General Assembly Raised Bill No. 876
January Session, 2017 LCO No. 4024
*04024_______INS*
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
General Assembly
Raised Bill No. 876
January Session, 2017
LCO No. 4024
*04024_______INS*
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING REIMBURSEMENT OF OUT-OF-NETWORK HEALTH CARE PROVIDERS AND LIABILITY FOR CERTAIN UNLAWFUL BILLING AND COLLECTION PRACTICES.
Be it enacted by the Senate and House of Representatives in General Assembly convened:
Section 1. Section 38a-477aa of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2017):
(a) As used in this section:
(1) "Emergency condition" has the same meaning as "emergency medical condition", as provided in section 38a-591a;
(2) "Emergency services" means, with respect to an emergency condition, (A) a medical screening examination [as required] of an individual that a hospital emergency department is required to provide under Section 1867 of the Social Security Act, as amended from time to time, that is within the capability of [a] the hospital emergency department, including ancillary services routinely available to such department to evaluate such condition, and (B) such further medical examinations and treatment [required] of an individual that a hospital emergency department is required to provide under said Section 1867 to stabilize such individual, that are within the capability of the hospital staff and facilities;
(3) "Health care plan" means an individual or a group health insurance policy or health benefit plan that provides coverage of the type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-469;
(4) "Health care provider" means an individual licensed to provide health care services under chapters 370 to 373, inclusive, chapters 375 to 383b, inclusive, and chapters 384a to 384c, inclusive;
(5) "Health carrier" means an insurance company, health care center, hospital service corporation, medical service corporation, fraternal benefit society or other entity that delivers, issues for delivery, renews, amends or continues a health care plan in this state;
(6) (A) "Surprise bill" means a bill for health care services, other than emergency services, [received by] submitted to an insured for services rendered by an out-of-network health care provider, where (i) such services were rendered by such out-of-network provider at an in-network facility, during a service or procedure performed by an in-network provider or during a service or procedure previously approved or authorized by the health carrier, and (ii) the insured did not knowingly elect to [obtain] receive such services from such out-of-network provider.
(B) "Surprise bill" does not include a bill for health care services received by an insured when an in-network health care provider was available to render such services and the insured knowingly elected to [obtain] receive such services from another health care provider who was out-of-network.
(b) (1) No health carrier shall require prior authorization for [rendering] emergency services rendered to an insured.
(2) No health carrier shall impose, for emergency services rendered to an insured by an out-of-network health care provider, a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such emergency services were rendered by an in-network health care provider.
(3) (A) If [emergency services] health care services were rendered to an insured by an out-of-network health care provider at an in-network facility, such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest of the following amounts: (i) The amount the insured's health care plan would pay for such services if rendered by an in-network health care provider; (ii) the usual, customary and reasonable rate for such services; or (iii) the amount Medicare would reimburse for such services. As used in this subparagraph, "usual, customary and reasonable rate" means the eightieth percentile of all charges for the particular health care service [performed] rendered by a health care provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization specified by the Insurance Commissioner. Such organization shall not be affiliated with any health carrier.
(B) Nothing in this subdivision shall be construed to prohibit such health carrier and out-of-network health care provider from agreeing to a greater reimbursement amount.
(c) [With respect to a surprise bill:
(1) An] In the case of a surprise bill, an insured shall only be required to pay the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such health care services if such services were rendered by an in-network health care provider. [; and
(2) A health carrier shall reimburse the out-of-network health care provider or insured, as applicable, for health care services rendered at the in-network rate under the insured's health care plan as payment in full, unless such health carrier and health care provider agree otherwise.]
(d) If health care services were rendered to an insured by an out-of-network health care provider and the health carrier failed to inform such insured, if such insured was required to be informed, of the network status of such health care provider pursuant to subdivision (3) of subsection (d) of section 38a-591b, the health carrier shall not impose a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such services were rendered by an in-network health care provider.
Sec. 2. Section 20-7f of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2017):
(a) For purposes of this section:
(1) "Request payment" includes, but is not limited to, submitting a bill for services not actually owed or submitting for such services an invoice or other communication detailing the cost of the services that is not clearly marked with the phrase "This is not a bill".
(2) "Health care provider" means a person licensed to provide health care services under chapters 370 to 373, inclusive, chapters 375 to 383b, inclusive, chapters 384a to 384c, inclusive, or chapter 400j.
(3) "Enrollee" means a person who has contracted for or who participates in a health care plan for such enrollee or such enrollee's eligible dependents.
(4) "Coinsurance, copayment, deductible or other out-of-pocket expense" means the portion of a charge for services covered by a health care plan that, under the plan's terms, it is the obligation of the enrollee to pay.
(5) "Health care plan" has the same meaning as provided in subsection (a) of section 38a-477aa, as amended by this act.
(6) "Health carrier" has the same meaning as provided in subsection (a) of section 38a-477aa, as amended by this act.
(7) "Emergency services" has the same meaning as provided in subsection (a) of section 38a-477aa, as amended by this act.
(b) [It shall be an unfair trade practice in violation of chapter 735a for any] A health care provider [to] shall not request payment from an enrollee, other than a coinsurance, copayment, deductible or other out-of-pocket expense, for (1) health care services or a facility fee, as defined in section 19a-508c, covered under a health care plan, (2) emergency services covered under a health care plan and rendered by an out-of-network health care provider, or (3) a surprise bill, as defined in section 38a-477aa, as amended by this act.
(c) [It shall be an unfair trade practice in violation of chapter 735a for any] A health care provider [to] shall not report to a credit reporting agency an enrollee's failure to pay a bill for the services, facility fee or surprise bill as set forth in subsection (b) of this section, when a health carrier has primary responsibility for payment of such services, fees or bills.
(d) Any health care provider who violates subsection (b) or (c) of this section has engaged in unlawful, unprofessional and immoral conduct and is subject to reprimand or discipline by the state regulating board governing the provider's profession or occupation as provided by law.
Sec. 3. Subsection (c) of section 38a-193 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1, 2017):
(c) (1) Every contract between a health care center and a participating provider of health care services shall be in writing and shall contain the following provisions or variations approved by the commissioner:
"(A) (Name of provider or facility) .... hereby agrees that in no event, including, but not limited to, nonpayment by (name of health care center) ...., (name of health care center's) .... insolvency, or breach of this contract shall (name of provider or facility) .... bill, charge, collect a deposit from, seek compensation, remuneration, or reimbursement from, or have any recourse against a covered person or person acting on their behalf, other than (name of health care center) ...., for services provided pursuant to this contract. This provision shall not prohibit collection of cost-sharing amounts, or costs for noncovered services, which have not otherwise been paid by a primary or secondary carrier in accordance with regulatory standards for coordination of benefits, from covered persons in accordance with the terms of the covered person's health plan.
(B) (Name of provider or facility) .... agrees, in the event of (name of health care center's) .... insolvency, to continue to provide the services promised in this contract to covered persons of (name of health care center) .... for the duration of the period for which premiums on behalf of the covered person were paid to (name of health care center) .... or until the covered person's discharge from inpatient facilities, whichever time is greater.
(C) Notwithstanding any other provision in this contract, nothing in this contract shall be construed to modify the rights and benefits contained in the covered person's health plan.
(D) (Name of provider or facility) .... may not bill the covered person for covered services, except for cost-sharing amounts, where (name of health care center) .... denies payment because the provider or facility has failed to comply with the terms or conditions of this contract.
(E) (Name of provider or facility) .... further agrees (i) that the provisions of subparagraphs (A), (B), (C) and (D) of this subdivision (or citations appropriate to the contract form) .... shall survive termination of this contract regardless of the cause giving rise to termination and shall be construed to be for the benefit of (name of health care center's) .... covered persons, and (ii) that this provision supersedes any oral or written contrary agreement now existing or hereafter entered into between (name of provider or facility) .... and covered persons or persons acting on their behalf.
(F) If (name of provider or facility) .... contracts with other providers or facilities who agree to provide covered services to covered persons of (name of health care center) .... with the expectation of receiving payment directly or indirectly from (name of health care center) ...., such providers or facilities shall agree to abide by the provisions of subparagraphs (A), (B), (C), (D) and (E) of this subsection (or citations appropriate to the contract form) ....."
(2) In the event that the participating provider contract has not been reduced to writing as required by this subsection or that the contract fails to contain the provisions required by subdivision (1) of this subsection, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health care center.
(3) No participating provider, or agent, trustee or assignee thereof, may: (A) Maintain any action at law against a subscriber or enrollee to collect sums owed by the health care center; (B) request payment from a subscriber or enrollee for such sums; (C) request payment from a subscriber or enrollee for covered emergency services that are provided by an out-of-network provider; or (D) request payment from a subscriber or enrollee for a surprise bill, as defined in section 38a-477aa, as amended by this act. For purposes of this subdivision "request payment" includes, but is not limited to, submitting a bill for services not actually owed or submitting for such services an invoice or other communication detailing the cost of the services that is not clearly marked with the phrase "THIS IS NOT A BILL". The contract between a health care center and a participating provider shall inform the participating provider that pursuant to section 20-7f, as amended by this act, it is [an unfair trade practice in violation of chapter 735a] unlawful, unprofessional and immoral for any health care provider to request payment from a subscriber or an enrollee, other than a coinsurance, copayment, deductible or other out-of-pocket expense, for covered medical or emergency services or facility fees, as defined in section 19a-508c, or surprise bills, or to report to a credit reporting agency an enrollee's failure to pay a bill for such services when a health care center has primary responsibility for payment of such services, fees or bills, and that a participating provider who violates section 20-7f, as amended by this act, shall be subject to reprimand or discipline by the state regulating board governing the provider's profession or occupation as provided by law.
This act shall take effect as follows and shall amend the following sections:
Section 1 July 1, 2017 38a-477aa
Sec. 2 July 1, 2017 20-7f
Sec. 3 July 1, 2017 38a-193(c)
This act shall take effect as follows and shall amend the following sections:
Section 1
July 1, 2017
38a-477aa
Sec. 2
July 1, 2017
20-7f
Sec. 3
July 1, 2017
38a-193(c)
Statement of Purpose:
To: (1) Require a health carrier to reimburse an out-of-network health care provider for certain health care services; (2) increase the amount of said reimbursements; and (3) change a health care provider's liability for certain unlawful billing and collection practices under the Connecticut Unfair Trade Practices Act.
[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline, except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is not underlined.]