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General Assembly Raised Bill No. 905
January Session, 2019
LCO No. 4328
Referred to Committee on INSURANCE AND REAL ESTATE
Introduced by:
(INS)
AN ACT CONCERNING SU RPRISE BILLING AND REIMBURS EMENTS
FOR EMERGENCY SERVIC ES PROVIDED BY OUT-OF-NETWORK
FACILITY-BASED PROVIDERS.
Be it enacted by the Senate and House of Representatives in General
Assembly convened:
Section 1. Section 20-7f of the general statutes is repealed and the 1
following is substituted in lieu thereof (Effective January 1, 2020): 2
(a) For purposes of this section: 3
(1) "Request payment" includes, but is not limited to, submitting a 4
bill for services not actually owed or submitting for such services an 5
invoice or other communication detailing the cost of the services that is 6
not clearly marked with the phrase "This is not a bill". 7
(2) "Health care provider" means a person licensed to provide health 8
care services under chapters 370 to 373, inclusive, chapters 375 to 383b, 9
inclusive, chapters 384a to 384c, inclusive, or chapter 400j. 10
(3) "Enrollee" means a person who has contracted for, or who 11
participates in, a health care plan for such enrollee or such enrollee's 12 Raised Bill No. 905
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eligible dependents. 13
(4) "Coinsurance, copayment [,] or deductible" [or other out-of-14
pocket expense"] means the portion of a charge for services covered by 15
a health care plan that, under the plan's terms, it is the obligation of the 16
enrollee to pay. 17
(5) "Health care plan" has the same meaning as provided in 18
subsection (a) of section 38a-477aa, as amended by this act. 19
(6) "Health carrier" has the same meaning as provided in subsection 20
(a) of section 38a-477aa, as amended by this act. 21
(7) "Emergency services" has the same meaning as provided in 22
subsection (a) of section 38a-477aa, as amended by this act. 23
(8) "Facility" has the same meaning as provided in section 38a-591a. 24
(b) It shall be an unfair trade practice in violation of chapter 735a for 25
any health care provider or facility to request payment from an 26
enrollee, other than a coinsurance, copayment [,] or deductible, [or 27
other out-of-pocket expense,] for (1) health care services or a facility 28
fee, as defined in section 19a-508c, covered under a health care plan, (2) 29
emergency services covered under a health care plan and rendered by 30
an out-of-network health care provider or facility, or (3) a surprise bill, 31
as defined in section 38a-477aa, as amended by this act. 32
(c) It shall be an unfair trade practice in violation of chapter 735a for 33
any health care provider or facility to report to a credit reporting 34
agency an enrollee's failure to pay a bill for the services, facility fee or 35
surprise bill as set forth in subsection (b) of this section, when a health 36
carrier has primary responsibility for payment of such services, fees or 37
bills. 38
Sec. 2. Subsections (a) and (b) of section 38a-477aa of the general 39
statutes are repealed and the following is substituted in lieu thereof 40
(Effective January 1, 2020): 41 Raised Bill No. 905
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(a) As used in this section: 42
(1) "Emergency condition" has the same meaning as "emergency 43
medical condition", as provided in section 38a-591a; 44
(2) "Emergency services" means, with respect to an emergency 45
condition, (A) a medical screening examination as required under 46
Section 1867 of the Social Security Act, as amended from time to time, 47
that is within the capability of a hospital emergency department, 48
including ancillary services routinely available to such department to 49
evaluate such condition, and (B) such further medical examinations 50
and treatment required under said Section 1867 to stabilize such 51
individual, that are within the capability of the hospital staff and 52
facilities; 53
(3) "Facility" has the same meaning as provided in section 38a-591a; 54
[(3)] (4) "Health care plan" means an individual or a group health 55
insurance policy or health benefit plan that provides coverage of the 56
type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-57
469; 58
[(4)] (5) "Health care provider" means an individual licensed to 59
provide health care services under chapters 370 to 373, inclusive, 60
chapters 375 to 383b, inclusive, and chapters 384a to 384c, inclusive; 61
[(5)] (6) "Health carrier" means an insurance company, health care 62
center, hospital service corporation, medical service corporation, 63
fraternal benefit society or other entity that delivers, issues for 64
delivery, renews, amends or continues a health care plan in this state; 65
[(6)] (7) (A) "Surprise bill" means a bill for health care services, other 66
than emergency services, received by an insured for services rendered 67
by an out-of-network health care provider, where such services were 68
rendered by such out-of-network provider at an in-network facility, 69
during a service or procedure performed by an in-network provider or 70
during a service or procedure previously approved or authorized by 71 Raised Bill No. 905
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the health carrier and the insured did not knowingly elect to obtain 72
such services from such out-of-network provider. 73
(B) "Surprise bill" does not include a bill for health care services 74
received by an insured when an in-network health care provider was 75
available to render such services and the insured knowingly elected to 76
obtain such services from another health care provider who was out-77
of-network. 78
(b) (1) No health carrier shall require prior authorization for 79
rendering emergency services to an insured. 80
(2) No health carrier shall impose, for emergency services rendered 81
to an insured by an out-of-network health care provider or facility, a 82
coinsurance, copayment, deductible or other out-of-pocket expense 83
that is greater than the coinsurance, copayment, deductible or other 84
out-of-pocket expense that would be imposed if such emergency 85
services were rendered by an in-network health care provider or 86
facility. 87
(3) (A) If emergency services were rendered to an insured by an out-88
of-network health care provider or facility, such health care provider 89
or facility may bill the health carrier directly and the health carrier 90
shall reimburse such health care provider or facility in the greatest of 91
the following amounts: (i) The amount the insured's health care plan 92
would pay for such services if rendered by an in-network health care 93
provider or facility; (ii) [the usual, customary and reasonable rate for 94
such services] the amount the insured's health care plan would pay for 95
such services calculated using the same method such plan uses to 96
calculate payments for out-of-network services, excluding any (I) 97
copayment or coinsurance that such plan would impose on such 98
insured for such services if such services were provided by an in-99
network provider or facility, or (II) reduction for out-of-network cost-100
sharing that generally applies under such plan for out-of-network 101
services; or (iii) the amount Medicare would reimburse for such 102
services. [As used in this subparagraph, "usual, customary and 103 Raised Bill No. 905
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reasonable rate" means the eightieth percentile of all charges for the 104
particular health care service performed by a health care provider in 105
the same or similar specialty and provided in the same geographical 106
area, as reported in a benchmarking database maintained by a 107
nonprofit organization specified by the Insurance Commissioner. Such 108
organization shall not be affiliated with any health carrier.] Each health 109
carrier shall disclose, in such health carrier's plan document, the 110
methods such health carrier uses to calculate payments for out-of-111
network services, including, but not limited to, benchmarking 112
databases and other information sources. 113
(B) Each out-of-network facility-based provider that renders 114
emergency services to an insured shall: (i) Accept reimbursement for 115
such services from a health carrier in the amount calculated pursuant 116
to subparagraph (A) of this subdivision; or (ii) if such provider is 117
eligible to participate in the mediation program established by the 118
reimbursing health carrier pursuant to subparagraph (C) of this 119
subdivision, refuse to accept reimbursement for such services from 120
such health carrier and notify such health carrier that such provider 121
intends to participate in such program. 122
(C) (i) Each health carrier shall establish a mediation program for 123
the mediation of disputes concerning reimbursements for emergency 124
services rendered to insureds by out-of-network facility-based 125
providers. Each mediation program established pursuant to this 126
subparagraph shall adhere to generally accepted mediation standards 127
established by: 128
(I) The National Conference of Commissioners on Uniform State 129
Laws in the Uniform Mediation Act, as amended from time to time; 130
(II) The American Arbitration Association; 131
(III) The Association for Conflict Resolution; 132
(IV) The Section of Dispute Resolution of the American Bar 133
Association; or 134 Raised Bill No. 905
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(V) An alternative dispute resolution program identified by the 135
judicial branch. 136
(ii) Except as provided in subparagraph (C)(iii) of this subdivision, 137
each out-of-network facility-based provider shall be eligible to 138
participate in the mediation program established by a health carrier 139
pursuant to subparagraph (C)(i) of this subdivision if: (I) Such 140
provider rendered emergency services to an individual insured by the 141
health carrier; (II) such provider received, but did not accept, 142
reimbursement from the health carrier for such services; (III) such 143
provider's fee for such services exceeds the amount of the 144
reimbursement that such provider received from the health carrier for 145
such services by more than one thousand dollars; and (IV) such 146
provider notifies the health carrier that such provider wishes to 147
participate in such program. 148
(iii) No mediation program established by a health carrier pursuant 149
to subparagraph (C)(i) of this subdivision shall be used if (I) the health 150
carrier and an out-of-network facility-based provider who is otherwise 151
eligible to participate in such program agree to a payment 152
arrangement outside of such program, or (II) the insured who received 153
emergency services from the out-of-network facility-based provider 154
agrees to pay such provider's fee for such services. 155
(iv) In performing a mediation pursuant to subparagraph (C) of this 156
subdivision, the mediator shall select, as the reimbursement amount 157
due from the health carrier to the out-of-network facility-based 158
provider, (I) the reimbursement amount issued by such health carrier 159
to such provider pursuant to subparagraph (A) of this subdivision, or 160
(II) such provider's fee for the emergency services that such provider 161
rendered to the insured. 162
(v) The cost of a mediation performed pursuant to subparagraph (C) 163
of this subdivision shall be borne equally by the health carrier and the 164
out-of-network facility-based provider. 165
(vi) Each health carrier shall maintain records concerning all notices 166 Raised Bill No. 905
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submitted to such health carrier pursuant to subparagraph (C)(ii) of 167
this subdivision and all mediations conducted pursuant to 168
subparagraph (C) of this subdivision. Each health carrier shall, upon 169
request from the commissioner, submit to the commissioner, in a form 170
and manner prescribed by the commissioner, a report concerning the 171
records maintained by such health carrier pursuant to this 172
subparagraph. 173
[(B)] (D) Nothing in this subdivision shall be construed to prohibit 174
[such] a health carrier and out-of-network health care provider from 175
agreeing to a greater reimbursement amount. 176
This act shall take effect as follows and shall amend the following
sections:
Section 1 January 1, 2020 20-7f
Sec. 2 January 1, 2020 38a-477aa(a) and (b)
Statement of Purpose:
To: (1) Subject certain bills for emergency services to, and modify the
forms of cost-sharing that qualify for protection under, provisions
concerning surprise billing; and (2) modify the manner in which
reimbursements for emergency services provided by out-of-network
facility-based providers are calculated and paid.
[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.]