SB 778

This bill creates disclosure, notice, billing, and mediation requirements for the

situation in which a patient may receive services from a health care provider that is

not in the network of the patient's defined network plan or preferred provider plan.

Under the bill, a defined network plan or a preferred provider plan must annually

provide to members of the plan a directory of providers that are in its network. The

defined network plan or preferred provider plan must also provide its members a list

of health care facilities that are in its network.

The bill also requires that a provider who is not in the network of the enrollee's

defined network plan or preferred provider plan but is providing a service at an

in-network health care facility must disclose that information to the enrollee,

provide the enrollee a good-faith estimate of the cost of services the enrollee may be

responsible for, and inform the enrollee of the availability of mediation to settle

disputes over the cost of services. In particular, the enrollee is entitled to mediation

for a claim if the amount that the enrollee is financially responsible for, after

copayments, deductibles, and coinsurance, is more than $500. The enrollee is not

entitled to mediation if the out-of-network provider provides the required disclosure

and the amount the enrollee is financially responsible for is less than the good-faith

estimate provided by the provider. The health care facility may opt to provide the

notice for the provider.

Under the bill, if an enrollee of a defined network plan or preferred provider

plan requires medically necessary services that are not available from an

in-network provider within a reasonable time, then the plan must provide an

opportunity for referral to an out-of-network provider. The plan must reimburse the

out-of-network provider at the usual and customary rate or at a rate agreed to

between the provider and the plan and may only require that the enrollee pay no

more than the enrollee would have paid had the provider been in the plan's network.

The bill requires the enrollee to provide the out-of-network provider an assignment

of benefits for any service, item or supply provided by that provider.

Similarly, under the bill, if an enrollee of a defined network plan or preferred

provider plan receives emergency services from an out-of-network provider, then

the plan must reimburse the provider at the usual and customary rate or at a rate

agreed to between the provider and the plan and may only require the enrollee to pay

no more than the enrollee would have paid if the provider was in the plan's network.