SB 894

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

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

(“plan”) may receive services from a health care provider that is not in the plan's

network.

Under the bill, a 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 arbitration to settle disputes over the cost of services. The health care

facility may opt to provide the notice for the provider.

Under the bill, if an enrollee of a 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. If there a dispute over the reimbursement, the plan or provider may

submit the dispute using the arbitration process described below. 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 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. If there a dispute over the reimbursement,

the plan or provider may submit the dispute using the arbitration process described

below.

The bill requires the commissioner of insurance to promulgate rules to

establish the arbitration process under which enrollees, plans, and out-of-network

providers may submit billing disputes to an independent dispute resolution entity.

Under the bill, an enrollee may request arbitration for a claim if the amount that the

enrollee is financially responsible for, after copayments, deductibles, and

coinsurance, is more than $500, unless that amount is less than the good faith

estimate provided by the provider. The plan or provider may not use the arbitration

process to dispute bills for certain emergency services that do not exceed a specified

amount or services for which provider fees are subject by law to monetary

limitations.

Once a dispute is filed, the independent dispute resolution entity has 30 days