Relating to insurance coverage for emergency services, reimbursements for out-of-network providers, and complicating factors

This bill relates to insurance coverage for emergency services, reimbursements for out-of-network providers, and complicating factors. The bill requires a policy, contract, or plan providing for third-party payment or prepayment of medical expenses to provide coverage for health care services (services) provided to a covered person by an out-of-network provider if the services are emergency services, or the services were provided at a participating facility and the covered person could not receive the services from a participating provider. “Emergency services”, “out-of-network provider”, “participating facility”, and “participating provider” are defined in the bill. An out-of-network provider that provides services to a covered person under the bill shall submit a claim to a health carrier (carrier) no later than days after providing services. No more than days after receipt of a claim, the carrier shall reimburse the out-of-network provider in an amount that is the greater of the median amount that would have been paid to a participating provider for providing the same services, or 150 percent of the fee schedule for the service, excluding any cost sharing. An out-of-network provider who provides services shall not bill, attempt to collect from, or collect from a covered person any amount other than the cost sharing required by the covered person’s health benefit plan. An out-of-network provider who provides a service to a covered person that involves a complicating factor may submit, as part of an initial claim, a claim for an additional reimbursement. “Complicating factor” is defined in the bill. The claim for additional reimbursement must be accompanied by medical records and clinical documentation sufficient to demonstrate the complicating factor and justify the request for additional reimbursement. A carrier that receives a claim for additional reimbursement shall, within days, either pay the out-of-network provider an additional reimbursement in an amount equal to percent of the initial claim reimbursement, or issue a letter denying the claim for additional reimbursement. If a carrier denies a claim for additional reimbursement, the out-of-network provider may file a written request for binding arbitration with the commissioner of insurance (commissioner) that includes the information detailed in the bill. The commissioner shall notify the out-of-network provider and carrier within days whether the request has been accepted or denied. A carrier that receives notice of arbitration shall submit written documentation to the commissioner, within days of the notice, that either reconfirms the carrier’s denial of additional reimbursement, or provides an alternative payment offer for consideration during arbitration. Prior to an arbitration, the out-of-network provider and carrier shall agree upon an arbitrator from the arbitrator list, and submit documentation required by the bill to the arbitrator. The arbitrator shall provide a written decision regarding the outcome of the arbitration within days. The arbitrator shall consider the complicating factor at issue and documentation required by the bill. The costs of arbitration shall be paid equally by the carrier and the out-of-network provider. The bill does not prohibit an out-of-network provider and a carrier from agreeing to a reimbursement amount that is greater than the reimbursement amount required by the bill. The bill applies to third-party payment provider contracts, policies, or plans delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2027, by the third-party payment providers enumerated in the bill. The bill specifies the types of specialized health-related insurance which are not subject to the bill’s coverage requirements. The commissioner may adopt rules to administer the bill.