AB 329

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

situation in which an enrollee in a defined network plan or preferred provider plan

may receive services from a health care provider that is not in the plan's network.

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

provide to enrollees a directory of providers and 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

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 not require the enrollee to pay 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 not require the enrollee to pay

more than the enrollee would have paid if the provider was in the plan's network.