits capped at $2,500, regardless of how much treatment you need.¹

Soft tissue injuries, chronic pain, and conditions that develop gradually after a crash often fail the emergency medical condition threshold. If a provider documents your injuries as non-emergent, the insurer can lawfully stop paying medical benefits at $2,500. What a treating provider writes in those first records shapes what gets paid.

When an Insurer Can Actually Use the Fee Schedule

An insurer cannot default to Medicare-based rates. The policy itself must contain a clear election to use the fee schedule methodology for calculating reimbursements.⁵ Without that election, the insurer has to pay based on reasonable medical expenses, which typically produces higher reimbursements for providers and smaller balances for patients.

The Florida Supreme Court held in 2013’s Geico General Insurance Co. v. Virtual Imaging Services, Inc. that applying the fee schedule without a clear policy election violated the statute.⁶ The 2012 reforms codified the notice requirement directly into the statute, so the rule is both statutory and judicially affirmed. Vague policy language can still cost insurers the right to apply the lower rates.

Deductibles

Florida law requires insurers to offer PIP deductibles of $250, $500, or $1,000.⁷ A higher deductible lowers your premium but means you pay more before PIP starts covering anything. The deductible applies to 100 percent of covered expenses and lost wages. Once satisfied, the full $10,000 benefit pool remains available; the deductible does not reduce it.

What PIP Won’t Cover That You Might Expect

Two boundaries catch people off guard. First, the $10,000 (or $2,500) pool covers both medical bills and disability benefits. If you cannot work, PIP pays 60 percent of lost gross income from the same pool as your treatment.¹ Heavy medical use can exhaust the pool before any lost-wage check is written.

Second, PIP is the primary payer for auto accident injuries in Florida. Your private health insurance does not step in until PIP is exhausted, and Medicare operates the same way under federal secondary payer rules: no-fault must pay first.⁸ If Medicare does make conditional payments while a PIP claim is pending, it has a right to be reimbursed. MedPay coverage, if you carry it, can absorb the 20 percent coinsurance PIP leaves behind and any bills that exceed your PIP cap.

1
Florida Senate. Florida Code 627.736 – Required Personal Injury Protection Benefits; Exclusions; Priority; Claims
2
Florida Senate. Florida Code 627.736 – Required Personal Injury Protection Benefits; Exclusions; Priority; Claims
3
Florida Senate. Florida Code 627.736 – Required Personal Injury Protection Benefits; Exclusions; Priority; Claims
4
Centers for Medicare & Medicaid Services. Calendar Year (CY) 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F)
5
Online Sunshine. Florida Code 627.736 – Required Personal Injury Protection Benefits; Exclusions; Priority; Claims
6
Justia Law. Geico Gen. Ins. Co. v. Virtual Imaging Servs., Inc.
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Online Sunshine. Florida Code 627.739 – Personal Injury Protection; Optional Limitations; Deductibles
8
Centers for Medicare & Medicaid Services. Medicare Secondary Payer (MSP) Liability Insurance, No-Fault Insurance and Workers’ Compensation Recovery Process