Under current law, when a health care provider who is not under a contract with a health insurer (out-of-network provider) renders health care services to a person covered under a health benefit plan at a facility that is part of the provider network under the plan (in-network facility), the health insurer is required to cover the services of the out-of-network provider at the in-network benefit level and at no greater cost to the covered person than if the services were provided by an in-network provider.
The bill outlines the method for a health insurer to use in determining the amount it must pay an out-of-network provider that rendered covered services to a covered person at an in-network facility and requires the health insurer to pay the out-of-network provider directly. The bill also establishes an independent dispute resolution process by which an out-of-network provider may obtain review of a payment from a health insurer.
Additionally, the bill requires an in-network facility where a covered person will receive a health care procedure or treatment, the health insurer, and an out-of-network provider who provides health care services to a covered person at an in-network facility to provide specified disclosures to the covered person, explaining that:
- An out-of-network provider may provide health care services to the covered person as part of the procedure or treatment provided at the in-network facility;
- If the covered person's plan is governed by state law, the services rendered by an out-of-network provider are covered under the plan at the in-network benefit level;
- The out-of-network provider will submit a bill to the covered person's health insurer, and if the covered person receives a bill from the out-of-network provider, he or she should contact the health insurer's customer service to resolve the bill; and
- The covered person is only responsible for paying the applicable in-network cost-sharing amount, and the carrier is responsible for paying any remaining balance owed the out-of-network provider.
A health insurer that fails to reimburse out-of-network providers as required by the bill and under current law or fails to provide the required notice to the covered person engages in an unfair or deceptive act or practice in the business of insurance and is subject to monetary penalties and other penalties authorized by law.
(Note: This summary applies to this bill as introduced.)