Connecticut 2019 Regular Session

Connecticut Senate Bill SB00905 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2
3	3	LCO No. 4328 1 of 7
4	4
5	5	General Assembly Raised Bill No. 905
6	6	January Session, 2019
7	7	LCO No. 4328
8	8
9	9
10	10	Referred to Committee on INSURANCE AND REAL ESTATE
11	11
12	12
13	13	Introduced by:
14	14	(INS)
15	15
16	16
17	17
18	18
19	19	AN ACT CONCERNING SU RPRISE BILLING AND REIMBURS EMENTS
20	20	FOR EMERGENCY SERVIC ES PROVIDED BY OUT-OF-NETWORK
21	21	FACILITY-BASED PROVIDERS.
22	22	Be it enacted by the Senate and House of Representatives in General
23	23	Assembly convened:
24	24
25	25	Section 1. Section 20-7f of the general statutes is repealed and the 1
26	26	following is substituted in lieu thereof (Effective January 1, 2020): 2
27	27	(a) For purposes of this section: 3
28	28	(1) "Request payment" includes, but is not limited to, submitting a 4
29	29	bill for services not actually owed or submitting for such services an 5
30	30	invoice or other communication detailing the cost of the services that is 6
31	31	not clearly marked with the phrase "This is not a bill". 7
32	32	(2) "Health care provider" means a person licensed to provide health 8
33	33	care services under chapters 370 to 373, inclusive, chapters 375 to 383b, 9
34	34	inclusive, chapters 384a to 384c, inclusive, or chapter 400j. 10
35	35	(3) "Enrollee" means a person who has contracted for, or who 11
36	36	participates in, a health care plan for such enrollee or such enrollee's 12 Raised Bill No. 905
37	37
38	38
39	39
40	40	LCO No. 4328 2 of 7
41	41
42	42	eligible dependents. 13
43	43	(4) "Coinsurance, copayment [,] or deductible" [or other out-of-14
44	44	pocket expense"] means the portion of a charge for services covered by 15
45	45	a health care plan that, under the plan's terms, it is the obligation of the 16
46	46	enrollee to pay. 17
47	47	(5) "Health care plan" has the same meaning as provided in 18
48	48	subsection (a) of section 38a-477aa, as amended by this act. 19
49	49	(6) "Health carrier" has the same meaning as provided in subsection 20
50	50	(a) of section 38a-477aa, as amended by this act. 21
51	51	(7) "Emergency services" has the same meaning as provided in 22
52	52	subsection (a) of section 38a-477aa, as amended by this act. 23
53	53	(8) "Facility" has the same meaning as provided in section 38a-591a. 24
54	54	(b) It shall be an unfair trade practice in violation of chapter 735a for 25
55	55	any health care provider or facility to request payment from an 26
56	56	enrollee, other than a coinsurance, copayment [,] or deductible, [or 27
57	57	other out-of-pocket expense,] for (1) health care services or a facility 28
58	58	fee, as defined in section 19a-508c, covered under a health care plan, (2) 29
59	59	emergency services covered under a health care plan and rendered by 30
60	60	an out-of-network health care provider or facility, or (3) a surprise bill, 31
61	61	as defined in section 38a-477aa, as amended by this act. 32
62	62	(c) It shall be an unfair trade practice in violation of chapter 735a for 33
63	63	any health care provider or facility to report to a credit reporting 34
64	64	agency an enrollee's failure to pay a bill for the services, facility fee or 35
65	65	surprise bill as set forth in subsection (b) of this section, when a health 36
66	66	carrier has primary responsibility for payment of such services, fees or 37
67	67	bills. 38
68	68	Sec. 2. Subsections (a) and (b) of section 38a-477aa of the general 39
69	69	statutes are repealed and the following is substituted in lieu thereof 40
70	70	(Effective January 1, 2020): 41 Raised Bill No. 905
71	71
72	72
73	73
74	74	LCO No. 4328 3 of 7
75	75
76	76	(a) As used in this section: 42
77	77	(1) "Emergency condition" has the same meaning as "emergency 43
78	78	medical condition", as provided in section 38a-591a; 44
79	79	(2) "Emergency services" means, with respect to an emergency 45
80	80	condition, (A) a medical screening examination as required under 46
81	81	Section 1867 of the Social Security Act, as amended from time to time, 47
82	82	that is within the capability of a hospital emergency department, 48
83	83	including ancillary services routinely available to such department to 49
84	84	evaluate such condition, and (B) such further medical examinations 50
85	85	and treatment required under said Section 1867 to stabilize such 51
86	86	individual, that are within the capability of the hospital staff and 52
87	87	facilities; 53
88	88	(3) "Facility" has the same meaning as provided in section 38a-591a; 54
89	89	[(3)] (4) "Health care plan" means an individual or a group health 55
90	90	insurance policy or health benefit plan that provides coverage of the 56
91	91	type specified in subdivisions (1), (2), (4), (11) and (12) of section 38a-57
92	92	469; 58
93	93	[(4)] (5) "Health care provider" means an individual licensed to 59
94	94	provide health care services under chapters 370 to 373, inclusive, 60
95	95	chapters 375 to 383b, inclusive, and chapters 384a to 384c, inclusive; 61
96	96	[(5)] (6) "Health carrier" means an insurance company, health care 62
97	97	center, hospital service corporation, medical service corporation, 63
98	98	fraternal benefit society or other entity that delivers, issues for 64
99	99	delivery, renews, amends or continues a health care plan in this state; 65
100	100	[(6)] (7) (A) "Surprise bill" means a bill for health care services, other 66
101	101	than emergency services, received by an insured for services rendered 67
102	102	by an out-of-network health care provider, where such services were 68
103	103	rendered by such out-of-network provider at an in-network facility, 69
104	104	during a service or procedure performed by an in-network provider or 70
105	105	during a service or procedure previously approved or authorized by 71 Raised Bill No. 905
106	106
107	107
108	108
109	109	LCO No. 4328 4 of 7
110	110
111	111	the health carrier and the insured did not knowingly elect to obtain 72
112	112	such services from such out-of-network provider. 73
113	113	(B) "Surprise bill" does not include a bill for health care services 74
114	114	received by an insured when an in-network health care provider was 75
115	115	available to render such services and the insured knowingly elected to 76
116	116	obtain such services from another health care provider who was out-77
117	117	of-network. 78
118	118	(b) (1) No health carrier shall require prior authorization for 79
119	119	rendering emergency services to an insured. 80
120	120	(2) No health carrier shall impose, for emergency services rendered 81
121	121	to an insured by an out-of-network health care provider or facility, a 82
122	122	coinsurance, copayment, deductible or other out-of-pocket expense 83
123	123	that is greater than the coinsurance, copayment, deductible or other 84
124	124	out-of-pocket expense that would be imposed if such emergency 85
125	125	services were rendered by an in-network health care provider or 86
126	126	facility. 87
127	127	(3) (A) If emergency services were rendered to an insured by an out-88
128	128	of-network health care provider or facility, such health care provider 89
129	129	or facility may bill the health carrier directly and the health carrier 90
130	130	shall reimburse such health care provider or facility in the greatest of 91
131	131	the following amounts: (i) The amount the insured's health care plan 92
132	132	would pay for such services if rendered by an in-network health care 93
133	133	provider or facility; (ii) [the usual, customary and reasonable rate for 94
134	134	such services] the amount the insured's health care plan would pay for 95
135	135	such services calculated using the same method such plan uses to 96
136	136	calculate payments for out-of-network services, excluding any (I) 97
137	137	copayment or coinsurance that such plan would impose on such 98
138	138	insured for such services if such services were provided by an in-99
139	139	network provider or facility, or (II) reduction for out-of-network cost-100
140	140	sharing that generally applies under such plan for out-of-network 101
141	141	services; or (iii) the amount Medicare would reimburse for such 102
142	142	services. [As used in this subparagraph, "usual, customary and 103 Raised Bill No. 905
143	143
144	144
145	145
146	146	LCO No. 4328 5 of 7
147	147
148	148	reasonable rate" means the eightieth percentile of all charges for the 104
149	149	particular health care service performed by a health care provider in 105
150	150	the same or similar specialty and provided in the same geographical 106
151	151	area, as reported in a benchmarking database maintained by a 107
152	152	nonprofit organization specified by the Insurance Commissioner. Such 108
153	153	organization shall not be affiliated with any health carrier.] Each health 109
154	154	carrier shall disclose, in such health carrier's plan document, the 110
155	155	methods such health carrier uses to calculate payments for out-of-111
156	156	network services, including, but not limited to, benchmarking 112
157	157	databases and other information sources. 113
158	158	(B) Each out-of-network facility-based provider that renders 114
159	159	emergency services to an insured shall: (i) Accept reimbursement for 115
160	160	such services from a health carrier in the amount calculated pursuant 116
161	161	to subparagraph (A) of this subdivision; or (ii) if such provider is 117
162	162	eligible to participate in the mediation program established by the 118
163	163	reimbursing health carrier pursuant to subparagraph (C) of this 119
164	164	subdivision, refuse to accept reimbursement for such services from 120
165	165	such health carrier and notify such health carrier that such provider 121
166	166	intends to participate in such program. 122
167	167	(C) (i) Each health carrier shall establish a mediation program for 123
168	168	the mediation of disputes concerning reimbursements for emergency 124
169	169	services rendered to insureds by out-of-network facility-based 125
170	170	providers. Each mediation program established pursuant to this 126
171	171	subparagraph shall adhere to generally accepted mediation standards 127
172	172	established by: 128
173	173	(I) The National Conference of Commissioners on Uniform State 129
174	174	Laws in the Uniform Mediation Act, as amended from time to time; 130
175	175	(II) The American Arbitration Association; 131
176	176	(III) The Association for Conflict Resolution; 132
177	177	(IV) The Section of Dispute Resolution of the American Bar 133
178	178	Association; or 134 Raised Bill No. 905
179	179
180	180
181	181
182	182	LCO No. 4328 6 of 7
183	183
184	184	(V) An alternative dispute resolution program identified by the 135
185	185	judicial branch. 136
186	186	(ii) Except as provided in subparagraph (C)(iii) of this subdivision, 137
187	187	each out-of-network facility-based provider shall be eligible to 138
188	188	participate in the mediation program established by a health carrier 139
189	189	pursuant to subparagraph (C)(i) of this subdivision if: (I) Such 140
190	190	provider rendered emergency services to an individual insured by the 141
191	191	health carrier; (II) such provider received, but did not accept, 142
192	192	reimbursement from the health carrier for such services; (III) such 143
193	193	provider's fee for such services exceeds the amount of the 144
194	194	reimbursement that such provider received from the health carrier for 145
195	195	such services by more than one thousand dollars; and (IV) such 146
196	196	provider notifies the health carrier that such provider wishes to 147
197	197	participate in such program. 148
198	198	(iii) No mediation program established by a health carrier pursuant 149
199	199	to subparagraph (C)(i) of this subdivision shall be used if (I) the health 150
200	200	carrier and an out-of-network facility-based provider who is otherwise 151
201	201	eligible to participate in such program agree to a payment 152
202	202	arrangement outside of such program, or (II) the insured who received 153
203	203	emergency services from the out-of-network facility-based provider 154
204	204	agrees to pay such provider's fee for such services. 155
205	205	(iv) In performing a mediation pursuant to subparagraph (C) of this 156
206	206	subdivision, the mediator shall select, as the reimbursement amount 157
207	207	due from the health carrier to the out-of-network facility-based 158
208	208	provider, (I) the reimbursement amount issued by such health carrier 159
209	209	to such provider pursuant to subparagraph (A) of this subdivision, or 160
210	210	(II) such provider's fee for the emergency services that such provider 161
211	211	rendered to the insured. 162
212	212	(v) The cost of a mediation performed pursuant to subparagraph (C) 163
213	213	of this subdivision shall be borne equally by the health carrier and the 164
214	214	out-of-network facility-based provider. 165
215	215	(vi) Each health carrier shall maintain records concerning all notices 166 Raised Bill No. 905
216	216
217	217
218	218
219	219	LCO No. 4328 7 of 7
220	220
221	221	submitted to such health carrier pursuant to subparagraph (C)(ii) of 167
222	222	this subdivision and all mediations conducted pursuant to 168
223	223	subparagraph (C) of this subdivision. Each health carrier shall, upon 169
224	224	request from the commissioner, submit to the commissioner, in a form 170
225	225	and manner prescribed by the commissioner, a report concerning the 171
226	226	records maintained by such health carrier pursuant to this 172
227	227	subparagraph. 173
228	228	[(B)] (D) Nothing in this subdivision shall be construed to prohibit 174
229	229	[such] a health carrier and out-of-network health care provider from 175
230	230	agreeing to a greater reimbursement amount. 176
231	231	This act shall take effect as follows and shall amend the following
232	232	sections:
233	233
234	234	Section 1 January 1, 2020 20-7f
235	235	Sec. 2 January 1, 2020 38a-477aa(a) and (b)
236	236
237	237	Statement of Purpose:
238	238	To: (1) Subject certain bills for emergency services to, and modify the
239	239	forms of cost-sharing that qualify for protection under, provisions
240	240	concerning surprise billing; and (2) modify the manner in which
241	241	reimbursements for emergency services provided by out-of-network
242	242	facility-based providers are calculated and paid.
243	243	[Proposed deletions are enclosed in brackets. Proposed additions are indicated by underline,
244	244	except that when the entire text of a bill or resolution or a section of a bill or resolution is new, it is
245	245	not underlined.]
246	246