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2019 SESSION

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HB 2538 Health insurance; payment of out-of-network providers, patient access to elective services.

Introduced by: R. Lee Ware | all patrons    ...    notes | add to my profiles | history

SUMMARY AS PASSED HOUSE:

Balance billing; elective services. Requires a facility where a covered person receives scheduled elective services to post the required notice or inform the covered person of the required notice at the time of pre-admission or pre-registration. The bill also requires such a facility to inform the covered person or his legal representative of the names of all provider groups providing health care services at the facility, that consultation with the covered person's managed care plan is recommended to determine if the provider groups providing health care services at the facility are in-network providers, and that the covered person may be financially responsible for health care services performed by a provider that is not an in-network provider, in addition to any cost-sharing requirements.

SUMMARY AS INTRODUCED:

Balance billing; emergency and elective services. Requires health care facilities and health care providers to determine if providers scheduled to deliver elective services to a covered person are in the network of the covered person's managed care plan. The measure requires that when an elective service provider is determined to be out-of-network, in order for the covered person to assume financial responsibility for the out-of-network provider's charges, the health care facility or provider shall (i) inform the covered person of the out-of-network status of the provider, (ii) provide the covered person with the opportunity to be referred to an in-network provider, and (iii) prepare a document for signature by the covered person in which the covered person or his legal representative assumes financial responsibility for services performed by the out-of-network provider, and the covered person must sign the document described in clause (iii). The bill provides that such requirements will also apply to a health care provider in an office-based setting making a referral for elective radiology or pathology services. The bill identifies post-stabilization services, performed in order to maintain or improve a person's stabilized condition related to an emergency medical condition, as emergency services if (a) the post-stabilization services are pre-approved or related to pre-approved services; (b) for an out-of-network facility, the health carrier does not effectuate transfer of the covered person within a reasonable amount of time after being notified by the facility of the covered person's need for post-stabilization services; (c) for an out-of-network health care professional, the facility is in-network; or (d) the out-of-network facility is unable to reasonably obtain health carrier information from the covered person prior to the furnishing of such services. The measure directs health carriers that provide individual or group health insurance that provide any benefits with respect to services rendered in an emergency department of a hospital to pay directly to an out-of-network health care provider the fair market value, as defined in the bill, for the emergency services, less applicable cost-sharing requirements. The bill provides that direct payment from the health carrier to the out-of-network health care provider precludes the out-of-network health care provider from billing or seeking payment from the covered person for any other amount other than the applicable cost-sharing requirements. The bill removes from the determination of whether a medical condition is an emergency medical condition the final diagnosis rendered to the covered person.