AB 539

Under current law, if an applicant for Medical Assistance (MA) is determined

to be eligible for MA retroactively (for three months) and a provider bills the

applicant directly for services and benefits rendered during the retroactive period,

the provider must submit MA claims for those services and benefits that are covered

under MA. Upon receiving MA payment under the claims, the provider must

reimburse the MA recipient, or other person who made the prior payment on behalf

of the recipient, the amount of the prior payment made for services provided to the

recipient during the retroactive eligibility period.

This bill restricts payment that a "health care provider," as defined in the bill,

may accept from certain patients who are uninsured or who do not have "public

coverage," as defined in the bill. If the patient, within 90 days after receiving a health

care service, diagnostic test, or procedure or the first treatment or visit of a course

of treatment as part of a health care service, obtains coverage from an insurer or a

self-insured health plan under a contract for not less than one year, the health care

provider must accept, as payment from the patient for the service, test, or procedure

no more than the insurer's or plan's payment amount for that service, test, or

procedure, or, if the service or provider is not covered under the coverage the patient

obtains, no more than the average rate paid by insurers or self-insured health plans

for the service, test, or procedure. However, the patient may be liable to the health

care provider for out-of-pocket costs, finance charges, and collection costs incurred

that would not have been covered under the patient's coverage. The insurer or

self-insured health plan that provides coverage must provide to the patient a dollar

estimate of the applicable payment amount for the service, test, or procedure the

patient received. A health care provider must provide to a patient who is uninsured

or does not have public coverage, at the time the health care service, test, or

procedure is provided or after the first treatment or visit of a course of treatment,

information about this restriction on payment and information about the restriction

on acceptance of patient payment for MA applicants who receive retroactive

eligibility.

Under the bill, if a patient is recommended, referred for service, or prescribed

a health care service (including any applicable course of treatment), diagnostic test,

or procedure for which the charge exceeds $500 or any higher amount that the

Department of Health Services (DHS) promulgates by rule (the minimum cost), the

health care provider must provide an estimate of the charge to the patient, whether

insured or uninsured, or the patient's agent who requests it. The estimate of the

charge must be provided at the time of scheduling of the health care service,

diagnostic test, procedure, or course of treatment, or within ten business days of the

request, whichever is later. The bill specifies numerous requirements for the

estimate of charge, except that, in lieu of several of the requirements, a health care

provider may provide to the patient or his or her agent an estimate of charge that is