SB 743

This bill requires defined network plans, such as health maintenance

organizations, and certain preferred provider plans and self-insured governmental

plans that cover benefits or services provided in either an emergency department of

a hospital or independent freestanding emergency department to cover emergency

medical services without requiring a prior authorization determination and without

regard to whether the health care provider providing the emergency medical services

is a participating provider or facility. If the emergency medical services for which

coverage is required are provided by a nonparticipating provider, the plan must 1)

not impose a prior authorization requirement or other limitation that is more

restrictive than if the service was provided by a participating provider; 2) not impose

cost sharing on an enrollee that is greater than the cost sharing required if the

service was provided by a participating provider; 3) calculate the cost-sharing

amount to be equal to the amount that would have been charged if the service was

provided by a participating provider; 4) provide, within 30 days of the provider's or

facility's bill, an initial payment or denial notice to the provider or facility and then

pay a total amount to the provider or facility that is equal to the amount by which

the provider's or facility's rate exceeds the amount it received in cost sharing from

the enrollee; and 5) count any cost-sharing payment made by the enrollee for the

emergency medical services toward any in-network deductible or out-of-pocket

maximum as if the cost-sharing payment was made for services provided by a

participating provider or facility. The provider or facility may not bill or hold liable

an enrollee of the plan for any amount for the emergency medical service that is more

than the cost-sharing amount that is calculated as described in the bill for the

emergency medical service.

For coverage of an item or service that is provided by a nonparticipating

provider in a participating facility, a plan must 1) not impose a cost-sharing

requirement for the item or service that is greater than the cost-sharing

requirement that would have been imposed if the item or service was provided by a

participating provider; 2) calculate the cost-sharing amount to be equal to the

amount that would have been charged if the service was provided by a participating

provider; 3) provide, within 30 days of the provider's bill, an initial payment or denial

notice to the provider and then pay a total amount to the provider that is equal to the

amount by which the provider's rate exceeds the amount it received in cost sharing

from the enrollee; and 4) count any cost-sharing payment made by the enrollee for

the items or services toward any in-network deductible or out-of-pocket maximum

as if the cost-sharing payment was made for items or services provided by a

participating provider. A nonparticipating provider providing an item or service in

a participating facility may not bill or hold liable an enrollee for more than the

cost-sharing amount unless the provider provides notice and obtains consent as

described in the bill. However, if the nonparticipating provider is providing an