Out-of-network Providers Carriers Required Notices

Under current law, when a health care provider who is not under a contract with a health insurer, and is therefore an 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 specifies that the in-network benefit level also applies to emergency services provided to a covered person by an out-of-network provider or at an out-of-network facility.

The bill also requires health care facilities, providers, and health insurers to provide disclosures to consumers about the potential effects of receiving nonemergency services from an out-of-network provider or emergency services at an out-of-network facility. The commissioner of insurance, the director of the division of professions and occupations, and the state board of health are directed to adopt rules detailing the disclosure requirements imposed on carriers, providers, and health facilities.

Additionally, if a covered person receives nonemergency services provided by an out-of-network provider at an in-network facility or emergency services provided by an out-of-network provider or at an out-of-network facility and pays the out-of-network provider or facility an amount in excess of the required cost-sharing amount, the out-of-network provider or facility must refund the overpayment and must pay interest on the overpayment if the provider or facility fails to timely refund the overpayment.

(Note: This summary applies to this bill as introduced.)