SB 767

Abstract

Health insurance; payment to out-of-networkproviders. Provides that when a covered person receives coveredemergency services from an out-of-network health care provider or receives out-of-network services at an in-network facility, the coveredperson is not required to pay the out-of-network provider any amountother than the applicable cost-sharing requirement. The measure alsoestablishes a standard for calculating the health carrier's requiredpayment to the out-of-network provider of the services, which standardis the lower of the market-based value for the service or 125 percentof the amount that would be paid under Medicare for the service.If such provider determines that the amount to be paid by the healthcarrier does not comply with the applicable requirements, the measure requires the provider and the health carrier to make a good faitheffort to reach a resolution on the appropriate amount of the reimbursementand, if a resolution is not reached, authorizes either party to request the State Corporation Commission to review the disputed reimbursement amount and determine if the amount complies with applicable requirements.The measure provides that such provisions do not apply to an entitythat provides or administers self-insured or self-funded plans; however, such entities may elect to be subject such provisions. Themeasure requires health carriers to make reports to the Bureau ofInsurance and directs the Bureau to provide reports to certain committeesof the General Assembly.