North Carolina 2025-2026 Regular Session

North Carolina Senate Bill S316 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		GENERAL ASSEMBLY OF NORTH CAROLINA
2	2		SESSION 2025
3		-	S 4
	3	+	S 3
4	4		SENATE BILL 316
5	5		Health Care Committee Substitute Adopted 3/19/25
6	6		Judiciary Committee Substitute Adopted 3/25/25
7		-	Fourth Edition Engrossed 3/27/25
8	7
9	8		Short Title: Lower Healthcare Costs. (Public)
10	9		Sponsors:
11	10		Referred to:
12	11		March 18, 2025
13		-	S316 -v-4
	12	+	S316 -v-3
14	13		A BILL TO BE ENTITLED 1
15	14		AN ACT LOWERING HEAL THCARE COSTS AND INC REASING PRICE 2
16	15		TRANSPARENCY. 3
17	16		Whereas, rising healthcare costs place a significant financial burden on individuals, 4
18	17		families, employers, and taxpayers, greatly contribute to inflation, and make it increasingly 5
19	18		difficult for residents to access essential healthcare services; and 6
20	19		Whereas, North Carolina has intolerably high healthcare costs, with recent studies 7
21	20		ranking the State 50th out of 50 in the United States; and 8
22	21		Whereas, skyrocketing healthcare costs have resulted in over 40 percent of Americans 9
23	22		reporting some type of healthcare debt, according to one study; and 10
24	23		Whereas, many patients face unexpected medical bills due to a lack of disclosure 11
25	24		about out-of-network providers and a general lack of transparency in healthcare pricing, resulting 12
26	25		in financial strain and hardship; and 13
27	26		Whereas, employers are burdened with the increasing costs of providing health 14
28	27		insurance for employees, leading to higher premiums, deductibles, and out-of-pocket expenses; 15
29	28		and 16
30	29		Whereas, patients and employers are often unable to compare the costs of medical 17
31	30		services due to a lack of clear and accessible pricing information, hindering their ability to make 18
32	31		informed decisions; and 19
33	32		Whereas, the absence of price transparency in the healthcare system leads to market 20
34	33		inefficiencies, less awareness of price difference, less competition, and higher prices, with 21
35	34		consumers often unable to identify the most cost-effective providers; and 22
36	35		Whereas, transparency in healthcare pricing allows consumers to shop for affordable 23
37	36		healthcare services and encourages competition among healthcare providers to offer more 24
38	37		competitive pricing; and 25
39	38		Whereas, providing consumers with clear, understandable, and accessible 26
40	39		information about the costs of healthcare services will foster a more competitive and 27
41	40		patient-centered healthcare market; and 28
42	41		Whereas, requiring healthcare providers and insurers to disclose their prices in 29
43	42		advance, including all providers and services a patient may need, both in-network and 30
44	43		out-of-network, will enable consumers to make more informed choices about their care, leading 31
45	44		to better healthcare outcomes at lower costs; and 32
46	45		Whereas, price transparency will incentivize hospitals and healthcare providers to 33
47	46		improve the quality of care while reducing prices, to the benefit of patients and employers; and 34 General Assembly Of North Carolina Session 2025
48		-	Page 2 Senate Bill 316-~~Fourth~~ Edition
	47	+	Page 2 Senate Bill 316-Third Edition
49	48		Whereas, clear pricing and competition among healthcare providers will encourage 1
50	49		innovation in healthcare delivery and improve overall efficiency within the system; and 2
51	50		Whereas, empowering patients and employers with pricing information will help 3
52	51		create a healthcare system that prioritizes affordability, access, and choice; and 4
53	52		Whereas, President Trump recently signed an Executive Order to make healthcare 5
54	53		prices transparent, "empower[ing] patients with clear, accurate, and actionable healthcare pricing 6
55	54		information," also "ensur[ing] hospitals and insurers disclose actual prices, not estimates, and 7
56	55		take action to make prices comparable across hospitals and insurers, including prescription drug 8
57	56		prices; Now, therefore, 9
58	57		The General Assembly of North Carolina enacts: 10
59	58		11
60	59		PART I. GREATER TRAN SPARENCY IN HOSPITAL AND AMBULATORY 12
61	60		SURGICAL FACILITY HE ALTHCARE COSTS 13
62	61		SECTION 1.1. Article 11B of Chapter 131E of the General Statutes reads as 14
63	62		rewritten: 15
64	63		"Article 11B. 16
65	64		"Transparency in Health Care Costs. 17
66	65		"Part 1. Health Care Cost Reduction and Transparency Act of 2013. 18
67	66		"§ 131E-214.11. Title. 19
68	67		This article Part shall be known as the Health Care Cost Reduction and Transparency Act of 20
69	68		2013. 21
70	69		… 22
71	70		"§ 131E-214.13. Disclosure of prices for most frequently reported DRGs, CPTs, and 23
72	71		HCPCSs. 24
73	72		(a) Definitions. – The following definitions apply in this Article:Part: 25
74	73		(1) Ambulatory surgical facility. – A facility licensed under Part 4 of Article 6 of 26
75	74		this Chapter. 27
76	75		(2) Commission. – The North Carolina Medical Care Commission. 28
77	76		(2a) CPT. – Current Procedural Terminology. 29
78	77		(2b) DRG. – Diagnostic Related Group. 30
79	78		(2c) HCPCS. – The Healthcare Common Procedure Coding System. 31
80	79		(3) Health insurer. – An entity that writes a health benefit plan and is one of the 32
81	80		following: 33
82	81		a. An insurance company under Article 3 of Chapter 58 of the General 34
83	82		Statutes. 35
84	83		b. A service corporation under Article 65 of Chapter 58 of the General 36
85	84		Statutes. 37
86	85		c. A health maintenance organization under Article 67 of Chapter 58 of 38
87	86		the General Statutes. 39
88	87		d. A third-party administrator of one or more group health plans, as 40
89	88		defined in section 607(1) of the Employee Retirement Income Security 41
90	89		Act of 1974 (29 U.S.C. § 1167(1)). 42
91	90		(4) Hospital. – A medical care facility licensed under Article 5 of this Chapter or 43
92	91		under Article 2 of Chapter 122C of the General Statutes. 44
93	92		(5) Public or private third party. – Includes the State, the federal government, 45
94	93		employers, health insurers, third-party administrators, and managed care 46
95	94		organizations. 47
96		-	(6) Statewide data processor. – As defined in G.S. 131E-214.1. 48
97		-	(b) Beginning with the reporting period ending September 30, 2015, and annually 49
98		-	thereafter, Quarterly Report on Most Frequently Reported DRGs for Inpatients. – On a quarterly 50
99		-	basis, each hospital shall provide to the Department of Health and Human Services statewide 51 General Assembly Of North Carolina Session 2025
100		-	Senate Bill 316-Fourth Edition Page 3
101		-	data processor, utilizing electronic health records software, the following information about the 1
102		-	100 most frequently reported admissions by DRG for inpatients as established by the 2
103		-	Department: 3
104		-	(1) The amount that will be charged to a patient for each DRG if all charges are 4
105		-	paid in full without a public or private third party paying for any portion of 5
106		-	the charges. In calculating this amount, each hospital shall include charges for 6
107		-	each billable item and service associated with the DRG regardless of whether 7
108		-	the health service is performed by a physician or nonphysician practitioner 8
109		-	employed by the hospital. 9
110		-	(2) The average negotiated settlement on the amount that will be charged to a 10
111		-	patient required to be provided in subdivision (1) of this subsection. 11
112		-	(3) The amount of Medicaid reimbursement for each DRG, including claims and 12
113		-	pro rata supplemental payments. 13
114		-	(4) The amount of Medicare reimbursement for each DRG. 14
115		-	(5) For each of the five largest health insurers providing payment to the hospital 15
116		-	on behalf of insureds and teachers and State employees, the range and the 16
117		-	average of the amount of payment made for each DRG. Prior to providing this 17
118		-	information to the Department statewide data processor, each hospital shall 18
119		-	redact the names of the health insurers and any other information that would 19
120		-	otherwise identify the health insurers. 20
121		-	A hospital shall not be required to report the information required by this subsection for any 21
122		-	of the 100 most frequently reported admissions where the reporting of that information 22
123		-	reasonably could lead to the identification of the person or persons admitted to the hospital in 23
124		-	violation of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or 24
125		-	other federal law. 25
126		-	(c) The Commission shall adopt rules on or before March 1, 2016, to ensure that 26
127		-	subsection (b) of this section is properly implemented and that hospitals report this information 27
128		-	to the Department in a uniform manner. The rules shall include all of the following: 28
129		-	(1) The method by which the Department shall determine the 100 most frequently 29
130		-	reported DRGs for inpatients for which hospitals must provide the data set out 30
131		-	in subsection (b) of this section. 31
132		-	(2) Specific categories by which hospitals shall be grouped for the purpose of 32
133		-	disclosing this information to the public on the Department's Internet Web 33
134		-	site. 34
135		-	(d) Beginning with the reporting period ending September 30, 2015, and annually 35
136		-	thereafter, Quarterly Report on Total Costs for the Most Common Surgical and Imaging 36
137		-	Procedures. – On a quarterly basis, each hospital and ambulatory surgical facility shall provide 37
138		-	to the Department,statewide data processor, utilizing electronic health records software, 38
139		-	information on the total costs for the 20 most common surgical procedures and the 20 most 39
140		-	common imaging procedures, by volume, performed in hospital outpatient settings or in 40
141		-	ambulatory surgical facilities, along with the related CPT and HCPCS codes. In providing 41
142		-	information on total costs, each hospital and ambulatory surgical facility shall include the costs 42
143		-	for each billable item and service associated with the procedure regardless of whether the health 43
144		-	service is performed by a physician or nonphysician practitioner employed by the hospital or 44
145		-	ambulatory surgical facility. Hospitals and ambulatory surgical facilities shall report this 45
146		-	information in the same manner as required by subdivisions (b)(1) through (5) of this section, 46
147		-	provided that hospitals and ambulatory surgical facilities shall not be required to report the 47
148		-	information required by this subsection where the reporting of that information reasonably could 48
149		-	lead to the identification of the person or persons admitted to the hospital in violation of the 49
150		-	federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or other federal 50
151		-	law. 51 General Assembly Of North Carolina Session 2025
152		-	Page 4 Senate Bill 316-Fourth Edition
153		-	(e) The Commission shall adopt rules on or before March 1, 2016, to ensure that 1
154		-	subsection (d) of this section is properly implemented and that hospitals and ambulatory surgical 2
155		-	facilities report this information to the Department in a uniform manner. The rules shall include 3
156		-	the method by which the Department shall determine the 20 most common surgical procedures 4
157		-	and the 20 most common imaging procedures for which the hospitals and ambulatory surgical 5
158		-	facilities must provide the data set out in subsection (d) of this section. 6
159		-	(e1) The Commission shall adopt rules to establish and define no fewer than 10 quality 7
160		-	measures for licensed hospitals and licensed ambulatory surgical facilities. 8
161		-	(f) Upon request of a patient for a particular DRG, imaging procedure, or surgery 9
162		-	procedure reported in this section, a hospital or ambulatory surgical facility shall provide the 10
163		-	information required by subsection (b) or subsection (d) of this section to the patient in writing, 11
164		-	either electronically or by mail, within three business days after receiving the request. 12
165		-	(f1) Commission Rules. – The Commission shall adopt rules to accomplish all of the 13
166		-	following: 14
167		-	(1) To ensure that subsection (b) of this section is properly implemented and that 15
168		-	hospitals report this information to the statewide data processor in a uniform 16
169		-	manner. The rules shall include the method by which the statewide data 17
170		-	processor shall determine the 100 most frequently reported DRGs for 18
171		-	inpatients for which hospitals must provide the data set out in subsection (b) 19
172		-	of this section and the specific categories by which hospitals shall be grouped 20
173		-	for the purpose of disclosing this information to the public on the Department's 21
174		-	website. 22
175		-	(2) To ensure that subsection (d) of this section is properly implemented and that 23
176		-	hospitals and ambulatory surgical facilities report this information to the 24
177		-	statewide data processor in a uniform manner. The rules shall include the 25
178		-	method by which the statewide data processor shall determine the 20 most 26
179		-	common surgical procedures and the 20 most common imaging procedures 27
180		-	for which the hospitals and ambulatory surgical facilities must provide the 28
181		-	data set out in subsection (d) of this section. 29
182		-	(3) To establish and define no fewer than 10 quality measures for licensed 30
183		-	hospitals and licensed ambulatory surgical facilities. 31
184		-	(4) To establish procedures for the statewide data processor to receive the data 32
185		-	required by subsections (b) and (d) of this section and submit that data to the 33
186		-	Department for publication on the Department's website. 34
187		-	(g) G.S. 150B-21.3 does not apply to rules adopted under subsections (c) and (e) 35
188		-	subdivision (f1)(1) or subdivision (f1)(2) of this section. A rule adopted under subsections (c) 36
189		-	and (e) subdivision (f1)(1) or subdivision (f1)(2) of this section becomes effective on the last day 37
190		-	of the month following the month in which the rule is approved by the Rules Review 38
191		-	Commission. 39
192		-	… 40
193		-	"§ 131E-214.18. Penalty for noncompliance. 41
194		-	The Department may impose a civil penalty on any hospital or ambulatory surgical facility 42
195		-	that fails to comply with the requirements of this Part. For each day of violation, the amount of 43
196		-	the civil penalty shall not be (i) less than one hundredth of one percent (.01%) of the annual salary 44
197		-	of the chief executive officer of the noncompliant hospital or ambulatory surgical facility or (ii) 45
198		-	greater than two thousand dollars ($2,000). This civil penalty shall be in addition to any fine or 46
199		-	civil penalty that the Centers for Medicare and Medicaid Services or other federal agency may 47
200		-	choose to impose on the facility. The Department shall remit the clear proceeds of civil penalties 48
201		-	assessed pursuant to this section to the Civil Penalty and Forfeiture Fund in accordance with 49
202		-	G.S. 115C-457.2." 50
203		-	SECTION 1.1A. G.S. 131E-214.4(a) reads as rewritten: 51 General Assembly Of North Carolina Session 2025
204		-	Senate Bill 316-Fourth Edition Page 5
205		-	"(a) A statewide data processor shall perform the following duties: 1
206		-	… 2
207		-	(8) Receive data required to be submitted by hospitals under G.S. 131E-214.13(b) 3
208		-	and by hospitals and ambulatory surgical facilities under G.S. 131E-214.13(d) 4
209		-	and submit that data to the Department of Health and Human Services 5
210		-	(Department) for publication on the Department's website." 6
211		-	SECTION 1.2. This Part becomes effective on the later of January 1, 2026, or the 7
212		-	date the rules adopted by the North Carolina Medical Care Commission under 8
213		-	G.S. 131E-214.13(f1)(2) take effect, and G.S. 131E-214.18, as enacted by this Part, applies to 9
214		-	acts occurring on or after that date. The Commission shall notify the Revisor of Statutes when 10
215		-	the rules required under G.S. 131E-214.13(f1)(1) and (f1)(2) take effect. 11
216		-	12
217		-	PART II. GREATER TRA NSPARENCY IN HEALTHC ARE PROVIDER BILLING 13
218		-	PRACTICES 14
219		-	SECTION 2.1. Article 11B of Chapter 131E of the General Statutes, as amended by 15
220		-	Part I of this act, is amended by adding a new Part to read: 16
221		-	"Part 2. Transparency in Healthcare Provider Billing Practices. 17
222		-	"§ 131E-214.25. Definitions. 18
223		-	The following definitions apply in this Part: 19
224		-	(1) Health benefit plan. – As defined in G.S. 58-3-167, or under the laws of 20
225		-	another state or the federal government. 21
226		-	(2) Healthcare provider. – As defined in G.S. 90-410. 22
227		-	(3) Insurer. – As defined in G.S. 58-3-167. 23
228		-	"§ 131E-214.30. Fair notice requirements; heath service facilities. 24
229		-	(a) Services Provided at a Participating Health Service Facility. – At the time a health 25
230		-	service facility participating in an insurer's healthcare provider network (i) treats an insured 26
231		-	individual for anything other than screening and stabilization in accordance with G.S. 58-3-190, 27
232		-	(ii) admits an insured individual to receive emergency services, (iii) schedules a procedure for 28
233		-	nonemergency services for an insured individual, or (iv) seeks prior authorization from an insurer 29
234		-	for the provision of nonemergency services to an insured individual, the health service facility 30
235		-	shall provide the insured individual with a written disclosure containing all of the following 31
236		-	information: 32
237		-	(1) Services may be provided at the health service facility for which the insured 33
238		-	individual may receive a separate bill. 34
239		-	(2) Certain healthcare providers may be called upon to render care to the insured 35
240		-	individual during the course of treatment and those healthcare providers may 36
241		-	not have contracts with the insured's insurer and are considered to be 37
242		-	nonparticipating healthcare providers in the insurer's healthcare provider 38
243		-	network. Any nonparticipating healthcare providers shall be identified in the 39
244		-	written disclosure using the individual's healthcare provider's name and 40
245		-	practice name as used on the applicable health service facility's or healthcare 41
246		-	provider's credentials or name badge. 42
247		-	(3) Text, using a bold or other distinguishable font, that states that certain 43
248		-	consumer protections available to the insured individual when services are 44
249		-	rendered by a health service facility or healthcare provider participating in the 45
250		-	insurer's healthcare provider network may not be applicable when services are 46
251		-	rendered by a nonparticipating healthcare provider. 47
252		-	(b) Emergency Services Provided at Nonparticipating Health Service Facilities. – As 48
253		-	soon as practicable after a health service facility begins the provision of emergency services to 49
254		-	an insured individual, if the facility does not have a contract with the applicable insurer, then the 50 General Assembly Of North Carolina Session 2025
255		-	Page 6 Senate Bill 316-Fourth Edition
256		-	health service facility shall provide the insured individual with a written disclosure containing 1
257		-	all of the following: 2
258		-	(1) A statement that the health service facility does not have a provider network 3
259		-	contract with the applicable insurer and is considered to be a nonparticipating 4
260		-	provider. 5
261		-	(2) Text, using a bold or other distinguishable font, that states that certain 6
262		-	consumer protections available to the insured individual when services are 7
263		-	rendered by a health service facility or healthcare provider participating in the 8
264		-	insurer's healthcare provider network may not be applicable when services are 9
265		-	rendered by a nonparticipating health service facility. 10
266		-	"§ 131E-214.31. Fair notice requirements; healthcare providers. 11
267		-	At the time a healthcare provider not participating in an insurer's healthcare provider network 12
268		-	(i) treats an insured individual for anything other than screening and stabilization in accordance 13
269		-	with G.S. 58-3-190, (ii) schedules an appointment or procedure for nonemergency services for 14
270		-	an insured individual, or (iii) seeks prior authorization from an insurer for the provision of 15
271		-	nonemergency services to an insured individual, the healthcare provider shall provide the insured 16
272		-	individual with a written disclosure containing all of the following information: 17
273		-	(1) A statement that the healthcare provider is not in the insurer's healthcare 18
274		-	provider network applicable to the individual. 19
275		-	(2) Text, using a bold or other distinguishable font, that states that certain 20
276		-	consumer protections available to the insured individual when services are 21
277		-	rendered by a healthcare provider participating in the insurer's healthcare 22
278		-	provider network may not be applicable when services are rendered by a 23
279		-	nonparticipating healthcare provider. 24
280		-	"§ 131E-214.35. Penalties. 25
281		-	A healthcare provider's repeated failure to comply with this Article shall indicate a general 26
282		-	business practice that is deemed an unfair and deceptive trade practice and is actionable under 27
283		-	Chapter 75 of the General Statutes. Nothing in this Article forecloses other remedies available 28
284		-	under law or equity." 29
285		-	SECTION 2.2.(a) G.S. 58-3-200(a)(1) and G.S. 58-3-200(a)(2) are repealed. 30
286		-	SECTION 2.2.(b) G.S. 58-3-200(a), as amended by subsection (a) of this section, 31
287		-	reads as rewritten: 32
288		-	"(a) Definitions. – As used The following definitions apply in this section: 33
	95	+	(b) Beginning with the reporting period ending September 30, 2015, and annually 48
	96	+	thereafter, Quarterly Report on Most Frequently Reported DRGs for Inpatients. – On a quarterly 49
	97	+	basis, each hospital shall provide to the Department of Health and Human Services, Department, 50 General Assembly Of North Carolina Session 2025
	98	+	Senate Bill 316-Third Edition Page 3
	99	+	utilizing electronic health records software, the following information about the 100 most 1
	100	+	frequently reported admissions by DRG for inpatients as established by the Department: 2
	101	+	(1) The amount that will be charged to a patient for each DRG if all charges are 3
	102	+	paid in full without a public or private third party paying for any portion of 4
	103	+	the charges. In calculating this amount, each hospital shall include charges for 5
	104	+	each billable item and service associated with the DRG regardless of whether 6
	105	+	the health service is performed by a physician or nonphysician practitioner 7
	106	+	employed by the hospital. 8
	107	+	(2) The average negotiated settlement on the amount that will be charged to a 9
	108	+	patient required to be provided in subdivision (1) of this subsection. 10
	109	+	(3) The amount of Medicaid reimbursement for each DRG, including claims and 11
	110	+	pro rata supplemental payments. 12
	111	+	(4) The amount of Medicare reimbursement for each DRG. 13
	112	+	(5) For each of the five largest health insurers providing payment to the hospital 14
	113	+	on behalf of insureds and teachers and State employees, the range and the 15
	114	+	average of the amount of payment made for each DRG. Prior to providing this 16
	115	+	information to the Department, each hospital shall redact the names of the 17
	116	+	health insurers and any other information that would otherwise identify the 18
	117	+	health insurers. 19
	118	+	A hospital shall not be required to report the information required by this subsection for any 20
	119	+	of the 100 most frequently reported admissions where the reporting of that information 21
	120	+	reasonably could lead to the identification of the person or persons admitted to the hospital in 22
	121	+	violation of the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) or 23
	122	+	other federal law. 24
	123	+	(c) The Commission shall adopt rules on or before March 1, 2016, to ensure that 25
	124	+	subsection (b) of this section is properly implemented and that hospitals report this information 26
	125	+	to the Department in a uniform manner. The rules shall include all of the following: 27
	126	+	(1) The method by which the Department shall determine the 100 most frequently 28
	127	+	reported DRGs for inpatients for which hospitals must provide the data set out 29
	128	+	in subsection (b) of this section. 30
	129	+	(2) Specific categories by which hospitals shall be grouped for the purpose of 31
	130	+	disclosing this information to the public on the Department's Internet Web 32
	131	+	site. 33
	132	+	(d) Beginning with the reporting period ending September 30, 2015, and annually 34
	133	+	thereafter, Quarterly Report on Total Costs for the Most Common Surgical and Imaging 35
	134	+	Procedures. – On a quarterly basis, each hospital and ambulatory surgical facility shall provide 36
	135	+	to the Department, utilizing electronic health records software, information on the total costs for 37
	136	+	the 20 most common surgical procedures and the 20 most common imaging procedures, by 38
	137	+	volume, performed in hospital outpatient settings or in ambulatory surgical facilities, along with 39
	138	+	the related CPT and HCPCS codes. In providing information on total costs, each hospital and 40
	139	+	ambulatory surgical facility shall include the costs for each billable item and service associated 41
	140	+	with the procedure regardless of whether the health service is performed by a physician or 42
	141	+	nonphysician practitioner employed by the hospital or ambulatory surgical facility. Hospitals and 43
	142	+	ambulatory surgical facilities shall report this information in the same manner as required by 44
	143	+	subdivisions (b)(1) through (5) of this section, provided that hospitals and ambulatory surgical 45
	144	+	facilities shall not be required to report the information required by this subsection where the 46
	145	+	reporting of that information reasonably could lead to the identification of the person or persons 47
	146	+	admitted to the hospital in violation of the federal Health Insurance Portability and 48
	147	+	Accountability Act of 1996 (HIPAA) or other federal law. 49
	148	+	(e) The Commission shall adopt rules on or before March 1, 2016, to ensure that 50
	149	+	subsection (d) of this section is properly implemented and that hospitals and ambulatory surgical 51 General Assembly Of North Carolina Session 2025
	150	+	Page 4 Senate Bill 316-Third Edition
	151	+	facilities report this information to the Department in a uniform manner. The rules shall include 1
	152	+	the method by which the Department shall determine the 20 most common surgical procedures 2
	153	+	and the 20 most common imaging procedures for which the hospitals and ambulatory surgical 3
	154	+	facilities must provide the data set out in subsection (d) of this section. 4
	155	+	(e1) The Commission shall adopt rules to establish and define no fewer than 10 quality 5
	156	+	measures for licensed hospitals and licensed ambulatory surgical facilities. 6
	157	+	(f) Upon request of a patient for a particular DRG, imaging procedure, or surgery 7
	158	+	procedure reported in this section, a hospital or ambulatory surgical facility shall provide the 8
	159	+	information required by subsection (b) or subsection (d) of this section to the patient in writing, 9
	160	+	either electronically or by mail, within three business days after receiving the request. 10
	161	+	(f1) Commission Rules. – The Commission shall adopt rules to accomplish all of the 11
	162	+	following: 12
	163	+	(1) To ensure that subsection (b) of this section is properly implemented and that 13
	164	+	hospitals report this information to the Department in a uniform manner. The 14
	165	+	rules shall include the method by which the Department shall determine the 15
	166	+	100 most frequently reported DRGs for inpatients for which hospitals must 16
	167	+	provide the data set out in subsection (b) of this section and the specific 17
	168	+	categories by which hospitals shall be grouped for the purpose of disclosing 18
	169	+	this information to the public on the Department's internet website. 19
	170	+	(2) To ensure that subsection (d) of this section is properly implemented and that 20
	171	+	hospitals and ambulatory surgical facilities report this information to the 21
	172	+	Department in a uniform manner. The rules shall include the method by which 22
	173	+	the Department shall determine the 20 most common surgical procedures and 23
	174	+	the 20 most common imaging procedures for which the hospitals and 24
	175	+	ambulatory surgical facilities must provide the data set out in subsection (d) 25
	176	+	of this section. 26
	177	+	(3) To establish and define no fewer than 10 quality measures for licensed 27
	178	+	hospitals and licensed ambulatory surgical facilities. 28
	179	+	(g) G.S. 150B-21.3 does not apply to rules adopted under subsections (c) and (e) 29
	180	+	subdivision (f1)(1) or subdivision (f1)(2) of this section. A rule adopted under subsections (c) 30
	181	+	and (e) subdivision (f1)(1) or subdivision (f1)(2) of this section becomes effective on the last day 31
	182	+	of the month following the month in which the rule is approved by the Rules Review 32
	183	+	Commission. 33
289	184		… 34
290		-	(3) Clinical laboratory. – An entity in which services are performed to provide 35
291		-	information or materials for use in the diagnosis, prevention, or treatment of 36
292		-	disease or assessment of a medical or physical condition. 37
293		-	(4) Healthcare provider. – As defined in G.S. 90-410." 38
294		-	SECTION 2.2.(c) G.S. 58-3-200(d) reads as rewritten: 39
295		-	"(d) Services Outside Provider Networks. – No insurer shall penalize an insured or subject 40
296		-	an insured to the out-of-network benefit levels offered under the insured's approved health benefit 41
297		-	plan, including an insured receiving an extended or standing referral under G.S. 58-3-223, unless 42
298		-	contracting health care healthcare providers able to meet health needs of the insured are 43
299		-	reasonably available to the insured without unreasonable delay. Upon notice or request from the 44
300		-	insured, the insurer shall determine whether a healthcare provider able to meet the needs of the 45
301		-	insured is available to the insured without unreasonable delay by reference to the insured's 46
302		-	location and the specific medical needs of the insured." 47
303		-	SECTION 2.3. This Part becomes effective October 1, 2026, and applies to 48
304		-	healthcare services provided on or after that date and to contracts issued, renewed, or amended 49
305		-	on or after that date. 50
306		-	51 General Assembly Of North Carolina Session 2025
307		-	Senate Bill 316-Fourth Edition Page 7
308		-	PART III. GREATER FAIRNESS IN BILLING AND COLLECTIONS PRACTI CES 1
309		-	FOR HOSPITALS AND AMBULATORY S URGICAL FACILITIES 2
310		-	SECTION 3.1.(a) Chapter 131E of the General Statutes is amended by adding a new 3
311		-	Article 11C to be entitled "Fair Billing and Collections Practices for Hospitals and Ambulatory 4
312		-	Surgical Facilities." 5
313		-	SECTION 3.1.(b) G.S. 131E-91 is recodified as G.S. 131E-214.50 under Article 6
314		-	11C of Chapter 131E of the General Statutes, as created by subsection (a) of this section. 7
315		-	SECTION 3.1.(c) G.S. 131E-214.50(d) reads as rewritten: 8
316		-	"(d) Hospitals and ambulatory surgical facilities shall abide by the following reasonable 9
317		-	collections practices: 10
318		-	… 11
319		-	(1a) A hospital or ambulatory surgical facility shall not refer a patient's unpaid bill 12
320		-	to a collections agency, entity, or other assignee unless it has first presented 13
321		-	an itemized list of charges to the patient detailing, in language comprehensible 14
322		-	to an ordinary layperson, the specific nature of the charges or expenses 15
323		-	incurred by the patient. 16
	185	+	"§ 131E-214.18. Penalty for noncompliance. 35
	186	+	The Department may impose a civil penalty on any hospital or ambulatory surgical facility 36
	187	+	that fails to comply with the requirements of this Part. For each day of violation, the amount of 37
	188	+	the civil penalty shall not be (i) less than one hundredth of one percent (.01%) of the annual salary 38
	189	+	of the chief executive officer of the noncompliant hospital or ambulatory surgical facility or (ii) 39
	190	+	greater than two thousand dollars ($2,000). This civil penalty shall be in addition to any fine or 40
	191	+	civil penalty that the Centers for Medicare and Medicaid Services or other federal agency may 41
	192	+	choose to impose on the facility. The Department shall remit the clear proceeds of civil penalties 42
	193	+	assessed pursuant to this section to the Civil Penalty and Forfeiture Fund in accordance with 43
	194	+	G.S. 115C-457.2." 44
	195	+	SECTION 1.2. This Part becomes effective on the later of January 1, 2026, or the 45
	196	+	date the rules adopted by the North Carolina Medical Care Commission under 46
	197	+	G.S. 131E-214.13(f1)(2) take effect, and G.S. 131E-214.18, as enacted by this Part, applies to 47
	198	+	acts occurring on or after that date. The Commission shall notify the Revisor of Statutes when 48
	199	+	the rules required under G.S. 131E-214.13(f1)(1) and (f1)(2) take effect. 49
	200	+	50 General Assembly Of North Carolina Session 2025
	201	+	Senate Bill 316-Third Edition Page 5
	202	+	PART II. GREATER TRANSPARENCY IN HE ALTHCARE PROVIDER BI LLING 1
	203	+	PRACTICES 2
	204	+	SECTION 2.1. Article 11B of Chapter 131E of the General Statutes, as amended by 3
	205	+	Part I of this act, is amended by adding a new Part to read: 4
	206	+	"Part 2. Transparency in Healthcare Provider Billing Practices. 5
	207	+	"§ 131E-214.25. Definitions. 6
	208	+	The following definitions apply in this Part: 7
	209	+	(1) Health benefit plan. – As defined in G.S. 58-3-167, or under the laws of 8
	210	+	another state or the federal government. 9
	211	+	(2) Healthcare provider. – As defined in G.S. 90-410. 10
	212	+	(3) Insurer. – As defined in G.S. 58-3-167. 11
	213	+	"§ 131E-214.30. Fair notice requirements; heath service facilities. 12
	214	+	(a) Services Provided at a Participating Health Service Facility. – At the time a health 13
	215	+	service facility participating in an insurer's healthcare provider network (i) treats an insured 14
	216	+	individual for anything other than screening and stabilization in accordance with G.S. 58-3-190, 15
	217	+	(ii) admits an insured individual to receive emergency services, (iii) schedules a procedure for 16
	218	+	nonemergency services for an insured individual, or (iv) seeks prior authorization from an insurer 17
	219	+	for the provision of nonemergency services to an insured individual, the health service facility 18
	220	+	shall provide the insured individual with a written disclosure containing all of the following 19
	221	+	information: 20
	222	+	(1) Services may be provided at the health service facility for which the insured 21
	223	+	individual may receive a separate bill. 22
	224	+	(2) Certain healthcare providers may be called upon to render care to the insured 23
	225	+	individual during the course of treatment and those healthcare providers may 24
	226	+	not have contracts with the insured's insurer and are considered to be 25
	227	+	nonparticipating healthcare providers in the insurer's healthcare provider 26
	228	+	network. Any nonparticipating healthcare providers shall be identified in the 27
	229	+	written disclosure using the individual's healthcare provider's name and 28
	230	+	practice name as used on the applicable health service facility's or healthcare 29
	231	+	provider's credentials or name badge. 30
	232	+	(3) Text, using a bold or other distinguishable font, that states that certain 31
	233	+	consumer protections available to the insured individual when services are 32
	234	+	rendered by a health service facility or healthcare provider participating in the 33
	235	+	insurer's healthcare provider network may not be applicable when services are 34
	236	+	rendered by a nonparticipating healthcare provider. 35
	237	+	(b) Emergency Services Provided at Nonparticipating Health Service Facilities. – As 36
	238	+	soon as practicable after a health service facility begins the provision of emergency services to 37
	239	+	an insured individual, if the facility does not have a contract with the applicable insurer, then the 38
	240	+	health service facility shall provide the insured individual with a written disclosure containing 39
	241	+	all of the following: 40
	242	+	(1) A statement that the health service facility does not have a provider network 41
	243	+	contract with the applicable insurer and is considered to be a nonparticipating 42
	244	+	provider. 43
	245	+	(2) Text, using a bold or other distinguishable font, that states that certain 44
	246	+	consumer protections available to the insured individual when services are 45
	247	+	rendered by a health service facility or healthcare provider participating in the 46
	248	+	insurer's healthcare provider network may not be applicable when services are 47
	249	+	rendered by a nonparticipating health service facility. 48
	250	+	"§ 131E-214.31. Fair notice requirements; healthcare providers. 49
	251	+	At the time a healthcare provider not participating in an insurer's healthcare provider network 50
	252	+	(i) treats an insured individual for anything other than screening and stabilization in accordance 51 General Assembly Of North Carolina Session 2025
	253	+	Page 6 Senate Bill 316-Third Edition
	254	+	with G.S. 58-3-190, (ii) schedules an appointment or procedure for nonemergency services for 1
	255	+	an insured individual, or (iii) seeks prior authorization from an insurer for the provision of 2
	256	+	nonemergency services to an insured individual, the healthcare provider shall provide the insured 3
	257	+	individual with a written disclosure containing all of the following information: 4
	258	+	(1) A statement that the healthcare provider is not in the insurer's healthcare 5
	259	+	provider network applicable to the individual. 6
	260	+	(2) Text, using a bold or other distinguishable font, that states that certain 7
	261	+	consumer protections available to the insured individual when services are 8
	262	+	rendered by a healthcare provider participating in the insurer's healthcare 9
	263	+	provider network may not be applicable when services are rendered by a 10
	264	+	nonparticipating healthcare provider. 11
	265	+	"§ 131E-214.35. Penalties. 12
	266	+	A healthcare provider's repeated failure to comply with this Article shall indicate a general 13
	267	+	business practice that is deemed an unfair and deceptive trade practice and is actionable under 14
	268	+	Chapter 75 of the General Statutes. Nothing in this Article forecloses other remedies available 15
	269	+	under law or equity." 16
	270	+	SECTION 2.2.(a) G.S. 58-3-200(a)(1) and G.S. 58-3-200(a)(2) are repealed. 17
	271	+	SECTION 2.2.(b) G.S. 58-3-200(a), as amended by subsection (a) of this section, 18
	272	+	reads as rewritten: 19
	273	+	"(a) Definitions. – As used The following definitions apply in this section: 20
	274	+	… 21
	275	+	(3) Clinical laboratory. – An entity in which services are performed to provide 22
	276	+	information or materials for use in the diagnosis, prevention, or treatment of 23
	277	+	disease or assessment of a medical or physical condition. 24
	278	+	(4) Healthcare provider. – As defined in G.S. 90-410." 25
	279	+	SECTION 2.2.(c) G.S. 58-3-200(d) reads as rewritten: 26
	280	+	"(d) Services Outside Provider Networks. – No insurer shall penalize an insured or subject 27
	281	+	an insured to the out-of-network benefit levels offered under the insured's approved health benefit 28
	282	+	plan, including an insured receiving an extended or standing referral under G.S. 58-3-223, unless 29
	283	+	contracting health care healthcare providers able to meet health needs of the insured are 30
	284	+	reasonably available to the insured without unreasonable delay. Upon notice or request from the 31
	285	+	insured, the insurer shall determine whether a healthcare provider able to meet the needs of the 32
	286	+	insured is available to the insured without unreasonable delay by reference to the insured's 33
	287	+	location and the specific medical needs of the insured." 34
	288	+	SECTION 2.3. This Part becomes effective October 1, 2026, and applies to 35
	289	+	healthcare services provided on or after that date and to contracts issued, renewed, or amended 36
	290	+	on or after that date. 37
	291	+	38
	292	+	PART III. GREATER FAIRNESS IN BILLING AND COLLECTIONS PRACTI CES 39
	293	+	FOR HOSPITALS AND AM BULATORY SURGICAL FA CILITIES 40
	294	+	SECTION 3.1.(a) Chapter 131E of the General Statutes is amended by adding a new 41
	295	+	Article 11C to be entitled "Fair Billing and Collections Practices for Hospitals and Ambulatory 42
	296	+	Surgical Facilities." 43
	297	+	SECTION 3.1.(b) G.S. 131E-91 is recodified as G.S. 131E-214.50 under Article 44
	298	+	11C of Chapter 131E of the General Statutes, as created by subsection (a) of this section. 45
	299	+	SECTION 3.1.(c) G.S. 131E-214.50(d) reads as rewritten: 46
	300	+	"(d) Hospitals and ambulatory surgical facilities shall abide by the following reasonable 47
	301	+	collections practices: 48
	302	+	… 49
	303	+	(1a) A hospital or ambulatory surgical facility shall not refer a patient's unpaid bill 50
	304	+	to a collections agency, entity, or other assignee unless it has first presented 51 General Assembly Of North Carolina Session 2025
	305	+	Senate Bill 316-Third Edition Page 7
	306	+	an itemized list of charges to the patient detailing, in language comprehensible 1
	307	+	to an ordinary layperson, the specific nature of the charges or expenses 2
	308	+	incurred by the patient. 3
	309	+	…." 4
	310	+	SECTION 3.2. Article 11C of Chapter 131E of the General Statutes, as created by 5
	311	+	Section 3.1(a) of this act, is amended by adding a new section to read: 6
	312	+	"§ 131E-214.52. Patient's right to a good-faith estimate. 7
	313	+	(a) Definitions. – The following definitions apply in this section: 8
	314	+	(1) CMS. – The federal Centers for Medicare and Medicaid Services. 9
	315	+	(2) Facility. – A hospital or ambulatory surgical facility licensed under this 10
	316	+	Chapter. 11
	317	+	(3) Items and services. – All items and services, including individual items and 12
	318	+	services and service packages, that could be provided by a facility to a patient 13
	319	+	in connection with an inpatient admission or an outpatient visit for which the 14
	320	+	facility has established a standard charge. Examples include, but are not 15
	321	+	limited to, all of the following: 16
	322	+	a. Supplies and procedures. 17
	323	+	b. Room and board. 18
	324	+	c. Fees for use of the facility or other items. 19
	325	+	d. Professional charges for services of physicians and nonphysician 20
	326	+	practitioners who are employed by the facility. 21
	327	+	e. Professional charges for services of physicians and nonphysician 22
	328	+	practitioners who are not employed by the facility. 23
	329	+	f. Any other items or services for which a facility has established a 24
	330	+	standard charge. 25
	331	+	(4) Service package. – An aggregation of individual items and services into a 26
	332	+	single service with a single charge. 27
	333	+	(5) Shoppable service. – A non-urgent service that can be scheduled by a patient 28
	334	+	in advance. The term includes all CMS-specified shoppable services plus as 29
	335	+	many additional facility-selected shoppable services as are necessary for a 30
	336	+	combined total of at least 300 shoppable services. 31
	337	+	(b) Good-Faith Estimate. – Upon request of any patient for a good-faith estimate for a 32
	338	+	shoppable service, the facility shall provide to the patient, in writing, at least three business days 33
	339	+	prior to the date the patient schedules the shoppable service, an itemized list of expected charges, 34
	340	+	in language comprehensible to an ordinary layperson, that the patient will be obligated to pay for 35
	341	+	all items and services related to the shoppable service. The good-faith estimate shall include the 36
	342	+	Diagnostic Related Group (DRG), Current Procedural Terminology (CPT), or Healthcare 37
	343	+	Common Procedure Coding System (HCPCS) code for each expected charge. 38
	344	+	(c) In any case in which a patient has requested a good-faith estimate from a facility for 39
	345	+	a shoppable service, the patient's final bill for that shoppable service shall not exceed more than 40
	346	+	five percent (5%) of the good-faith estimate provided to the patient pursuant to this section. 41
	347	+	(d) The Department shall adopt rules to implement this section." 42
	348	+	SECTION 3.3. This Part becomes effective on the later of January 1, 2026, or the 43
	349	+	date the rules adopted by the Department under G.S. 131E-214.52 take effect and applies to acts 44
	350	+	occurring on or after that date. The Department shall notify the Revisor of Statutes when the rules 45
	351	+	required under G.S. 131E-214.52 take effect. 46
	352	+	47
	353	+	PART IV. GREATER PRO TECTION FOR HEALTHCA RE CONSUMERS FROM 48
	354	+	FACILITY FEES 49
	355	+	SECTION 4.1.(a) Article 11C of Chapter 131E of the General Statutes, as created 50
	356	+	by Section 3.1(a) of this act, is amended by adding a new section to read: 51 General Assembly Of North Carolina Session 2025
	357	+	Page 8 Senate Bill 316-Third Edition
	358	+	"§ 131E-214.54. Facility fees. 1
	359	+	(a) Definitions. – The following definitions apply in this section: 2
	360	+	(1) Ambulatory surgical facility. – As defined in G.S. 131E-176. 3
	361	+	(2) Campus. – Any of the following: 4
	362	+	a. The main building of a hospital. 5
	363	+	b. The physical area immediately adjacent to a hospital's main building. 6
	364	+	c. Other structures not contiguous to the main building of a hospital that 7
	365	+	are within 250 yards of the main building. 8
	366	+	d. Any other area that has been determined to be part of a hospital's 9
	367	+	campus by the Centers for Medicare and Medicaid Services. 10
	368	+	(3) Facility fee. – Any fee charged or billed by a health care provider for 11
	369	+	outpatient services provided in a hospital-based facility that is (i) intended to 12
	370	+	compensate the health care provider for the operational expenses of the health 13
	371	+	care provider, (ii) separate and distinct from a professional fee, and (iii) 14
	372	+	charged regardless of the modality through which the health care services 15
	373	+	were provided. 16
	374	+	(4) Health care provider. – As defined in G.S. 90-410. 17
	375	+	(5) Health systems. – A parent corporation of one or more hospitals and any entity 18
	376	+	affiliated with that parent corporation through ownership, governance, 19
	377	+	membership, or other means, or a hospital and any entity affiliated with that 20
	378	+	hospital through ownership, governance, membership, or other means. 21
	379	+	(6) Hospital. – Any hospital as defined in G.S. 90-176(13) and any facility 22
	380	+	licensed under Chapter 122C of the General Statutes. 23
	381	+	(7) Hospital-based facility. – A facility that is owned or operated, in whole or in 24
	382	+	part, by a hospital and at which hospital or professional medical services are 25
	383	+	provided. 26
	384	+	(8) Professional fee. – Any fee charged or billed by a provider for hospital or 27
	385	+	professional medical services provided in a hospital-based facility. 28
	386	+	(9) Remote location of a hospital. – A hospital-based facility that is created, 29
	387	+	acquired, or purchased by a hospital or health system for the purpose of 30
	388	+	furnishing inpatient services under the name, ownership, and financial and 31
	389	+	administrative control of the hospital. 32
	390	+	(b) Limits on Facility Fees. – The following limitations are applicable to facility fees: 33
	391	+	(1) No health care provider shall charge, bill, or collect a facility fee unless the 34
	392	+	services are provided on a hospital's main campus, at a remote location of a 35
	393	+	hospital, at a facility that includes an emergency department, or at an 36
	394	+	ambulatory surgical facility. 37
	395	+	(2) Regardless of where the services are provided, no health care provider shall 38
	396	+	charge, bill, or collect a facility fee for outpatient evaluation and management 39
	397	+	services, or any other outpatient, diagnostic, or imaging services identified by 40
	398	+	the Department. 41
	399	+	(c) Identification of Services. – The Department shall annually identify services subject 42
	400	+	to the limitations on facility fees provided in subdivision (2) of subsection (b) of this section that 43
	401	+	may reliably be provided safely and effectively in non-hospital settings. 44
	402	+	(d) Reporting Requirements. – Each hospital and health system shall submit a report to 45
	403	+	the Department annually on July 1. The report shall be published on the Department's website 46
	404	+	and shall contain the following: 47
	405	+	(1) The name and full address of each facility owned or operated by the hospital 48
	406	+	or health system that provides services for which a facility fee is charged or 49
	407	+	billed. 50 General Assembly Of North Carolina Session 2025
	408	+	Senate Bill 316-Third Edition Page 9
	409	+	(2) The number of patient visits at each such hospital-based facility for which a 1
	410	+	facility fee was charged or billed. 2
	411	+	(3) The number, total amount, and range of allowable facility fees paid at each 3
	412	+	facility by Medicare, Medicaid, and private insurance. 4
	413	+	(4) For each hospital-based facility and for the hospital or health system as a 5
	414	+	whole, the total amount billed, and the total revenue received from facility 6
	415	+	fees. 7
	416	+	(5) The top 10 procedures or services, identified by Current Procedural 8
	417	+	Terminology (CPT) category I codes, provided by the hospital or health 9
	418	+	system that generated the greatest amount of facility fee gross revenue; the 10
	419	+	number of each of these 10 procedures or services provided; the gross and net 11
	420	+	revenue totals for each such procedure or service; and the total net amount of 12
	421	+	revenue received by the hospital or health system derived from facility fees 13
	422	+	for each procedure or service. 14
	423	+	(6) Any other information the Department may require. 15
	424	+	(e) Enforcement. – This section shall be enforced as follows: 16
	425	+	(1) Any violation of this section constitutes an unfair or deceptive trade practice 17
	426	+	in violation of G.S. 75-1.1 and is subject to all of the enforcement and penalty 18
	427	+	provisions of an unfair or deceptive trade practice under Article 1 of Chapter 19
	428	+	75 of the General Statutes. 20
	429	+	(2) In addition to the remedies described in subdivision (1) of this subsection, any 21
	430	+	health care provider who violates any provision of this section shall be subject 22
	431	+	to an administrative penalty of not more than one thousand dollars ($1,000) 23
	432	+	per occurrence." 24
	433	+	SECTION 4.1.(b) No later than January 1, 2026, the Department of Health and 25
	434	+	Human Services shall adopt rules necessary to implement G.S. 131E-214.54, as enacted by 26
	435	+	subsection (a) of this section. 27
	436	+	SECTION 4.2. G.S. 131E-214.54, as enacted by Section 4.1(a) of this Part, becomes 28
	437	+	effective January 1, 2026, or on the date the rules adopted by the Department of Health and 29
	438	+	Human Services pursuant to Section 4.1(b) of this Part become effective, whichever is later, and 30
	439	+	applies to healthcare services provided on or after that date. The Department shall notify the 31
	440	+	Revisor of Statutes when the rules required under Section 4.1(b) of this Part become effective. 32
	441	+	33
	442	+	PART V. STATE AUDITOR REVIEW OF HEAL TH SERVICE FACILITY PRICES 34
	443	+	SECTION 5.1. G.S. 147-64.6(c) reads as rewritten: 35
	444	+	"(c) Responsibilities. – The Auditor is responsible for the following acts and activities: 36
	445	+	… 37
	446	+	(24) The Auditor shall periodically examine (i) health service facilities, as defined 38
	447	+	in G.S. 131E-176, that are recipients of State funds and (ii) facilities licensed 39
	448	+	under Chapter 122C of the General Statutes that are recipients of State funds 40
	449	+	and report findings to the Joint Legislative Oversight Committee on Health 41
	450	+	and Human Services on April 1, 2026, and periodically thereafter. The report 42
	451	+	must include at least the following: 43
	452	+	a. The prices that the health service facility charges patients whose 44
	453	+	insurance is out-of-network or who are uninsured. 45
	454	+	b. To what extent the health service facility is transparent about the prices 46
	455	+	described in sub-subdivision a. of this subdivision." 47
	456	+	48
	457	+	PART VI. ENHANCEMENT S TO EMPLOYEE SAFETY BY ALLOWING FOR THE 49
	458	+	REMOVAL OF CERTAIN E MPLOYEE DETAILS FROM HEALTH INSURANCE 50
	459	+	APPEALS AND GRIEVANC E REVIEWS 51 General Assembly Of North Carolina Session 2025
	460	+	Page 10 Senate Bill 316-Third Edition
	461	+	SECTION 6.1.(a) G.S. 58-50-61(k) reads as rewritten: 1
	462	+	"(k) Nonexpedited Appeals. – Within three business days after receiving a request for a 2
	463	+	standard, nonexpedited appeal, the insurer or its URO shall provide the covered person with the 3
	464	+	name, address, and telephone number of the coordinator and information on how and where to 4
	465	+	submit written material. material for the appeal, including contact information for the insurer. 5
	466	+	For standard, nonexpedited appeals, the insurer or its URO shall give written notification of the 6
	467	+	decision, in clear terms, to the covered person and the covered person's provider within 30 days 7
	468	+	after the insurer receives the request for an appeal. If the decision is not in favor of the covered 8
	469	+	person, the written decision shall contain:contain all of the following information: 9
	470	+	(1) The professional qualifications and licensure of the person or persons 10
	471	+	reviewing the appeal. 11
	472	+	(2) A statement of the reviewers' understanding of the reason for the covered 12
	473	+	person's basis of the appeal. 13
	474	+	(3) The reviewers' insurer's or URO's decision in clear terms and the medical 14
	475	+	rationale in sufficient detail for the covered person to respond further to the 15
	476	+	insurer's position. 16
324	477		…." 17
325		-	SECTION 3.2. Article 11C of Chapter 131E of the General Statutes, as created by 18
326		-	Section 3.1(a) of this act, is amended by adding a new section to read: 19
327		-	"§ 131E-214.52. Patient's right to a good-faith estimate. 20
328		-	(a) Definitions. – The following definitions apply in this section: 21
329		-	(1) CMS. – The federal Centers for Medicare and Medicaid Services. 22
330		-	(2) Facility. – A hospital or ambulatory surgical facility licensed under this 23
331		-	Chapter. 24
332		-	(3) Items and services. – All items and services, including individual items and 25
333		-	services and service packages, that could be provided by a facility to a patient 26
334		-	in connection with an inpatient admission or an outpatient visit for which the 27
335		-	facility has established a standard charge. Examples include, but are not 28
336		-	limited to, all of the following: 29
337		-	a. Supplies and procedures. 30
338		-	b. Room and board. 31
339		-	c. Fees for use of the facility or other items. 32
340		-	d. Professional charges for services of physicians and nonphysician 33
341		-	practitioners who are employed by the facility. 34
342		-	e. Professional charges for services of physicians and nonphysician 35
343		-	practitioners who are not employed by the facility. 36
344		-	f. Any other items or services for which a facility has established a 37
345		-	standard charge. 38
346		-	(4) Service package. – An aggregation of individual items and services into a 39
347		-	single service with a single charge. 40
348		-	(5) Shoppable service. – A non-urgent service that can be scheduled by a patient 41
349		-	in advance. The term includes all CMS-specified shoppable services plus as 42
350		-	many additional facility-selected shoppable services as are necessary for a 43
351		-	combined total of at least 300 shoppable services. 44
352		-	(b) Good-Faith Estimate. – Upon request of any patient for a good-faith estimate for a 45
353		-	shoppable service, the facility shall provide to the patient, in writing, at least three business days 46
354		-	prior to the date the patient schedules the shoppable service, an itemized list of expected charges, 47
355		-	in language comprehensible to an ordinary layperson, that the patient will be obligated to pay for 48
356		-	all items and services related to the shoppable service. The good-faith estimate shall include the 49
357		-	Diagnostic Related Group (DRG), Current Procedural Terminology (CPT), or Healthcare 50
358		-	Common Procedure Coding System (HCPCS) code for each expected charge. 51 General Assembly Of North Carolina Session 2025
359		-	Page 8 Senate Bill 316-Fourth Edition
360		-	(c) In any case in which a patient has requested a good-faith estimate from a facility for 1
361		-	a shoppable service, the patient's final bill for that shoppable service shall not exceed more than 2
362		-	five percent (5%) of the good-faith estimate provided to the patient pursuant to this section. 3
363		-	(d) The Department shall adopt rules to implement this section." 4
364		-	SECTION 3.3. This Part becomes effective on the later of January 1, 2026, or the 5
365		-	date the rules adopted by the Department under G.S. 131E-214.52 take effect and applies to acts 6
366		-	occurring on or after that date. The Department shall notify the Revisor of Statutes when the rules 7
367		-	required under G.S. 131E-214.52 take effect. 8
368		-	9
369		-	PART IV. GREATER PRO TECTION FOR HEALTHCA RE CONSUMERS FROM 10
370		-	FACILITY FEES 11
371		-	SECTION 4.1.(a) Article 11C of Chapter 131E of the General Statutes, as created 12
372		-	by Section 3.1(a) of this act, is amended by adding a new section to read: 13
373		-	"§ 131E-214.54. Facility fees. 14
374		-	(a) Definitions. – The following definitions apply in this section: 15
375		-	(1) Ambulatory surgical facility. – As defined in G.S. 131E-176. 16
376		-	(2) Campus. – Any of the following: 17
377		-	a. The main building of a hospital. 18
378		-	b. The physical area immediately adjacent to a hospital's main building. 19
379		-	c. Other structures not contiguous to the main building of a hospital that 20
380		-	are within 250 yards of the main building. 21
381		-	d. Any other area that has been determined to be part of a hospital's 22
382		-	campus by the Centers for Medicare and Medicaid Services. 23
383		-	(3) Facility fee. – Any fee charged or billed by a health care provider for 24
384		-	outpatient services provided in a hospital-based facility that is (i) intended to 25
385		-	compensate the health care provider for the operational expenses of the health 26
386		-	care provider, (ii) separate and distinct from a professional fee, and (iii) 27
387		-	charged regardless of the modality through which the health care services 28
388		-	were provided. 29
389		-	(4) Health care provider. – As defined in G.S. 90-410. 30
390		-	(5) Health systems. – A parent corporation of one or more hospitals and any entity 31
391		-	affiliated with that parent corporation through ownership, governance, 32
392		-	membership, or other means, or a hospital and any entity affiliated with that 33
393		-	hospital through ownership, governance, membership, or other means. 34
394		-	(6) Hospital. – Any hospital as defined in G.S. 90-176(13) and any facility 35
395		-	licensed under Chapter 122C of the General Statutes. 36
396		-	(7) Hospital-based facility. – A facility that is owned or operated, in whole or in 37
397		-	part, by a hospital and at which hospital or professional medical services are 38
398		-	provided. 39
399		-	(8) Professional fee. – Any fee charged or billed by a provider for hospital or 40
400		-	professional medical services provided in a hospital-based facility. 41
401		-	(9) Remote location of a hospital. – A hospital-based facility that is created, 42
402		-	acquired, or purchased by a hospital or health system for the purpose of 43
403		-	furnishing inpatient services under the name, ownership, and financial and 44
404		-	administrative control of the hospital. 45
405		-	(b) Limits on Facility Fees. – The following limitations are applicable to facility fees: 46
406		-	(1) No health care provider shall charge, bill, or collect a facility fee unless the 47
407		-	services are provided on a hospital's main campus, at a remote location of a 48
408		-	hospital, at a facility that includes an emergency department, or at an 49
409		-	ambulatory surgical facility. 50 General Assembly Of North Carolina Session 2025
410		-	Senate Bill 316-Fourth Edition Page 9
411		-	(2) Regardless of where the services are provided, no health care provider shall 1
412		-	charge, bill, or collect a facility fee for outpatient evaluation and management 2
413		-	services, or any other outpatient, diagnostic, or imaging services identified by 3
414		-	the Department. 4
415		-	(c) Identification of Services. – The Department shall annually identify services subject 5
416		-	to the limitations on facility fees provided in subdivision (2) of subsection (b) of this section that 6
417		-	may reliably be provided safely and effectively in non-hospital settings. 7
418		-	(d) Reporting Requirements. – Each hospital and health system shall submit a report to 8
419		-	the Department annually on July 1. The report shall be published on the Department's website 9
420		-	and shall contain the following: 10
421		-	(1) The name and full address of each facility owned or operated by the hospital 11
422		-	or health system that provides services for which a facility fee is charged or 12
423		-	billed. 13
424		-	(2) The number of patient visits at each such hospital-based facility for which a 14
425		-	facility fee was charged or billed. 15
426		-	(3) The number, total amount, and range of allowable facility fees paid at each 16
427		-	facility by Medicare, Medicaid, and private insurance. 17
428		-	(4) For each hospital-based facility and for the hospital or health system as a 18
429		-	whole, the total amount billed, and the total revenue received from facility 19
430		-	fees. 20
431		-	(5) The top 10 procedures or services, identified by Current Procedural 21
432		-	Terminology (CPT) category I codes, provided by the hospital or health 22
433		-	system that generated the greatest amount of facility fee gross revenue; the 23
434		-	number of each of these 10 procedures or services provided; the gross and net 24
435		-	revenue totals for each such procedure or service; and the total net amount of 25
436		-	revenue received by the hospital or health system derived from facility fees 26
437		-	for each procedure or service. 27
438		-	(6) Any other information the Department may require. 28
439		-	(e) Enforcement. – This section shall be enforced as follows: 29
440		-	(1) Any violation of this section constitutes an unfair or deceptive trade practice 30
441		-	in violation of G.S. 75-1.1 and is subject to all of the enforcement and penalty 31
442		-	provisions of an unfair or deceptive trade practice under Article 1 of Chapter 32
443		-	75 of the General Statutes. 33
444		-	(2) In addition to the remedies described in subdivision (1) of this subsection, any 34
445		-	health care provider who violates any provision of this section shall be subject 35
446		-	to an administrative penalty of not more than one thousand dollars ($1,000) 36
447		-	per occurrence." 37
448		-	SECTION 4.1.(b) No later than January 1, 2026, the Department of Health and 38
449		-	Human Services shall adopt rules necessary to implement G.S. 131E-214.54, as enacted by 39
450		-	subsection (a) of this section. 40
451		-	SECTION 4.2. G.S. 131E-214.54, as enacted by Section 4.1(a) of this Part, becomes 41
452		-	effective January 1, 2026, or on the date the rules adopted by the Department of Health and 42
453		-	Human Services pursuant to Section 4.1(b) of this Part become effective, whichever is later, and 43
454		-	applies to healthcare services provided on or after that date. The Department shall notify the 44
455		-	Revisor of Statutes when the rules required under Section 4.1(b) of this Part become effective. 45
456		-	46
457		-	PART V. STATE AUDITOR REVIEW OF HEALTH S ERVICE FACILITY PRICES 47
458		-	SECTION 5.1. G.S. 147-64.6(c) reads as rewritten: 48
459		-	"(c) Responsibilities. – The Auditor is responsible for the following acts and activities: 49
460		-	… 50 General Assembly Of North Carolina Session 2025
461		-	Page 10 Senate Bill 316-Fourth Edition
462		-	(24) The Auditor shall periodically examine (i) health service facilities, as defined 1
463		-	in G.S. 131E-176, that are recipients of State funds and (ii) facilities licensed 2
464		-	under Chapter 122C of the General Statutes that are recipients of State funds 3
465		-	and report findings to the Joint Legislative Oversight Committee on Health 4
466		-	and Human Services on April 1, 2026, and periodically thereafter. The report 5
467		-	must include at least the following: 6
468		-	a. The prices that the health service facility charges patients whose 7
469		-	insurance is out-of-network or who are uninsured. 8
470		-	b. To what extent the health service facility is transparent about the prices 9
471		-	described in sub-subdivision a. of this subdivision." 10
472		-	11
473		-	PART VI. ENHANCEMENT S TO EMPLOYEE SAFETY BY ALLOWING FOR THE 12
474		-	REMOVAL OF CERTAIN E MPLOYEE DETAILS FROM HEALTH INSURANCE 13
475		-	APPEALS AND GRIEVANCE REVIEW S 14
476		-	SECTION 6.1.(a) G.S. 58-50-61(k) reads as rewritten: 15
477		-	"(k) Nonexpedited Appeals. – Within three business days after receiving a request for a 16
478		-	standard, nonexpedited appeal, the insurer or its URO shall provide the covered person with the 17
479		-	name, address, and telephone number of the coordinator and information on how and where to 18
480		-	submit written material. material for the appeal, including contact information for the insurer. 19
481		-	For standard, nonexpedited appeals, the insurer or its URO shall give written notification of the 20
482		-	decision, in clear terms, to the covered person and the covered person's provider within 30 days 21
483		-	after the insurer receives the request for an appeal. If the decision is not in favor of the covered 22
484		-	person, the written decision shall contain:contain all of the following information: 23
485		-	(1) The professional qualifications and licensure of the person or persons 24
486		-	reviewing the appeal. 25
487		-	(2) A statement of the reviewers' understanding of the reason for the covered 26
488		-	person's basis of the appeal. 27
489		-	(3) The reviewers' insurer's or URO's decision in clear terms and the medical 28
490		-	rationale in sufficient detail for the covered person to respond further to the 29
491		-	insurer's position. 30
492		-	…." 31
493		-	SECTION 6.1.(b) G.S. 58-50-62(e) reads as rewritten: 32
494		-	"(e) First-Level Grievance Review. – A covered person or a covered person's provider 33
495		-	acting on the covered person's behalf may submit a grievance. All of the following shall apply to 34
496		-	a first-level grievance review: 35
497		-	(1) The insurer does not have is not required to allow a covered person to attend 36
498		-	the first-level grievance review. A covered person may submit written 37
499		-	material. Except as provided in subdivision (3) of this subsection, within three 38
500		-	business days after receiving a grievance, the insurer shall provide the covered 39
501		-	person with the name, address, and telephone number of the coordinator and 40
502		-	information on where and how to submit written material.material for the 41
503		-	first-level grievance review, including contact information for the insurer. 42
504		-	(2) An insurer shall issue a written decision, in clear terms, to the covered person 43
505		-	and, if applicable, to the covered person's provider, within 30 days after 44
506		-	receiving a grievance. The person or persons reviewing the grievance shall not 45
507		-	be the same person or persons who initially handled the matter that is the 46
508		-	subject of the grievance and, if the issue is a clinical one, at least one of whom 47
509		-	shall be a medical doctor with appropriate expertise to evaluate the matter. 48
510		-	Except as provided in subdivision (3) of this subsection, if the decision is not 49
511		-	in favor of the covered person, the written decision issued in a first-level 50
512		-	grievance review shall contain:contain all of the following information: 51 General Assembly Of North Carolina Session 2025
513		-	Senate Bill 316-Fourth Edition Page 11
514		-	a. The professional qualifications and licensure of the person or persons 1
515		-	reviewing the grievance. 2
516		-	b. A statement of the reviewers' understanding basis of the grievance. 3
517		-	c. The reviewers' insurer's decision in clear terms and the contractual 4
518		-	basis or medical rationale in sufficient detail for the covered person to 5
519		-	respond further to the insurer's position. 6
520		-	…." 7
521		-	SECTION 6.1.(c) G.S. 58-50-62(f) reads as rewritten: 8
522		-	"(f) Second-Level Grievance Review. – An insurer shall establish a second-level 9
523		-	grievance review process for covered persons who are dissatisfied with the first-level grievance 10
524		-	review decision or a utilization review appeal decision. A covered person or the covered person's 11
525		-	provider acting on the covered person's behalf may submit a second-level grievance. All of the 12
526		-	following shall apply to a second-level grievance review: 13
527		-	(1) An insurer shall, within 10 business days after receiving a request for a 14
528		-	second-level grievance review, make known to provide the covered 15
529		-	person:person all of the following information: 16
530		-	a. The name, address, and telephone number of a person designated to 17
531		-	coordinate the grievance review for the insurer.Information on how 18
532		-	and where to submit written material for the second-level grievance 19
533		-	review, including contact information for the insurer. 20
534		-	…." 21
535		-	SECTION 6.2. This Part is effective when it becomes law. 22
	478	+	SECTION 6.1.(b) G.S. 58-50-62(e) reads as rewritten: 18
	479	+	"(e) First-Level Grievance Review. – A covered person or a covered person's provider 19
	480	+	acting on the covered person's behalf may submit a grievance. All of the following shall apply to 20
	481	+	a first-level grievance review: 21
	482	+	(1) The insurer does not have is not required to allow a covered person to attend 22
	483	+	the first-level grievance review. A covered person may submit written 23
	484	+	material. Except as provided in subdivision (3) of this subsection, within three 24
	485	+	business days after receiving a grievance, the insurer shall provide the covered 25
	486	+	person with the name, address, and telephone number of the coordinator and 26
	487	+	information on where and how to submit written material.material for the 27
	488	+	first-level grievance review, including contact information for the insurer. 28
	489	+	(2) An insurer shall issue a written decision, in clear terms, to the covered person 29
	490	+	and, if applicable, to the covered person's provider, within 30 days after 30
	491	+	receiving a grievance. The person or persons reviewing the grievance shall not 31
	492	+	be the same person or persons who initially handled the matter that is the 32
	493	+	subject of the grievance and, if the issue is a clinical one, at least one of whom 33
	494	+	shall be a medical doctor with appropriate expertise to evaluate the matter. 34
	495	+	Except as provided in subdivision (3) of this subsection, if the decision is not 35
	496	+	in favor of the covered person, the written decision issued in a first-level 36
	497	+	grievance review shall contain:contain all of the following information: 37
	498	+	a. The professional qualifications and licensure of the person or persons 38
	499	+	reviewing the grievance. 39
	500	+	b. A statement of the reviewers' understanding basis of the grievance. 40
	501	+	c. The reviewers' insurer's decision in clear terms and the contractual 41
	502	+	basis or medical rationale in sufficient detail for the covered person to 42
	503	+	respond further to the insurer's position. 43
	504	+	…." 44
	505	+	SECTION 6.1.(c) G.S. 58-50-62(f) reads as rewritten: 45
	506	+	"(f) Second-Level Grievance Review. – An insurer shall establish a second-level 46
	507	+	grievance review process for covered persons who are dissatisfied with the first-level grievance 47
	508	+	review decision or a utilization review appeal decision. A covered person or the covered person's 48
	509	+	provider acting on the covered person's behalf may submit a second-level grievance. All of the 49
	510	+	following shall apply to a second-level grievance review: 50 General Assembly Of North Carolina Session 2025
	511	+	Senate Bill 316-Third Edition Page 11
	512	+	(1) An insurer shall, within 10 business days after receiving a request for a 1
	513	+	second-level grievance review, make known to provide the covered 2
	514	+	person:person all of the following information: 3
	515	+	a. The name, address, and telephone number of a person designated to 4
	516	+	coordinate the grievance review for the insurer.Information on how 5
	517	+	and where to submit written material for the second-level grievance 6
	518	+	review, including contact information for the insurer. 7
	519	+	…." 8
	520	+	SECTION 6.2. This Part is effective when it becomes law. 9
	521	+	10
	522	+	PART VII. ELIMINATION OF CERTIFICATE OF NEED REVIEW FOR INPA TIENT 11
	523	+	REHABILITATION SERVI CES, REHABILITATION FACILITIES, AND 12
	524	+	REHABILITATION BEDS 13
	525	+	SECTION 7.1. G.S. 131E-176 reads as rewritten: 14
	526	+	"§ 131E-176. Definitions. 15
	527	+	The following definitions apply in this Article: 16
	528	+	… 17
	529	+	(9a) Health service. – An organized, interrelated activity that is medical, 18
	530	+	diagnostic, therapeutic, rehabilitative, or a combination thereof of these and 19
	531	+	that is integral to the prevention of disease or the clinical management of an 20
	532	+	individual who is sick or injured or who has a disability. "Health service" does 21
	533	+	not include administrative and other activities that are not integral to clinical 22
	534	+	management. 23
	535	+	(9b) Health service facility. – A hospital; long-term care hospital; rehabilitation 24
	536	+	facility; nursing home facility; adult care home; kidney disease treatment 25
	537	+	center, including freestanding hemodialysis units; intermediate care facility 26
	538	+	for individuals with intellectual disabilities; home health agency office; 27
	539	+	diagnostic center; hospice office, hospice inpatient facility, hospice residential 28
	540	+	care facility; and ambulatory surgical facility. 29
	541	+	(9c) Health service facility bed. – A bed licensed for use in a health service facility 30
	542	+	in the categories of (i) acute care beds; (iii) rehabilitation beds; (iv) (ii) nursing 31
	543	+	home beds; (v) (iii) intermediate care beds for individuals with intellectual 32
	544	+	disabilities; (vii) (iv) hospice inpatient facility beds; (viii) (v) hospice 33
	545	+	residential care facility beds; (ix) (vi) adult care home beds; and (x) (vii) 34
	546	+	long-term care hospital beds. 35
	547	+	… 36
	548	+	(13) Hospital. – A public or private institution which that is primarily engaged in 37
	549	+	providing to inpatients, by or under supervision of physicians, diagnostic 38
	550	+	services and therapeutic services for medical diagnosis, treatment, and care of 39
	551	+	injured, disabled, or sick persons, or rehabilitation services for the 40
	552	+	rehabilitation of injured, disabled, or sick persons. The term includes all 41
	553	+	facilities licensed pursuant to G.S. 131E-77, except rehabilitation facilities 42
	554	+	and long-term care hospitals. 43
	555	+	… 44
	556	+	(17a) Nursing care. – Any of the following: 45
	557	+	a. Skilled nursing care and related services for residents who require 46
	558	+	medical or nursing care. 47
	559	+	b. Rehabilitation services services, other than those provided at an 48
	560	+	inpatient rehabilitation facility, for the rehabilitation of individuals 49
	561	+	who are injured or sick or who have disabilities. 50 General Assembly Of North Carolina Session 2025
	562	+	Page 12 Senate Bill 316-Third Edition
	563	+	c. Health-related care and services provided on a regular basis to 1
	564	+	individuals who because of their mental or physical condition require 2
	565	+	care and services above the level of room and board, which can be 3
	566	+	made available to them only through institutional facilities. 4
	567	+	These are services which are not primarily for the care and treatment of 5
	568	+	mental diseases. 6
	569	+	… 7
	570	+	(22) Rehabilitation facility. – A public or private inpatient facility which is 8
	571	+	operated for the primary purpose of assisting in the rehabilitation of 9
	572	+	individuals with disabilities through an integrated program of medical and 10
	573	+	other services which are provided under competent, professional 11
	574	+	supervision.A facility that has been classified and designated as an inpatient 12
	575	+	rehabilitation facility by the Centers for Medicare and Medicaid Services 13
	576	+	pursuant to Part 412 of Subchapter B of Chapter IV of Title 42 of the Code of 14
	577	+	Federal Regulations. 15
	578	+	…." 16
	579	+	17
	580	+	PART VIII. UPDATED H EALTH INSURER PRIOR AUTHORIZATION 18
	581	+	REQUIREMENTS 19
	582	+	SECTION 8.(a) G.S. 58-50-61 reads as rewritten: 20
	583	+	"§ 58-50-61. Utilization review. 21
	584	+	(a) Definitions. – As used The following definitions apply in this section, in 22
	585	+	G.S. 58-50-62, and in Part 4 of this Article, the term:Article: 23
	586	+	… 24
	587	+	(2a) Course of treatment. – A prescribed order or ordered treatment protocol for a 25
	588	+	specific covered person with a specific condition that is outlined and decided 26
	589	+	upon ahead of time with the covered person and healthcare provider and 27
	590	+	approved by the insurer or utilization review organization when prospective 28
	591	+	review is applicable. 29
	592	+	… 30
	593	+	(8) "Health care provider" means any person who is licensed, registered, or 31
	594	+	certified under Chapter 90 of the General Statutes or the laws of another state 32
	595	+	to provide health care services in the ordinary care of business or practice or 33
	596	+	a profession or in an approved education or training program; a health care 34
	597	+	facility as defined in G.S. 131E-176(9b) or the laws of another state to operate 35
	598	+	as a health care facility; or a pharmacy.Healthcare provider. – As defined in 36
	599	+	G.S. 90-410. 37
	600	+	… 38
	601	+	(14a) Prior authorization. – The process by which insurers and UROs determine 39
	602	+	coverage on the basis of medical necessity and/or covered benefits prior to the 40
	603	+	rendering of those services. 41
	604	+	… 42
	605	+	(16a) Urgent health care service. – A health care service with respect to which the 43
	606	+	application of the time periods for making an urgent care determination that, 44
	607	+	in the opinion of a healthcare provider with knowledge of the covered person's 45
	608	+	medical condition, meets either of the following criteria: 46
	609	+	a. Could seriously jeopardize the life or health of the covered person or 47
	610	+	the ability of the covered person to regain maximum function. 48
	611	+	b. Would subject the covered person to severe pain that cannot be 49
	612	+	adequately managed without the care or treatment that is the subject 50
	613	+	of the utilization review. 51 General Assembly Of North Carolina Session 2025
	614	+	Senate Bill 316-Third Edition Page 13
	615	+	… 1
	616	+	(f) Time Lines for Prospective and Concurrent Utilization Reviews Based Upon Type of 2
	617	+	Health Care Service. – As used in this subsection, the term "necessary information" includes the 3
	618	+	results of any patient examination, clinical evaluation, or second opinion that may be required. 4
	619	+	Prospective and concurrent determinations shall be communicated to The time line for 5
	620	+	completion of a prospective or concurrent utilization review is as follows: 6
	621	+	(1) Non-urgent health care services. – If an insurer requires a prior authorization 7
	622	+	review of a healthcare service, then the insurer or its URO shall both render a 8
	623	+	prior authorization review determination or noncertification and notify the 9
	624	+	covered person and the covered person's provider within three business days 10
	625	+	after the insurer obtains all necessary information about the admission, 11
	626	+	procedure, or health care service. to make the prior authorization review 12
	627	+	determination or noncertification. 13
	628	+	(2) Urgent health care services. – An insurer or its URO shall both render a 14
	629	+	utilization review determination or noncertification concerning urgent health 15
	630	+	care services and notify the covered person and the covered person's provider 16
	631	+	of that utilization review determination or noncertification not later than 24 17
	632	+	hours after receiving all necessary information needed to complete the review 18
	633	+	of the requested health care services. If the covered person's provider or the 19
	634	+	insurer, or the entity conducting the review on behalf of the insurer, do not 20
	635	+	both have access to the electronic health records of the covered person, then 21
	636	+	this subdivision shall not apply and the utilization review will be subject to 22
	637	+	the time line under subdivision (1) of this subsection. 23
	638	+	(f1) Prior Authorization Determination Notifications. – If an insurer or its URO certifies 24
	639	+	a health care service, the insurer shall notify notification shall be sent to the covered person's 25
	640	+	provider. For If an insurer or its URO issues a noncertification, the insurer shall notify the covered 26
	641	+	person's provider and send then written or electronic confirmation of the noncertification to the 27
	642	+	covered person's provider and covered person. In person that is in compliance with subsection 28
	643	+	(h) of this section. 29
	644	+	(f2) Concurrent Review Liability. – For concurrent reviews, the insurer shall remain liable 30
	645	+	for health care healthcare services until the covered person has been notified of the 31
	646	+	noncertification. 32
	647	+	… 33
	648	+	(j1) Requirements Applicable to Appeals Reviews. – All of the following requirements 34
	649	+	apply to an appeals review: 35
	650	+	(1) Except as otherwise provided, appeals shall be reviewed by a licensed 36
	651	+	physician who meets all of the following criteria: 37
	652	+	a. Possesses a current and valid non-restricted license to practice 38
	653	+	medicine in any United States jurisdiction. 39
	654	+	b. Has practiced for a period of at least three consecutive years in the 40
	655	+	same or similar specialty as a medical doctor who typically manages 41
	656	+	the medical condition or disease for which prior authorization review 42
	657	+	is required or whose training and experience meets all of the following 43
	658	+	criteria: 44
	659	+	1. Includes treatment of the same condition as the condition of 45
	660	+	the covered person. 46
	661	+	2. Includes treatment of complications that may result from the 47
	662	+	service or procedure that is the subject of the appeal. 48
	663	+	3. Is sufficient for the medical doctor to determine if the service 49
	664	+	or procedure is medically necessary or clinically appropriate. 50 General Assembly Of North Carolina Session 2025
	665	+	Page 14 Senate Bill 316-Third Edition
	666	+	c. Had no direct involvement in making the prior adverse determination 1
	667	+	or noncertification that is the subject of the appeal. 2
	668	+	d. Has no financial interest, or other conflict of interest, in the outcome 3
	669	+	of the appeal. 4
	670	+	(2) Appeals initiated by a licensed mental health professional for a service 5
	671	+	provided by a licensed mental health professional may be reviewed by a 6
	672	+	licensed mental health professional rather than a medical doctor. The 7
	673	+	requirements of subdivision (1) of this subsection shall apply to the reviewing 8
	674	+	licensed mental health professional in the same manner that they apply to a 9
	675	+	medical doctor. 10
	676	+	(3) The medical doctor or licensed mental health professional shall consider all 11
	677	+	known clinical aspects of the healthcare service under review, including all 12
	678	+	pertinent medical records and any medical literature that have been provided 13
	679	+	by the covered person's provider or by a health care facility. 14
	680	+	… 15
	681	+	(m) Disclosure of Utilization Review Requirements. – All of the following apply to an 16
	682	+	insurer's responsibility to disclose any utilization review procedures: 17
	683	+	(1) Coverage and member handbook. – In the certificate of coverage and member 18
	684	+	handbook provided to covered persons, an insurer shall include a clear and 19
	685	+	comprehensive description of its utilization review procedures, including the 20
	686	+	procedures for appealing noncertifications and a statement of the rights and 21
	687	+	responsibilities of covered persons, including the voluntary nature of the 22
	688	+	appeal process, with respect to those procedures. An insurer shall also include 23
	689	+	in the certificate of coverage and the member handbook information about the 24
	690	+	availability of assistance from the Department's Health Insurance Smart NC, 25
	691	+	including the telephone number and address of the Program. program. 26
	692	+	(2) Prospective materials. – An insurer shall include a summary of its utilization 27
	693	+	review procedures in materials intended for prospective covered persons. 28
	694	+	(3) Membership cards. – An insurer shall print on its membership cards a toll-free 29
	695	+	telephone number to call for utilization review purposes. 30
	696	+	(4) Website. – An insurer shall make any current prior authorization requirements 31
	697	+	and restrictions readily accessible on its website. 32
	698	+	(m1) Changes to Prior Authorization. – If an insurer intends either to implement a new 33
	699	+	prior authorization review requirement or restriction or to amend an existing requirement or 34
	700	+	restriction, then the new or amended requirement shall not be in effect unless and until the 35
	701	+	insurer's website has been updated to reflect the new or amended requirement or restriction. A 36
	702	+	claim shall not be denied for failure to obtain a prior authorization if the prior authorization 37
	703	+	requirement or amended requirement was not in effect on the date of service of the claim. 38
	704	+	… 39
	705	+	(n1) Prior Authorization Determination Validity. – All of the following apply to the length 40
	706	+	of time an approved prior authorization shall remain valid under certain circumstances: 41
	707	+	(1) If a covered person enrolls in a new health benefit plan offered by the same 42
	708	+	insurer under which the prior authorization was approved, then the previously 43
	709	+	approved prior authorization remains valid for the initial 90 days of coverage 44
	710	+	under the new heath benefit plan. This section does not require coverage of a 45
	711	+	service if it is not a covered service under the new health benefit plan. 46
	712	+	(2) If a healthcare service, other than for in-patient care, requires prior 47
	713	+	authorization and is for the treatment of a covered person's chronic condition, 48
	714	+	then the prior authorization shall remain valid for no less than six months from 49
	715	+	the date the healthcare provider receives notification of the prior authorization 50
	716	+	approval. 51 General Assembly Of North Carolina Session 2025
	717	+	Senate Bill 316-Third Edition Page 15
	718	+	… 1
	719	+	(o) Violation. – A In accordance with this Chapter, a violation of this section subjects an 2
	720	+	insurer and an agent of the insurer to G.S. 58-2-70. 3
	721	+	(p) Federal Rule Alignment. – No later than January 1, 2028, an insurer offering a health 4
	722	+	benefit plan or a utilization review agent acting on behalf of an insurer offering a health benefit 5
	723	+	plan, shall implement and maintain a prior authorization application programming interface 6
	724	+	meeting the requirements under 45 C.F.R. § 156.223(b) as it existed on January 1, 2025. 7
	725	+	(q) Reserved for future codification purposes. 8
	726	+	(r) Reserved for future codification purposes. 9
	727	+	(s) Artificial Intelligence. – An artificial intelligence-based algorithm shall not be used 10
	728	+	as the sole basis to deny a utilization review determination." 11
	729	+	SECTION 8.(b) In accordance with G.S. 135-48.24(b) and G.S. 135-48.30(a)(7) 12
	730	+	which require the State Treasurer to implement procedures that are substantially similar to the 13
	731	+	provisions of G.S. 58-50-61 for the North Carolina State Health Plan for Teachers and State 14
	732	+	Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State 15
	733	+	Health Plan shall review all practices of the State Health Plan and all contracts with, and practices 16
	734	+	of, any third party conducting any utilization review on behalf of the State Health Plan to ensure 17
	735	+	compliance with subsection (a) of this section no later than the start of the next plan year. 18
	736	+	SECTION 8.(c) Section 8(a) of this act becomes effective October 1, 2026, and 19
	737	+	applies to insurance contracts, including contracts with utilization review organizations, issued, 20
	738	+	renewed, or amended on or after that date. The remainder of this section is effective when it 21
	739	+	becomes law. 22
536	740		23
537		-	PART VII. ELIMINATION OF CERTIFICATE OF NEED REVIEW FOR INPA TIENT 24
538		-	REHABILITATION SERVI CES, REHABILITATION FACILITIES, AND 25
539		-	REHABILITATION BEDS 26
540		-	SECTION 7.1. G.S. 131E-176 reads as rewritten: 27
541		-	"§ 131E-176. Definitions. 28
542		-	The following definitions apply in this Article: 29
543		-	… 30
544		-	(9a) Health service. – An organized, interrelated activity that is medical, 31
545		-	diagnostic, therapeutic, rehabilitative, or a combination thereof of these and 32
546		-	that is integral to the prevention of disease or the clinical management of an 33
547		-	individual who is sick or injured or who has a disability. "Health service" does 34
548		-	not include administrative and other activities that are not integral to clinical 35
549		-	management. 36
550		-	(9b) Health service facility. – A hospital; long-term care hospital; rehabilitation 37
551		-	facility; nursing home facility; adult care home; kidney disease treatment 38
552		-	center, including freestanding hemodialysis units; intermediate care facility 39
553		-	for individuals with intellectual disabilities; home health agency office; 40
554		-	diagnostic center; hospice office, hospice inpatient facility, hospice residential 41
555		-	care facility; and ambulatory surgical facility. 42
556		-	(9c) Health service facility bed. – A bed licensed for use in a health service facility 43
557		-	in the categories of (i) acute care beds; (iii) rehabilitation beds; (iv) (ii) nursing 44
558		-	home beds; (v) (iii) intermediate care beds for individuals with intellectual 45
559		-	disabilities; (vii) (iv) hospice inpatient facility beds; (viii) (v) hospice 46
560		-	residential care facility beds; (ix) (vi) adult care home beds; and (x) (vii) 47
561		-	long-term care hospital beds. 48
562		-	… 49
563		-	(13) Hospital. – A public or private institution which that is primarily engaged in 50
564		-	providing to inpatients, by or under supervision of physicians, diagnostic 51 General Assembly Of North Carolina Session 2025
565		-	Page 12 Senate Bill 316-Fourth Edition
566		-	services and therapeutic services for medical diagnosis, treatment, and care of 1
567		-	injured, disabled, or sick persons, or rehabilitation services for the 2
568		-	rehabilitation of injured, disabled, or sick persons. The term includes all 3
569		-	facilities licensed pursuant to G.S. 131E-77, except rehabilitation facilities 4
570		-	and long-term care hospitals. 5
571		-	… 6
572		-	(17a) Nursing care. – Any of the following: 7
573		-	a. Skilled nursing care and related services for residents who require 8
574		-	medical or nursing care. 9
575		-	b. Rehabilitation services services, other than those provided at an 10
576		-	inpatient rehabilitation facility, for the rehabilitation of individuals 11
577		-	who are injured or sick or who have disabilities. 12
578		-	c. Health-related care and services provided on a regular basis to 13
579		-	individuals who because of their mental or physical condition require 14
580		-	care and services above the level of room and board, which can be 15
581		-	made available to them only through institutional facilities. 16
582		-	These are services which are not primarily for the care and treatment of 17
583		-	mental diseases. 18
584		-	… 19
585		-	(22) Rehabilitation facility. – A public or private inpatient facility which is 20
586		-	operated for the primary purpose of assisting in the rehabilitation of 21
587		-	individuals with disabilities through an integrated program of medical and 22
588		-	other services which are provided under competent, professional 23
589		-	supervision.A facility that has been classified and designated as an inpatient 24
590		-	rehabilitation facility by the Centers for Medicare and Medicaid Services 25
591		-	pursuant to Part 412 of Subchapter B of Chapter IV of Title 42 of the Code of 26
592		-	Federal Regulations. 27
593		-	…." 28
594		-	29
595		-	PART VIII. UPDATED H EALTH INSURER PRIOR AUTHORIZATION 30
596		-	REQUIREMENTS 31
597		-	SECTION 8.(a) G.S. 58-50-61 reads as rewritten: 32
598		-	"§ 58-50-61. Utilization review. 33
599		-	(a) Definitions. – As used The following definitions apply in this section, in 34
600		-	G.S. 58-50-62, and in Part 4 of this Article, the term:Article: 35
601		-	… 36
602		-	(2a) Course of treatment. – A prescribed order or ordered treatment protocol for a 37
603		-	specific covered person with a specific condition that is outlined and decided 38
604		-	upon ahead of time with the covered person and healthcare provider and 39
605		-	approved by the insurer or utilization review organization when prospective 40
606		-	review is applicable. 41
607		-	… 42
608		-	(8) "Health care provider" means any person who is licensed, registered, or 43
609		-	certified under Chapter 90 of the General Statutes or the laws of another state 44
610		-	to provide health care services in the ordinary care of business or practice or 45
611		-	a profession or in an approved education or training program; a health care 46
612		-	facility as defined in G.S. 131E-176(9b) or the laws of another state to operate 47
613		-	as a health care facility; or a pharmacy.Healthcare provider. – As defined in 48
614		-	G.S. 90-410. 49
615		-	… 50 General Assembly Of North Carolina Session 2025
616		-	Senate Bill 316-Fourth Edition Page 13
617		-	(14a) Prior authorization. – The process by which insurers and UROs determine 1
618		-	coverage on the basis of medical necessity and/or covered benefits prior to the 2
619		-	rendering of those services. 3
620		-	… 4
621		-	(16a) Urgent health care service. – A health care service, including mental and 5
622		-	behavioral health care services, with respect to which the application of the 6
623		-	time periods for making an urgent care determination that, in the opinion of a 7
624		-	healthcare provider with knowledge of the covered person's medical 8
625		-	condition, meets either of the following criteria: 9
626		-	a. Could seriously jeopardize the life or health of the covered person or 10
627		-	the ability of the covered person to regain maximum function. 11
628		-	b. Would subject the covered person to severe pain that cannot be 12
629		-	adequately managed without the care or treatment that is the subject 13
630		-	of the utilization review. 14
631		-	… 15
632		-	(f) Time Lines for Prospective and Concurrent Utilization Reviews Based Upon Type of 16
633		-	Health Care Service. – As used in this subsection, the term "necessary information" includes the 17
634		-	results of any patient examination, clinical evaluation, or second opinion that may be required. 18
635		-	Prospective and concurrent determinations shall be communicated to The time line for 19
636		-	completion of a prospective or concurrent utilization review is as follows: 20
637		-	(1) Non-urgent health care services. – If an insurer requires a prior authorization 21
638		-	review of a healthcare service, then the insurer or its URO shall both render a 22
639		-	prior authorization review determination or noncertification and notify the 23
640		-	covered person and the covered person's provider within three business days 24
641		-	after the insurer obtains all necessary information about the admission, 25
642		-	procedure, or health care service. to make the prior authorization review 26
643		-	determination or noncertification. 27
644		-	(2) Urgent health care services. – An insurer or its URO shall both render a 28
645		-	utilization review determination or noncertification concerning urgent health 29
646		-	care services and notify the covered person and the covered person's provider 30
647		-	of that utilization review determination or noncertification not later than 24 31
648		-	hours after receiving all necessary information needed to complete the review 32
649		-	of the requested health care services. If the covered person's provider or the 33
650		-	insurer, or the entity conducting the review on behalf of the insurer, do not 34
651		-	both have access to the electronic health records of the covered person, then 35
652		-	this subdivision shall not apply and the utilization review will be subject to 36
653		-	the time line under subdivision (1) of this subsection. 37
654		-	(f1) Prior Authorization Determination Notifications. – If an insurer or its URO certifies 38
655		-	a health care service, the insurer shall notify notification shall be sent to the covered person's 39
656		-	provider. For If an insurer or its URO issues a noncertification, the insurer shall notify the covered 40
657		-	person's provider and send then written or electronic confirmation of the noncertification to the 41
658		-	covered person's provider and covered person. In person that is in compliance with subsection 42
659		-	(h) of this section. 43
660		-	(f2) Concurrent Review Liability. – For concurrent reviews, the insurer shall remain liable 44
661		-	for health care healthcare services until the covered person has been notified of the 45
662		-	noncertification. 46
663		-	… 47
664		-	(j1) Requirements Applicable to Appeals Reviews. – All of the following requirements 48
665		-	apply to an appeals review: 49
666		-	(1) Except as otherwise provided, appeals shall be reviewed by a licensed 50
667		-	physician who meets all of the following criteria: 51 General Assembly Of North Carolina Session 2025
668		-	Page 14 Senate Bill 316-Fourth Edition
669		-	a. Possesses a current and valid non-restricted license to practice 1
670		-	medicine in any United States jurisdiction. 2
671		-	b. Has practiced for a period of at least three consecutive years in the 3
672		-	same or similar specialty as a medical doctor who typically manages 4
673		-	the medical condition or disease for which prior authorization review 5
674		-	is required or whose training and experience meets all of the following 6
675		-	criteria: 7
676		-	1. Includes treatment of the same condition as the condition of 8
677		-	the covered person. 9
678		-	2. Includes treatment of complications that may result from the 10
679		-	service or procedure that is the subject of the appeal. 11
680		-	3. Is sufficient for the medical doctor to determine if the service 12
681		-	or procedure is medically necessary or clinically appropriate. 13
682		-	c. Had no direct involvement in making the prior adverse determination 14
683		-	or noncertification that is the subject of the appeal. 15
684		-	d. Has no financial interest, or other conflict of interest, in the outcome 16
685		-	of the appeal. 17
686		-	(2) Appeals initiated by a licensed mental health professional for a service 18
687		-	provided by a licensed mental health professional may be reviewed by a 19
688		-	licensed mental health professional rather than a medical doctor. The 20
689		-	requirements of subdivision (1) of this subsection shall apply to the reviewing 21
690		-	licensed mental health professional in the same manner that they apply to a 22
691		-	medical doctor. 23
692		-	(3) The medical doctor or licensed mental health professional shall consider all 24
693		-	known clinical aspects of the healthcare service under review, including all 25
694		-	pertinent medical records and any medical literature that have been provided 26
695		-	by the covered person's provider or by a health care facility. 27
696		-	… 28
697		-	(m) Disclosure of Utilization Review Requirements. – All of the following apply to an 29
698		-	insurer's responsibility to disclose any utilization review procedures: 30
699		-	(1) Coverage and member handbook. – In the certificate of coverage and member 31
700		-	handbook provided to covered persons, an insurer shall include a clear and 32
701		-	comprehensive description of its utilization review procedures, including the 33
702		-	procedures for appealing noncertifications and a statement of the rights and 34
703		-	responsibilities of covered persons, including the voluntary nature of the 35
704		-	appeal process, with respect to those procedures. An insurer shall also include 36
705		-	in the certificate of coverage and the member handbook information about the 37
706		-	availability of assistance from the Department's Health Insurance Smart NC, 38
707		-	including the telephone number and address of the Program. program. 39
708		-	(2) Prospective materials. – An insurer shall include a summary of its utilization 40
709		-	review procedures in materials intended for prospective covered persons. 41
710		-	(3) Membership cards. – An insurer shall print on its membership cards a toll-free 42
711		-	telephone number to call for utilization review purposes. 43
712		-	(4) Website. – An insurer shall make any current prior authorization requirements 44
713		-	and restrictions readily accessible on its website. 45
714		-	(m1) Changes to Prior Authorization. – If an insurer intends either to implement a new 46
715		-	prior authorization review requirement or restriction or to amend an existing requirement or 47
716		-	restriction, then the new or amended requirement shall not be in effect unless and until the 48
717		-	insurer's website has been updated to reflect the new or amended requirement or restriction. A 49
718		-	claim shall not be denied for failure to obtain a prior authorization if the prior authorization 50
719		-	requirement or amended requirement was not in effect on the date of service of the claim. 51 General Assembly Of North Carolina Session 2025
720		-	Senate Bill 316-Fourth Edition Page 15
721		-	… 1
722		-	(n1) Prior Authorization Determination Validity. – All of the following apply to the length 2
723		-	of time an approved prior authorization shall remain valid under certain circumstances: 3
724		-	(1) If a covered person enrolls in a new health benefit plan offered by the same 4
725		-	insurer under which the prior authorization was approved, then the previously 5
726		-	approved prior authorization remains valid for the initial 90 days of coverage 6
727		-	under the new heath benefit plan. This section does not require coverage of a 7
728		-	service if it is not a covered service under the new health benefit plan. 8
729		-	(2) If a healthcare service, other than for in-patient care, requires prior 9
730		-	authorization and is for the treatment of a covered person's chronic condition, 10
731		-	then the prior authorization shall remain valid for no less than six months from 11
732		-	the date the healthcare provider receives notification of the prior authorization 12
733		-	approval. 13
734		-	… 14
735		-	(o) Violation. – A In accordance with this Chapter, a violation of this section subjects an 15
736		-	insurer and an agent of the insurer to G.S. 58-2-70. 16
737		-	(p) Federal Rule Alignment. – No later than January 1, 2028, an insurer offering a health 17
738		-	benefit plan or a utilization review agent acting on behalf of an insurer offering a health benefit 18
739		-	plan, shall implement and maintain a prior authorization application programming interface 19
740		-	meeting the requirements under 45 C.F.R. § 156.223(b) as it existed on January 1, 2025. 20
741		-	(q) Reserved for future codification purposes. 21
742		-	(r) Reserved for future codification purposes. 22
743		-	(s) Artificial Intelligence. – An artificial intelligence-based algorithm shall not be used 23
744		-	as the sole basis to deny a utilization review determination." 24
745		-	SECTION 8.(b) In accordance with G.S. 135-48.24(b) and G.S. 135-48.30(a)(7) 25
746		-	which require the State Treasurer to implement procedures that are substantially similar to the 26
747		-	provisions of G.S. 58-50-61 for the North Carolina State Health Plan for Teachers and State 27
748		-	Employees (State Health Plan), the State Treasurer and the Executive Administrator of the State 28
749		-	Health Plan shall review all practices of the State Health Plan and all contracts with, and practices 29
750		-	of, any third party conducting any utilization review on behalf of the State Health Plan to ensure 30
751		-	compliance with subsection (a) of this section no later than the start of the next plan year. 31
752		-	SECTION 8.(c) Section 8(a) of this act becomes effective October 1, 2026, and 32
753		-	applies to insurance contracts, including contracts with utilization review organizations, issued, 33
754		-	renewed, or amended on or after that date. The remainder of this section is effective when it 34
755		-	becomes law. 35
756		-	36
757		-	PART IX. EFFECTIVE DATE 37
758		-	SECTION 9. Except as otherwise provided, this act is effective when it becomes 38
759		-	law. 39
	741	+	PART IX. EFFECTIVE DATE 24
	742	+	SECTION 9. Except as otherwise provided, this act is effective when it becomes 25
	743	+	law. 26