GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2025
S D
SENATE BILL DRS15139-MG-66B
Short Title: Lower Healthcare Costs. (Public)
Sponsors: Senators Burgin, Galey, and Sawrey (Primary Sponsors).
Referred to:
*DRS15139 -MG-66B*
A BILL TO BE ENTITLED 1
AN ACT LOWERING HEALTHCARE COSTS AND INCREASING PRICE 2
TRANSPARENCY. 3
Whereas, rising healthcare costs place a significant financial burden on individuals, 4
families, employers, and taxpayers, greatly contribute to inflation, and make it increasingly 5
difficult for residents to access essential healthcare services; and 6
Whereas, North Carolina has intolerably high healthcare costs, with recent studies 7
ranking the State 50th out of 50 in the United States; and 8
Whereas, skyrocketing healthcare costs have resulted in over 40 percent of Americans 9
reporting some type of healthcare debt, according to one study; and 10
Whereas, many patients face unexpected medical bills due to a lack of disclosure 11
about out-of-network providers and a general lack of transparency in healthcare pricing, resulting 12
in financial strain and hardship; and 13
Whereas, employers are burdened with the increasing costs of providing health 14
insurance for employees, leading to higher premiums, deductibles, and out-of-pocket expenses; 15
and 16
Whereas, patients and employers are often unable to compare the costs of medical 17
services due to a lack of clear and accessible pricing information, hindering their ability to make 18
informed decisions; and 19
Whereas, the absence of price transparency in the healthcare system leads to market 20
inefficiencies, less awareness of price difference, less competition, and higher prices, with 21
consumers often unable to identify the most cost-effective providers; and 22
Whereas, transparency in healthcare pricing allows consumers to shop for affordable 23
healthcare services and encourages competition among healthcare providers to offer more 24
competitive pricing; and 25
Whereas, providing consumers with clear, understandable, and accessible 26
information about the costs of healthcare services will foster a more competitive and 27
patient-centered healthcare market; and 28
Whereas, requiring healthcare providers and insurers to disclose their prices in 29
advance, including all providers and services a patient may need, both in-network and 30
out-of-network, will enable consumers to make more informed choices about their care, leading 31
to better healthcare outcomes at lower costs; and 32
Whereas, price transparency will incentivize hospitals and healthcare providers to 33
improve the quality of care while reducing prices, to the benefit of patients and employers; and 34
Whereas, clear pricing and competition among healthcare providers will encourage 35
innovation in healthcare delivery and improve overall efficiency within the system; and 36
FILED SENATE
Mar 17, 2025
S.B. 316
PRINCIPAL CLERK General Assembly Of North Carolina Session 2025
Page 2 DRS15139-MG-66B
Whereas, empowering patients and employers with pricing information will help 1
create a healthcare system that prioritizes affordability, access, and choice; and 2
Whereas, President Trump recently signed an Executive Order to make healthcare 3
prices transparent, "empower[ing] patients with clear, accurate, and actionable healthcare pricing 4
information," also "ensur[ing] hospitals and insurers disclose actual prices, not estimates, and 5
take action to make prices comparable across hospitals and insurers, including prescription drug 6
prices; Now, therefore, 7
The General Assembly of North Carolina enacts: 8
9
PART I. GREATER TRANSPARENCY IN HOSPITAL AND AMBULATORY 10
SURGICAL FACILITY HEALTHCARE COSTS 11
SECTION 1.1. Article 11B of Chapter 131E of the General Statutes reads as 12
rewritten: 13
"Article 11B. 14
"Transparency in Health Care Costs. 15
"Part 1. Health Care Cost Reduction and Transparency Act of 2013. 16
"§ 131E-214.11. Title. 17
This article Part shall be known as the Health Care Cost Reduction and Transparency Act of 18
2013. 19
… 20
"§ 131E-214.13. Disclosure of prices for most frequently reported DRGs, CPTs, and 21
HCPCSs. 22
(a) Definitions. – The following definitions apply in this Article:Part: 23
(1) Ambulatory surgical facility. – A facility licensed under Part 4 of Article 6 of 24
this Chapter. 25
(2) Commission. – The North Carolina Medical Care Commission. 26
(2a) CPT. – Current Procedural Terminology. 27
(2b) DRG. – Diagnostic Related Group. 28
(2c) HCPCS. – The Healthcare Common Procedure Coding System. 29
(3) Health insurer. – An entity that writes a health benefit plan and is one of the 30
following: 31
a. An insurance company under Article 3 of Chapter 58 of the General 32
Statutes. 33
b. A service corporation under Article 65 of Chapter 58 of the General 34
Statutes. 35
c. A health maintenance organization under Article 67 of Chapter 58 of 36
the General Statutes. 37
d. A third-party administrator of one or more group health plans, as 38
defined in section 607(1) of the Employee Retirement Income Security 39
Act of 1974 (29 U.S.C. § 1167(1)). 40
(4) Hospital. – A medical care facility licensed under Article 5 of this Chapter or 41
under Article 2 of Chapter 122C of the General Statutes. 42
(5) Public or private third party. – Includes the State, the federal government, 43
employers, health insurers, third-party administrators, and managed care 44
organizations. 45
(b) Beginning with the reporting period ending September 30, 2015, and annually 46
thereafter, Quarterly Report on Most Frequently Reported DRGs for Inpatients. – On a quarterly 47
basis, each hospital shall provide to the Department of Health and Human Services, Department, 48
utilizing electronic health records software, the following information about the 100 most 49
frequently reported admissions by DRG for inpatients as established by the Department: 50 General Assembly Of North Carolina Session 2025
DRS15139-MG-66B Page 3
(1) The amount that will be charged to a patient for each DRG if all charges are 1
paid in full without a public or private third party paying for any portion of 2
the charges. In calculating this amount, each hospital shall include charges for 3
each billable item and service associated with the DRG regardless of whether 4
the health service is performed by a physician or nonphysician practitioner 5
employed by the hospital. 6
(2) The average negotiated settlement on the amount that will be charged to a 7
patient required to be provided in subdivision (1) of this subsection. 8
(3) The amount of Medicaid reimbursement for each DRG, including claims and 9
pro rata supplemental payments. 10
(4) The amount of Medicare reimbursement for each DRG. 11
(5) For each of the five largest health insurers providing payment to the hospital 12
on behalf of insureds and teachers and State employees, the range and the 13
average of the amount of payment made for each DRG. Prior to providing this 14
information to the Department, each hospital shall redact the names of the 15
health insurers and any other information that would otherwise identify the 16
health insurers. 17
A hospital shall not be required to report the information required by this subsection for any 18
of the 100 most frequently reported admissions where the reporting of that information 19
reasonably could lead to the identification of the person or persons admitted to the hospital in 20
violation of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or 21
other federal law. 22
(c) The Commission shall adopt rules on or before March 1, 2016, to ensure that 23
subsection (b) of this section is properly implemented and that hospitals report this information 24
to the Department in a uniform manner. The rules shall include all of the following: 25
(1) The method by which the Department shall determine the 100 most frequently 26
reported DRGs for inpatients for which hospitals must provide the data set out 27
in subsection (b) of this section. 28
(2) Specific categories by which hospitals shall be grouped for the purpose of 29
disclosing this information to the public on the Department's Internet Web 30
site. 31
(d) Beginning with the reporting period ending September 30, 2015, and annually 32
thereafter, Quarterly Report on Total Costs for the Most Common Surgical and Imaging 33
Procedures. – On a quarterly basis, each hospital and ambulatory surgical facility shall provide 34
to the Department, utilizing electronic health records software, information on the total costs for 35
the 20 most common surgical procedures and the 20 most common imaging procedures, by 36
volume, performed in hospital outpatient settings or in ambulatory surgical facilities, along with 37
the related CPT and HCPCS codes. In providing information on total costs, each hospital and 38
ambulatory surgical facility shall include the costs for each billable item and service associated 39
with the procedure regardless of whether the health service is performed by a physician or 40
nonphysician practitioner employed by the hospital or ambulatory surgical facility. Hospitals and 41
ambulatory surgical facilities shall report this information in the same manner as required by 42
subdivisions (b)(1) through (5) of this section, provided that hospitals and ambulatory surgical 43
facilities shall not be required to report the information required by this subsection where the 44
reporting of that information reasonably could lead to the identification of the person or persons 45
admitted to the hospital in violation of the federal Health Insurance Portability and 46
Accountability Act of 1996 (HIPAA) or other federal law. 47
(e) The Commission shall adopt rules on or before March 1, 2016, to ensure that 48
subsection (d) of this section is properly implemented and that hospitals and ambulatory surgical 49
facilities report this information to the Department in a uniform manner. The rules shall include 50
the method by which the Department shall determine the 20 most common surgical procedures 51 General Assembly Of North Carolina Session 2025
Page 4 DRS15139-MG-66B
and the 20 most common imaging procedures for which the hospitals and ambulatory surgical 1
facilities must provide the data set out in subsection (d) of this section. 2
(e1) The Commission shall adopt rules to establish and define no fewer than 10 quality 3
measures for licensed hospitals and licensed ambulatory surgical facilities. 4
(f) Upon request of a patient for a particular DRG, imaging procedure, or surgery 5
procedure reported in this section, a hospital or ambulatory surgical facility shall provide the 6
information required by subsection (b) or subsection (d) of this section to the patient in writing, 7
either electronically or by mail, within three business days after receiving the request. 8
(f1) Commission Rules. – The Commission shall adopt rules to accomplish all of the 9
following: 10
(1) To ensure that subsection (b) of this section is properly implemented and that 11
hospitals report this information to the Department in a uniform manner. The 12
rules shall include the method by which the Department shall determine the 13
100 most frequently reported DRGs for inpatients for which hospitals must 14
provide the data set out in subsection (b) of this section and the specific 15
categories by which hospitals shall be grouped for the purpose of disclosing 16
this information to the public on the Department's internet website. 17
(2) To ensure that subsection (d) of this section is properly implemented and that 18
hospitals and ambulatory surgical facilities report this information to the 19
Department in a uniform manner. The rules shall include the method by which 20
the Department shall determine the 20 most common surgical procedures and 21
the 20 most common imaging procedures for which the hospitals and 22
ambulatory surgical facilities must provide the data set out in subsection (d) 23
of this section. 24
(3) To establish and define no fewer than 10 quality measures for licensed 25
hospitals and licensed ambulatory surgical facilities. 26
(g) G.S. 150B-21.3 does not apply to rules adopted under subsections (c) and (e) 27
subdivision (f1)(1) or subdivision (f1)(2) of this section. A rule adopted under subsections (c) 28
and (e) subdivision (f1)(1) or subdivision (f1)(2) of this section becomes effective on the last day 29
of the month following the month in which the rule is approved by the Rules Review 30
Commission. 31
… 32
"§ 131E-214.18. Penalty for noncompliance. 33
The Department may impose a civil penalty on any hospital or ambulatory surgical facility 34
that fails to comply with the requirements of this Part. For each day of violation, the amount of 35
the civil penalty shall not be (i) less than one hundredth of one percent (.01%) of the annual salary 36
of the chief executive officer of the noncompliant hospital or ambulatory surgical facility or (ii) 37
greater than two thousand dollars ($2,000). This civil penalty shall be in addition to any fine or 38
civil penalty that the Centers for Medicare and Medicaid Services or other federal agency may 39
choose to impose on the facility. The Department shall remit the clear proceeds of civil penalties 40
assessed pursuant to this section to the Civil Penalty and Forfeiture Fund in accordance with 41
G.S. 115C-457.2." 42
SECTION 1.2. This Part becomes effective on the later of January 1, 2026, or the 43
date the rules adopted by the North Carolina Medical Care Commission under 44
G.S. 131E-214.13(f1)(2) take effect, and G.S. 131E-214.18, as enacted by this Part, applies to 45
acts occurring on or after that date. 46
47
PART II. GREATER TRANSPARENCY IN HEALTHCARE PROVIDER BILLING 48
PRACTICES 49
SECTION 2.1. Article 11B of Chapter 131E of the General Statutes, as amended by 50
Part 1 of this act, is amended by adding a new Part to read: 51 General Assembly Of North Carolina Session 2025
DRS15139-MG-66B Page 5
"Part 2. Transparency in Healthcare Provider Billing Practices. 1
"§ 131E-214.25. Definitions. 2
The following definitions apply in this Part: 3
(1) Health benefit plan. – As defined in G.S. 58-3-167, or under the laws of 4
another state or the federal government. 5
(2) Health service facility. – A facility that is licensed under this Chapter or 6
Chapter 122C of the General Statutes, or under the licensing laws of another 7
state, for the provision of the same services in the ordinary course of business 8
or practice as would require the facility to be licensed under this Chapter or 9
Chapter 122C of the General Statutes were the facility located in this State. 10
(3) Healthcare provider. – Any person who is licensed, registered, or certified 11
under Chapter 90 or Chapter 90B of the General Statutes, or under the laws of 12
another state, to provide healthcare services in the ordinary care of business 13
or practice, or as a profession, or in an approved education or training 14
program, except that this term shall not include a pharmacy. 15
(4) Insurer. – As defined in G.S. 58-3-167. 16
"§ 131E-214.30. Fair notice requirements; heath service facilities. 17
(a) Services Provided at a Participating Health Service Facility. – At the time a health 18
service facility participating in an insurer's healthcare provider network (i) treats an insured 19
individual for anything other than screening and stabilization in accordance with G.S. 58-3-190, 20
(ii) admits an insured individual to receive emergency services, (iii) schedules a procedure for 21
nonemergency services for an insured individual, or (iv) seeks prior authorization from an insurer 22
for the provision of nonemergency services to an insured individual, the health service facility 23
shall provide the insured individual with a written disclosure containing all of the following 24
information: 25
(1) Services may be provided at the health service facility for which the insured 26
individual may receive a separate bill. 27
(2) Certain healthcare providers may be called upon to render care to the insured 28
individual during the course of treatment and those healthcare providers may 29
not have contracts with the insured's insurer and are considered to be 30
nonparticipating healthcare providers in the insurer's healthcare provider 31
network. Any nonparticipating healthcare providers shall be identified in the 32
written disclosure using the individual's healthcare provider's name and 33
practice name as used on the applicable health service facility's or healthcare 34
provider's credentials or name badge. 35
(3) Text, using a bold or other distinguishable font, that states that certain 36
consumer protections available to the insured individual when services are 37
rendered by a health service facility or healthcare provider participating in the 38
insurer's healthcare provider network may not be applicable when services are 39
rendered by a nonparticipating healthcare provider. 40
(b) Emergency Services Provided at Nonparticipating Health Service Facilities. – At the 41
time a health service facility begins the provision of emergency services to an insured individual, 42
if the facility does not have a contract with the applicable insurer, then the health service facility 43
shall provide the insured individual with a written disclosure containing all of the following: 44
(1) A statement that the health service facility does not have a provider network 45
contract with the applicable insurer and is considered to be a nonparticipating 46
provider. 47
(2) Text, using a bold or other distinguishable font, that states that certain 48
consumer protections available to the insured individual when services are 49
rendered by a health service facility or healthcare provider participating in the 50 General Assembly Of North Carolina Session 2025
Page 6 DRS15139-MG-66B
insurer's healthcare provider network may not be applicable when services are 1
rendered by a nonparticipating health service facility. 2
"§ 131E-214.31. Fair notice requirements; healthcare providers. 3
At the time a healthcare provider participating in an insurer's healthcare provider network (i) 4
treats an insured individual for anything other than screening and stabilization in accordance with 5
G.S. 58-3-190, (ii) schedules an appointment or procedure for nonemergency services for an 6
insured individual, or (iii) seeks prior authorization from an insurer for the provision of 7
nonemergency services to an insured individual, the healthcare provider shall provide the insured 8
individual with a written disclosure containing all of the following information: 9
(1) A statement that the healthcare provider is not the insurer's healthcare provider 10
network applicable to the individual. 11
(2) Text, using a bold or other distinguishable font, that states that certain 12
consumer protections available to the insured individual when services are 13
rendered by a healthcare provider participating in the insurer's healthcare 14
provider network may not be applicable when services are rendered by a 15
nonparticipating healthcare provider. 16
"§ 131E-214.35. Penalties. 17
A health service facility's or a healthcare provider's repeated failure to comply with this 18
Article shall indicate a general business practice that is deemed an unfair and deceptive trade 19
practice and is actionable under Chapter 75 of the General Statutes. Nothing in this Article 20
forecloses other remedies available under law or equity." 21
SECTION 2.2.(a) G.S. 58-3-200(a)(1) and G.S. 58-3-200(a)(2) are repealed. 22
SECTION 2.2.(b) G.S. 58-3-200(a), as amended by subsection (a) of this section, 23
reads as rewritten: 24
"(a) Definitions. – As used The following definitions apply in this section: 25
… 26
(3) Clinical laboratory. – An entity in which services are performed to provide 27
information or materials for use in the diagnosis, prevention, or treatment of 28
disease or assessment of a medical or physical condition. 29
(4) Health service facility. – A hospital; long-term care hospital; psychiatric 30
facility; rehabilitation facility; nursing home facility; adult care home; kidney 31
disease treatment center, including freestanding hemodialysis units; 32
intermediate care facility; home health agency office; chemical dependency 33
treatment facility; diagnostic center; hospice office; hospice inpatient facility; 34
hospice residential care facility; ambulatory surgical facility; urgent care 35
facility; freestanding emergency facility; and clinical laboratory. 36
(5) Healthcare provider. – Any health service facility or any person who is 37
licensed, registered, or certified under Chapter 90 or Chapter 90B of the 38
General Statutes, or under the laws of another state, to provide healthcare 39
services in the ordinary care of business or practice, or as a profession, or in 40
an approved education or training program, except that this term shall not 41
include a pharmacy." 42
SECTION 2.2.(c) G.S. 58-3-200(d) reads as rewritten: 43
"(d) Services Outside Provider Networks. – No insurer shall penalize an insured or subject 44
an insured to the out-of-network benefit levels offered under the insured's approved health benefit 45
plan, including an insured receiving an extended or standing referral under G.S. 58-3-223, unless 46
contracting health care healthcare providers able to meet health needs of the insured are 47
reasonably available to the insured without unreasonable delay. Upon notice or request from the 48
insured, the insurer shall determine whether a healthcare provider able to meet the needs of the 49
insured is available to the insured without unreasonable delay by reference to the insured's 50
location and the specific medical needs of the insured." 51 General Assembly Of North Carolina Session 2025
DRS15139-MG-66B Page 7
SECTION 2.3. This Part becomes effective October 1, 2026, and applies to 1
healthcare services provided on or after that date and to contracts issued, renewed, or amended 2
on or after that date. 3
4
PART III. GREATER FAIRNESS IN BILLING AND COLLECTIONS PRACTICES 5
FOR HOSPITALS AND AMBULATORY SURGICAL FACILITIES 6
SECTION 3.1.(a) Chapter 131E of the General Statutes is amended by adding a new 7
Article 11C to be entitled "Fair Billing and Collections Practices for Hospitals and Ambulatory 8
Surgical Facilities." 9
SECTION 3.1.(b) G.S. 131E-91 is recodified as G.S. 131E-214.50 under Article 10
11C of Chapter 131E of the General Statutes, as created by subsection (a) of this section. 11
SECTION 3.1.(c) G.S. 131E-214.50(d) reads as rewritten: 12
"(d) Hospitals and ambulatory surgical facilities shall abide by the following reasonable 13
collections practices: 14
… 15
(1a) A hospital or ambulatory surgical facility shall not refer a patient's unpaid bill 16
to a collections agency, entity, or other assignee unless it has first presented 17
an itemized list of charges to the patient detailing, in language comprehensible 18
to an ordinary layperson, the specific nature of the charges or expenses 19
incurred by the patient. 20
…." 21
SECTION 3.2. Article 11C of Chapter 131E of the General Statutes, as created by 22
Section 3.1(a) of this act, is amended by adding a new section to read: 23
"§ 131E-214.52. Patient's right to a good-faith estimate. 24
(a) Definitions. – The following definitions apply in this section: 25
(1) CMS. – The federal Centers for Medicare and Medicaid Services. 26
(2) Facility. – A hospital or ambulatory surgical facility licensed under this 27
Chapter. 28
(3) Items and services. – All items and services, including individual items and 29
services and service packages, that could be provided by a facility to a patient 30
in connection with an inpatient admission or an outpatient visit for which the 31
facility has established a standard charge. Examples include, but are not 32
limited to, all of the following: 33
a. Supplies and procedures. 34
b. Room and board. 35
c. Fees for use of the facility or other items. 36
d. Professional charges for services of physicians and nonphysician 37
practitioners who are employed by the facility. 38
e. Professional charges for services of physicians and nonphysician 39
practitioners who are not employed by the facility. 40
f. Any other items or services for which a facility has established a 41
standard charge. 42
(4) Service package. – An aggregation of individual items and services into a 43
single service with a single charge. 44
(5) Shoppable service. – A non-urgent service that can be scheduled by a patient 45
in advance. The term includes all CMS-specified shoppable services plus as 46
many additional facility-selected shoppable services as are necessary for a 47
combined total of at least 300 shoppable services. 48
(b) Good-Faith Estimate. – Upon request of any patient for a good-faith estimate for a 49
shoppable service, the facility shall provide to the patient, in writing, at least three business days 50
prior to the date the patient schedules the shoppable service, an itemized list of expected charges, 51 General Assembly Of North Carolina Session 2025
Page 8 DRS15139-MG-66B
in language comprehensible to an ordinary layperson, that the patient will be obligated to pay for 1
all items and services related to the shoppable service. The good-faith estimate shall include the 2
Diagnostic Related Group (DRG), Current Procedural Terminology (CPT), or Healthcare 3
Common Procedure Coding System (HCPCS) code for each expected charge. 4
(c) In any case in which a patient has requested a good-faith estimate from a facility for 5
a shoppable service, the patient's final bill for that shoppable service shall not exceed more than 6
five percent (5%) of the good-faith estimate provided to the patient pursuant to this section. 7
(d) The Department shall adopt rules to implement this section." 8
SECTION 3.3. This Part becomes effective on the later of January 1, 2026, or the 9
date the rules adopted by the Department under G.S. 131E-214.52 take effect and applies to acts 10
occurring on or after that date. 11
12
PART IV. GREATER PROTECTION FOR HEALTHCARE CONSUMERS FROM 13
FACILITY FEES 14
SECTION 4.1.(a) Article 11C of Chapter 131E of the General Statutes, as created 15
by Section 3.1(a) of this act, is amended by adding a new section to read: 16
"§ 131E-214.54. Facility fees. 17
(a) Definitions. – The following definitions apply in this section: 18
(1) Campus. – Any of the following: 19
a. The main building of a hospital. 20
b. The physical area immediately adjacent to a hospital's main building. 21
c. Other structures not contiguous to the main building of a hospital that 22
are within 250 yards of the main building. 23
d. Any other area that has been determined to be part of a hospital's 24
campus by the Centers for Medicare and Medicaid Services. 25
(2) Facility fee. – Any fee charged or billed by a health care provider for 26
outpatient services provided in a hospital-based facility that is (i) intended to 27
compensate the health care provider for the operational expenses of the health 28
care provider, (ii) separate and distinct from a professional fee, and (iii) 29
charged regardless of the modality through which the health care services 30
were provided. 31
(3) Health care provider. – As defined in G.S. 90-410. 32
(4) Health systems. – A parent corporation of one or more hospitals and any entity 33
affiliated with that parent corporation through ownership, governance, 34
membership, or other means, or a hospital and any entity affiliated with that 35
hospital through ownership, governance, membership, or other means. 36
(5) Hospital. – As defined in G.S. 131E-76. 37
(6) Hospital-based facility. – A facility that is owned or operated, in whole or in 38
part, by a hospital and at which hospital or professional medical services are 39
provided. 40
(7) Professional fee. – Any fee charged or billed by a provider for hospital or 41
professional medical services provided in a hospital-based facility. 42
(8) Remote location of a hospital. – A hospital-based facility that is created, 43
acquired, or purchased by a hospital or health system for the purpose of 44
furnishing inpatient services under the name, ownership, and financial and 45
administrative control of the hospital. 46
(b) Limits on Facility Fees. – The following limitations are applicable to facility fees: 47
(1) No health care provider shall charge, bill, or collect a facility fee unless the 48
services are provided on a hospital's main campus, at a remote location of a 49
hospital, or at a facility that includes an emergency department. 50 General Assembly Of North Carolina Session 2025
DRS15139-MG-66B Page 9
(2) Regardless of where the services are provided, no health care provider shall 1
charge, bill, or collect a facility fee for outpatient evaluation and management 2
services, or any other outpatient, diagnostic, or imaging services identified by 3
the Department. 4
(c) Identification of Services. – The Department shall annually identify services subject 5
to the limitations on facility fees provided in subdivision (2) of subsection (b) of this section that 6
may reliably be provided safely and effectively in non-hospital settings. 7
(d) Reporting Requirements. – Each hospital and health system shall submit a report to 8
the Department annually on July 1. The report shall be published on the Department's website 9
and shall contain the following: 10
(1) The name and full address of each facility owned or operated by the hospital 11
or health system that provides services for which a facility fee is charged or 12
billed. 13
(2) The number of patient visits at each such hospital-based facility for which a 14
facility fee was charged or billed. 15
(3) The number, total amount, and range of allowable facility fees paid at each 16
facility by Medicare, Medicaid, and private insurance. 17
(4) For each hospital-based facility and for the hospital or health system as a 18
whole, the total amount billed, and the total revenue received from facility 19
fees. 20
(5) The top 10 procedures or services, identified by Current Procedural 21
Terminology (CPT) category I codes, provided by the hospital or health 22
system that generated the greatest amount of facility fee gross revenue; the 23
number of each of these 10 procedures or services provided; the gross and net 24
revenue totals for each such procedure or service; and the total net amount of 25
revenue received by the hospital or health system derived from facility fees 26
for each procedure or service. 27
(6) Any other information the Department may require. 28
(e) Enforcement. – This section shall be enforced as follows: 29
(1) Any violation of this section constitutes an unfair or deceptive trade practice 30
in violation of G.S. 75-1.1 and is subject to all of the enforcement and penalty 31
provisions of an unfair or deceptive trade practice under Article 1 of Chapter 32
75 of the General Statutes. 33
(2) In addition to the remedies described in subdivision (1) of this subsection, any 34
health care provider who violates any provision of this section shall be subject 35
to an administrative penalty of not more than one thousand dollars ($1,000) 36
per occurrence." 37
SECTION 4.1.(b) No later than January 1, 2026, the Department of Health and 38
Human Services shall adopt rules necessary to implement G.S. 131E-214.54, as enacted by 39
subsection (a) of this section. 40
SECTION 4.2. G.S. 131E-214.54, as enacted by Section 4.1(a) of this Part, becomes 41
effective January 1, 2026, or on the date the rules adopted by the Department of Health and 42
Human Services pursuant to Section 4.1(b) of this Part become effective, whichever is later. 43
44
PART V. STATE AUDITOR REVIEW OF HEALTH SERVICE FACILITY PRICES 45
SECTION 5.1. G.S. 147-64.6(c) reads as rewritten: 46
"(c) Responsibilities. – The Auditor is responsible for the following acts and activities: 47
… 48
(24) The Auditor shall periodically examine health service facilities, as defined in 49
G.S. 131E-176, that are recipients of State funds for the following 50
information: 51 General Assembly Of North Carolina Session 2025
Page 10 DRS15139-MG-66B
a. The prices that the health service facility charges patients whose 1
insurance is out-of-network or who are uninsured. 2
b. To what extent the health service facility is transparent about the prices 3
described in sub-subdivision a. of this subdivision." 4
5
PART VI. ENHANCEMENTS TO EMPLOYEE SAFETY BY ALLOWING FOR THE 6
REMOVAL OF CERTAIN EMPLOYEE DETAILS FROM HEALTH INSURANCE 7
APPEALS AND GRIEVANCE REVIEWS 8
SECTION 6.1.(a) G.S. 58-50-61(k) reads as rewritten: 9
"(k) Nonexpedited Appeals. – Within three business days after receiving a request for a 10
standard, nonexpedited appeal, the insurer or its URO shall provide the covered person with the 11
name, address, and telephone number of the coordinator and information on how and where to 12
submit written material. material for the appeal, including contact information for the insurer. 13
For standard, nonexpedited appeals, the insurer or its URO shall give written notification of the 14
decision, in clear terms, to the covered person and the covered person's provider within 30 days 15
after the insurer receives the request for an appeal. If the decision is not in favor of the covered 16
person, the written decision shall contain:contain all of the following information: 17
(1) The professional qualifications and licensure of the person or persons 18
reviewing the appeal. 19
(2) A statement of the reviewers' understanding of the reason for the covered 20
person's basis of the appeal. 21
(3) The reviewers' insurer's or URO's decision in clear terms and the medical 22
rationale in sufficient detail for the covered person to respond further to the 23
insurer's position. 24
…." 25
SECTION 6.1.(b) G.S. 58-50-62(e) reads as rewritten: 26
"(e) First-Level Grievance Review. – A covered person or a covered person's provider 27
acting on the covered person's behalf may submit a grievance. All of the following shall apply to 28
a first-level grievance review: 29
(1) The insurer does not have is not required to allow a covered person to attend 30
the first-level grievance review. A covered person may submit written 31
material. Except as provided in subdivision (3) of this subsection, within three 32
business days after receiving a grievance, the insurer shall provide the covered 33
person with the name, address, and telephone number of the coordinator and 34
information on where and how to submit written material.material for the 35
first-level grievance review, including contact information for the insurer. 36
(2) An insurer shall issue a written decision, in clear terms, to the covered person 37
and, if applicable, to the covered person's provider, within 30 days after 38
receiving a grievance. The person or persons reviewing the grievance shall not 39
be the same person or persons who initially handled the matter that is the 40
subject of the grievance and, if the issue is a clinical one, at least one of whom 41
shall be a medical doctor with appropriate expertise to evaluate the matter. 42
Except as provided in subdivision (3) of this subsection, if the decision is not 43
in favor of the covered person, the written decision issued in a first-level 44
grievance review shall contain:contain all of the following information: 45
a. The professional qualifications and licensure of the person or persons 46
reviewing the grievance. 47
b. A statement of the reviewers' understanding basis of the grievance. 48
c. The reviewers' insurer's decision in clear terms and the contractual 49
basis or medical rationale in sufficient detail for the covered person to 50
respond further to the insurer's position. 51 General Assembly Of North Carolina Session 2025
DRS15139-MG-66B Page 11
…." 1
SECTION 6.1.(c) G.S. 58-50-62(f) reads as rewritten: 2
"(f) Second-Level Grievance Review. – An insurer shall establish a second-level 3
grievance review process for covered persons who are dissatisfied with the first-level grievance 4
review decision or a utilization review appeal decision. A covered person or the covered person's 5
provider acting on the covered person's behalf may submit a second-level grievance. All of the 6
following shall apply to a second-level grievance review: 7
(1) An insurer shall, within 10 business days after receiving a request for a 8
second-level grievance review, make known to provide the covered 9
person:person all of the following information: 10
a. The name, address, and telephone number of a person designated to 11
coordinate the grievance review for the insurer.Information on how 12
and where to submit written material for the second-level grievance 13
review, including contact information for the insurer. 14
…." 15
SECTION 6.2. This Part is effective when it becomes law. 16
17
PART VII. CLARIFY PARTNERSHIPS REGARDING THE PRACTICE OF 18
DENTISTRY 19
SECTION 7.1. G.S. 90-29(c) reads as rewritten: 20
"(c) The following acts, practices, or operations, however, shall not constitute the unlawful 21
practice of dentistry: 22
… 23
(15) The mechanism by which a "management company," as that term is defined 24
in G.S. 90-40.2(a)(4), and a licensee establish the fee in a "management 25
arrangement," as that term is defined in G.S. 90-40.2(a)(3). A management 26
fee established under this exception is a private business contract and shall not 27
be construed to be evidence of a partnership under Chapter 59 of the General 28
Statutes." 29
30
PART VIII. ELIMINATION OF CERTIFICATE OF NEED REVIEW FOR INPATIENT 31
REHABILITATION SERVICES, REHABILITATION FACILITIES, AND 32
REHABILITATION BEDS 33
SECTION 8.1. G.S. 131E-176 reads as rewritten: 34
"§ 131E-176. Definitions. 35
The following definitions apply in this Article: 36
… 37
(9a) Health service. – An organized, interrelated activity that is medical, 38
diagnostic, therapeutic, rehabilitative, or a combination thereof of these and 39
that is integral to the prevention of disease or the clinical management of an 40
individual who is sick or injured or who has a disability. "Health service" does 41
not include administrative and other activities that are not integral to clinical 42
management. 43
(9b) Health service facility. – A hospital; long-term care hospital; rehabilitation 44
facility; nursing home facility; adult care home; kidney disease treatment 45
center, including freestanding hemodialysis units; intermediate care facility 46
for individuals with intellectual disabilities; home health agency office; 47
diagnostic center; hospice office, hospice inpatient facility, hospice residential 48
care facility; and ambulatory surgical facility. 49
(9c) Health service facility bed. – A bed licensed for use in a health service facility 50
in the categories of (i) acute care beds; (iii) rehabilitation beds; (iv) (ii) nursing 51 General Assembly Of North Carolina Session 2025
Page 12 DRS15139-MG-66B
home beds; (v) (iii) intermediate care beds for individuals with intellectual 1
disabilities; (vii) (iv) hospice inpatient facility beds; (viii) (v) hospice 2
residential care facility beds; (ix) (vi) adult care home beds; and (x) (vii) 3
long-term care hospital beds. 4
… 5
(13) Hospital. – A public or private institution which that is primarily engaged in 6
providing to inpatients, by or under supervision of physicians, diagnostic 7
services and therapeutic services for medical diagnosis, treatment, and care of 8
injured, disabled, or sick persons, or rehabilitation services for the 9
rehabilitation of injured, disabled, or sick persons. The term includes all 10
facilities licensed pursuant to G.S. 131E-77, except rehabilitation facilities 11
and long-term care hospitals. 12
… 13
(17a) Nursing care. – Any of the following: 14
a. Skilled nursing care and related services for residents who require 15
medical or nursing care. 16
b. Rehabilitation services services, other than those provided at an 17
inpatient rehabilitation facility, for the rehabilitation of individuals 18
who are injured or sick or who have disabilities. 19
c. Health-related care and services provided on a regular basis to 20
individuals who because of their mental or physical condition require 21
care and services above the level of room and board, which can be 22
made available to them only through institutional facilities. 23
These are services which are not primarily for the care and treatment of 24
mental diseases. 25
… 26
(22) Rehabilitation facility. – A public or private inpatient facility which is 27
operated for the primary purpose of assisting in the rehabilitation of 28
individuals with disabilities through an integrated program of medical and 29
other services which are provided under competent, professional 30
supervision.A facility that has been classified and designated as an inpatient 31
rehabilitation facility by the Centers for Medicare and Medicaid Services 32
pursuant to Part 412 of Subchapter B of Chapter IV of Title 42 of the Code of 33
Federal Regulations. 34
…." 35
36
PART IX. EFFECTIVE DATE 37
SECTION 9.1. Except as otherwise provided, this act is effective when it becomes 38
law. 39