DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part of the
legislative instrument. The keyword, one-liner, abstract, and digest do not constitute part of the law
or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 371 Original 2019 Regular Session Talbot
Abstract: Establishes an independent dispute resolution process for out-of-network health benefit
claims in certain circumstances.
Proposed law defines "administrator", "commissioner", "department", "emergency care", "emergency
care provider", "emergency medical condition", "enrollee", "facility", "facility-based provider", and
"healthcare practitioner".
Proposed law applies to a preferred provider benefit plan offered by an insurer or an administrator
of a health benefit plan, other than a health maintenance organization plan.
Proposed law requires the commissioner of insurance to establish an independent dispute resolution
process by which a dispute for an out-of-network health benefit claim shall be referred to the division
of administrative law for resolution if both of the following apply:
(1)The amount for which the enrollee is responsible to a facility-based provider or emergency
care provider, after copayments, deductibles, and coinsurance, including the amount unpaid
by the administrator or insurer, is greater than $500.
(2)The health benefit claim is for either emergency care or a healthcare or medical service or
supply provided by a facility-based provider in a facility that is a preferred provider or that
has a contract with the administrator.
Proposed law exempts a facility-based provider who makes a disclosure of projected out-of-network
costs to an enrollee prior to service and obtains the enrollee's written acknowledgment of that
disclosure from participating in independent dispute resolution for a billed charge if the amount
billed is less than or equal to the maximum amount projected in the disclosure.
Proposed law requires notice of the available independent dispute resolution process to be provided
to an enrollee by a healthcare provider or an insurer or administrator for an out-of-network health
benefit claim eligible for independent dispute resolution.
Proposed law requires the commissioner of insurance, within five days of receipt of a request for
independent dispute resolution, to provide the division of administrative law with a copy of the
request and to notify the facility-based provider or emergency care provider and insurer or
administrator of the request. Proposed law prohibits the facility-based provider or emergency care provider, on receipt of notice
from the department that an enrollee has made a request for independent dispute resolution, from
pursuing any collection effort against the enrollee who has requested independent dispute resolution
for amounts other than copayments, deductibles, and coinsurance before the earlier of either the date
the independent dispute resolution is completed or the date the request for independent dispute
resolution is withdrawn.
Proposed law requires the insurer or administrator to immediately pay the facility-based provider or
emergency care provider any additional amounts required to provide for a reimbursement amount
not less than 100% of the Medicare rate for the healthcare services rendered by the facility-based
provider or emergency care provider, except for the enrollee's copayment, coinsurance, or deductible,
if any, and to ensure that the enrollee incurs no greater out-of-pocket costs for the healthcare services
than the enrollee would have incurred with an in-network provider.
Proposed law sets forth the criteria for determining a reasonable fee for the services rendered and
requires the division of administrative law judge to select either the insurer's or administrator's
payment or the out-of-network facility-based provider's or emergency care provider's fee.
Proposed law authorizes the administrative law judge, if a settlement between the insurer or
administrator and the facility-based provider or emergency care provider is reasonably likely, or both
the insurer's or administrator's payment and the out-of-network facility-based provider's or
emergency care provider's fee represent unreasonable extremes, to direct both parties to attempt a
good faith negotiation for settlement.
Proposed law provides for the payment of the costs of the independent dispute resolution.
(Adds R.S. 22:2481-2496)