2020 -- H 7127 | |
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LC003066 | |
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STATE OF RHODE ISLAND | |
IN GENERAL ASSEMBLY | |
JANUARY SESSION, A.D. 2020 | |
____________ | |
A N A C T | |
RELATING TO HEALTH AND SAFETY -- LICENSING OF HEALTH CARE FACILITIES | |
| |
Introduced By: Representatives Ruggiero, Craven, Blazejewski, Marszalkowski, and | |
Date Introduced: January 16, 2020 | |
Referred To: House Health, Education & Welfare | |
It is enacted by the General Assembly as follows: | |
1 | SECTION 1. Section 23-17-4 of the General Laws in Chapter 23-17 entitled "Licensing |
2 | of Health-Care Facilities" is hereby amended to read as follows: |
3 | 23-17-4. License required for health-care facility operation. |
4 | (a) No person acting severally or jointly with any other person shall establish, conduct, or |
5 | maintain a health-care facility in this state without a license under this chapter; provided, |
6 | however, that any person, firm, corporation, or other entity that provides volunteer, registered and |
7 | licensed practical nurses to the public shall not be required to have a license as a health-care |
8 | facility. |
9 | (b) Each location at which a health-care facility provides services shall be licensed; |
10 | provided, however, that a hospital or organized ambulatory-care facility shall be permitted to |
11 | provide, solely on an ambulatory basis, limited physician services, other limited, professional |
12 | health-care services, and/or other limited, professional mental-health-care services in conjunction |
13 | with services provided by and at community health centers, community mental-health centers, |
14 | organized ambulatory-care facilities or other licensed health-care facilities, physicians' offices, |
15 | and facilities operated by the department of corrections without establishing such locations as |
16 | additional licensed premises of the hospital or organized ambulatory-care facility; provided, that a |
17 | health-care facility licensed as an organized ambulatory-care facility in the state, may provide |
18 | services at other locations operated by that licensed organized ambulatory-care facility, without |
19 | the requirement of a separate, organized ambulatory-care facility license for such other locations. |
| |
1 | For purposes of this section, an organized ambulatory-care facility or other licensed health-care |
2 | facility shall not include a freestanding, emergency-care facility. The department is further |
3 | authorized to adopt rules and regulations to accomplish the purpose of this section, including, but |
4 | not limited to, defining "limited physician services, other limited, professional health-care |
5 | services, and/or other limited, professional mental-health-care services." |
6 | (c) The reimbursement rates for the services rendered in the settings listed in subsection |
7 | (b) shall be subject to negotiations between the hospitals, organized, ambulatory-care facilities, |
8 | and the payors, respectively, as defined in § 23-17.12-2 ; however, every health care facility shall |
9 | provide notice in writing to any patient receiving non-emergency or elective care of all charges |
10 | and expenses to include any services to be provided by an out-of-network physicians or provider |
11 | prior to rendering that non-emergency or elective care. |
12 | (d) Failure of a health care facility to provide a patient of charges or expenses prior to |
13 | providing non-emergency or elective services shall limit the health care facility charges and |
14 | recovery to the amount of accident and sickness insurance, if any, providing coverage for the |
15 | services. The director shall promulgate rules and regulations implementing the provisions of this |
16 | section. |
17 | SECTION 2. Section 27-18-76 of the General Laws in Chapter 27-18 entitled "Accident |
18 | and Sickness Insurance Policies" is hereby amended to read as follows: |
19 | 27-18-76. Emergency services. |
20 | (a) As used in this section: |
21 | (1) "Emergency medical condition" means a medical condition manifesting itself by acute |
22 | symptoms of sufficient severity (including severe pain) so that a prudent layperson, who |
23 | possesses an average knowledge of health and medicine, could reasonably expect the absence of |
24 | immediate medical attention to result in a condition: (i) Placing the health of the individual, or |
25 | with respect to a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious |
26 | impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or |
27 | part. |
28 | (2) "Emergency services" means, with respect to an emergency medical condition: |
29 | (A) A medical screening examination (as required under section 1867 of the Social |
30 | Security Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a |
31 | hospital, including ancillary services routinely available to the emergency department to evaluate |
32 | such emergency medical condition, and |
33 | (B) Such further medical examination and treatment, to the extent they are within the |
34 | capabilities of the staff and facilities available at the hospital, as are required under section 1867 |
| LC003066 - Page 2 of 13 |
1 | of the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient. |
2 | (3) "Stabilize", with respect to an emergency medical condition has the meaning given in |
3 | § 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)). |
4 | (b) If a health insurance carrier offering health insurance coverage provides any benefits |
5 | with respect to services in an emergency department of a hospital, the carrier must cover |
6 | emergency services in compliance with this section. |
7 | (c) A health insurance carrier shall provide coverage for emergency services in the |
8 | following manner: |
9 | (1) Without the need for any prior authorization determination, even if the emergency |
10 | services are provided on an out-of-network basis; |
11 | (2) Without regard to whether the health care provider furnishing the emergency services |
12 | is a participating network provider with respect to the services; |
13 | (3) If the emergency services are provided out of network, without imposing any |
14 | administrative requirement or limitation on coverage that is more restrictive than the requirements |
15 | or limitations that apply to emergency services received from in-network providers; |
16 | (4) If the emergency services are provided out of network, by complying with the cost- |
17 | sharing requirements of subsection (d) of this section; and |
18 | (5) Without regard to any other term or condition of the coverage, other than: |
19 | (A) The exclusion of or coordination of benefits; |
20 | (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of |
21 | title XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or |
22 | (C) Applicable cost-sharing. |
23 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance |
24 | rate imposed with respect to a participant or beneficiary for out-of-network emergency services |
25 | cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if |
26 | the services were provided in-network; provided, however, that a participant or beneficiary may |
27 | be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of- |
28 | network provider charges over the amount the health insurance carrier is required to pay under |
29 | subdivision (1) of this subsection. A health insurance carrier complies with the requirements of |
30 | this subsection if it provides benefits with respect to an emergency service in an amount equal to |
31 | the greatest of the three amounts specified in subdivisions (A), (B), and (C) of this subdivision (1) |
32 | (which are adjusted for in-network cost-sharing requirements). |
33 | (A) The amount negotiated with in-network providers for the emergency service |
34 | furnished, excluding any in-network copayment or coinsurance imposed with respect to the |
| LC003066 - Page 3 of 13 |
1 | participant or beneficiary. If there is more than one amount negotiated with in-network providers |
2 | for the emergency service, the amount described under this subdivision (A) is the median of these |
3 | amounts, excluding any in-network copayment or coinsurance imposed with respect to the |
4 | participant or beneficiary. In determining the median described in the preceding sentence, the |
5 | amount negotiated with each in-network provider is treated as a separate amount (even if the |
6 | same amount is paid to more than one provider). If there is no per-service amount negotiated with |
7 | in-network providers (such as under a capitation or other similar payment arrangement), the |
8 | amount under this subdivision (A) is disregarded. |
9 | (B) The amount for the emergency service shall be calculated using the same method the |
10 | plan generally uses to determine payments for out-of-network services in-network services (such |
11 | as the usual, customary, and reasonable amount), excluding any in-network copayment or |
12 | coinsurance imposed with respect to the participant or beneficiary. The amount in this subdivision |
13 | (B) is determined without reduction for out-of-network cost-sharing that generally applies under |
14 | the plan or health insurance coverage with respect to out-of-network services. |
15 | (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the |
16 | Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in- |
17 | network copayment or coinsurance imposed with respect to the participant or beneficiary. |
18 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement |
19 | (such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency |
20 | services provided out of network if the cost-sharing requirement generally applies to out-of- in- |
21 | network benefits. A deductible may be imposed with respect to out-of-network emergency |
22 | services only as part of a deductible that generally applies to out-of- in-network benefits. If an |
23 | out-of-pocket maximum generally applies to out-of-network benefits, that out-of-pocket |
24 | maximum must apply to out-of-network emergency services. |
25 | (e) The provisions of this section apply for plan years beginning on or after September |
26 | 23, 2010. |
27 | (f) This section shall not apply to grandfathered health plans. This section shall not apply |
28 | to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability |
29 | income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited benefit |
30 | health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both; |
31 | and (9) other limited benefit policies. |
32 | SECTION 3. Section 27-19-66 of the General Laws in Chapter 27-19 entitled "Nonprofit |
33 | Hospital Service Corporations" is hereby amended to read as follows: |
34 | 27-19-66. Emergency services. |
| LC003066 - Page 4 of 13 |
1 | (a) As used in this section: |
2 | (1) "Emergency medical condition" means a medical condition manifesting itself by acute |
3 | symptoms of sufficient severity (including severe pain) so that a prudent layperson, who |
4 | possesses an average knowledge of health and medicine, could reasonably expect the absence of |
5 | immediate medical attention to result in a condition: (i) Placing the health of the individual, or |
6 | with respect to a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious |
7 | impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or |
8 | part. |
9 | (2) "Emergency services" means, with respect to an emergency medical condition: |
10 | (A) A medical screening examination (as required under section 1867 of the Social |
11 | Security Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a |
12 | hospital, including ancillary services routinely available to the emergency department to evaluate |
13 | such emergency medical condition, and |
14 | (B) Such further medical examination and treatment, to the extent they are within the |
15 | capabilities of the staff and facilities available at the hospital, as are required under section 1867 |
16 | of the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient. |
17 | (3) "Stabilize", with respect to an emergency medical condition has the meaning given in |
18 | section 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)). |
19 | (b) If a nonprofit hospital service corporation provides any benefits to subscribers with |
20 | respect to services in an emergency department of a hospital, the plan must cover emergency |
21 | services consistent with the rules of this section. |
22 | (c) A nonprofit hospital service corporation shall provide coverage for emergency |
23 | services in the following manner: |
24 | (1) Without the need for any prior authorization determination, even if the emergency |
25 | services are provided on an out-of-network basis; |
26 | (2) Without regard to whether the health-care provider furnishing the emergency services |
27 | is a participating network provider with respect to the services; |
28 | (3) If the emergency services are provided out of network, without imposing any |
29 | administrative requirement or limitation on coverage that is more restrictive than the requirements |
30 | or limitations that apply to emergency services received from in-network providers; |
31 | (4) If the emergency services are provided out of network, by complying with the cost- |
32 | sharing requirements of subsection (d) of this section; and |
33 | (5) Without regard to any other term or condition of the coverage, other than: |
34 | (A) The exclusion of or coordination of benefits; |
| LC003066 - Page 5 of 13 |
1 | (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of |
2 | title XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or |
3 | (C) Applicable cost sharing. |
4 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance |
5 | rate imposed with respect to a participant or beneficiary for out-of-network emergency services |
6 | cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if |
7 | the services were provided in-network. However, a participant or beneficiary may be required to |
8 | pay, in addition to the in-network cost sharing, the excess of the amount the out-of-network |
9 | provider charges over the amount the plan or health insurance carrier is required to pay under |
10 | subdivision (1) of this subsection. A group health plan or health insurance carrier complies with |
11 | the requirements of this subsection if it provides benefits with respect to an emergency service in |
12 | an amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of |
13 | this subdivision (1) (which are adjusted for in-network cost-sharing requirements). |
14 | (A) The amount negotiated with in-network providers for the emergency service |
15 | furnished, excluding any in-network copayment or coinsurance imposed with respect to the |
16 | participant or beneficiary. If there is more than one amount negotiated with in-network providers |
17 | for the emergency service, the amount described under this subdivision (A) is the median of these |
18 | amounts, excluding any in-network copayment or coinsurance imposed with respect to the |
19 | participant or beneficiary. In determining the median described in the preceding sentence, the |
20 | amount negotiated with each in-network provider is treated as a separate amount (even if the |
21 | same amount is paid to more than one provider). If there is no per-service amount negotiated with |
22 | in-network providers (such as under a capitation or other similar payment arrangement), the |
23 | amount under this subdivision (A) is disregarded. |
24 | (B) The amount for the emergency service shall be calculated using the same method the |
25 | plan generally uses to determine payments for out-of- in-network services (such as the usual, |
26 | customary, and reasonable amount), excluding any in-network copayment or coinsurance |
27 | imposed with respect to the participant or beneficiary. The amount in this subdivision (B) is |
28 | determined without reduction for out-of-network cost sharing that generally applies under the |
29 | plan or health insurance coverage with respect to out-of-network services. Thus, for example, if a |
30 | plan generally pays seventy percent (70%) of the usual, customary, and reasonable amount for |
31 | out-of-network services, the amount in this subdivision (B) for an emergency service is the total, |
32 | that is, one hundred percent (100%), of the usual, customary, and reasonable amount for the |
33 | service, not reduced by the thirty percent (30%) coinsurance that would generally apply to out-of- |
34 | network services (but reduced by the in-network copayment or coinsurance that the individual |
| LC003066 - Page 6 of 13 |
1 | would be responsible for if the emergency service had been provided in-network). |
2 | (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the |
3 | Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in- |
4 | network copayment or coinsurance imposed with respect to the participant or beneficiary. |
5 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement |
6 | (such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency |
7 | services provided out of network if the cost-sharing requirement generally applies to out-of- in- |
8 | network benefits. A deductible may be imposed with respect to out-of-network emergency |
9 | services only as part of a deductible that generally applies to out-of- in-network benefits. If an |
10 | out-of-pocket maximum generally applies to out-of-network benefits, that out-of-pocket |
11 | maximum must apply to out-of-network emergency services. |
12 | (e) The provisions of this section apply for plan years beginning on or after September |
13 | 23, 2010. |
14 | (f) This section shall not apply to insurance coverage providing benefits for: (1) Hospital |
15 | confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5) |
16 | Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or |
17 | bodily injury or death by accident or both; and (9) Other limited benefit policies. |
18 | SECTION 4. Section 27-20-62 of the General Laws in Chapter 27-20 entitled "Nonprofit |
19 | Medical Service Corporations" is hereby amended to read as follows: |
20 | 27-20-62. Emergency services. |
21 | (a) As used in this section: |
22 | (1) "Emergency medical condition" means a medical condition manifesting itself by acute |
23 | symptoms of sufficient severity (including severe pain) so that a prudent layperson, who |
24 | possesses an average knowledge of health and medicine, could reasonably expect the absence of |
25 | immediate medical attention to result in a condition: (i) Placing the health of the individual, or |
26 | with respect to a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious |
27 | impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or |
28 | part. |
29 | (2) "Emergency services" means, with respect to an emergency medical condition: |
30 | (A) A medical screening examination (as required under section 1867 of the Social |
31 | Security Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a |
32 | hospital, including ancillary services routinely available to the emergency department to evaluate |
33 | such emergency medical condition, and |
34 | (B) Such further medical examination and treatment, to the extent they are within the |
| LC003066 - Page 7 of 13 |
1 | capabilities of the staff and facilities available at the hospital, as are required under section 1867 |
2 | of the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient. |
3 | (3) "Stabilize", with respect to an emergency medical condition has the meaning given in |
4 | section 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)). |
5 | (b) If a nonprofit medical service corporation offering health insurance coverage provides |
6 | any benefits with respect to services in an emergency department of a hospital, it must cover |
7 | emergency services consistent with the rules of this section. |
8 | (c) A nonprofit medical service corporation shall provide coverage for emergency |
9 | services in the following manner: |
10 | (1) Without the need for any prior authorization determination, even if the emergency |
11 | services are provided on an out-of-network basis; |
12 | (2) Without regard to whether the health care provider furnishing the emergency services |
13 | is a participating network provider with respect to the services; |
14 | (3) If the emergency services are provided out of network, without imposing any |
15 | administrative requirement or limitation on coverage that is more restrictive than the requirements |
16 | or limitations that apply to emergency services received from in-network providers; |
17 | (4) If the emergency services are provided out of network, by complying with the cost- |
18 | sharing requirements of subsection (d) of this section; and |
19 | (5) Without regard to any other term or condition of the coverage, other than: |
20 | (A) The exclusion of or coordination of benefits; |
21 | (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of |
22 | title XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or |
23 | (C) Applicable cost-sharing. |
24 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance |
25 | rate imposed with respect to a participant or beneficiary for out-of-network emergency services |
26 | cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if |
27 | the services were provided in-network. However, a participant or beneficiary may be required to |
28 | pay, in addition to the in-network cost sharing, the excess of the amount the out-of-network |
29 | provider charges over the amount the plan or health insurance carrier is required to pay under |
30 | subdivision (1) of this subsection. A group health plan or health insurance carrier complies with |
31 | the requirements of this subsection if it provides benefits with respect to an emergency service in |
32 | an amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of |
33 | this subdivision (1) (which are adjusted for in-network cost-sharing requirements). |
34 | (A) The amount negotiated with in-network providers for the emergency service |
| LC003066 - Page 8 of 13 |
1 | furnished, excluding any in-network copayment or coinsurance imposed with respect to the |
2 | participant or beneficiary. If there is more than one amount negotiated with in-network providers |
3 | for the emergency service, the amount described under this subdivision (A) is the median of these |
4 | amounts, excluding any in-network copayment or coinsurance imposed with respect to the |
5 | participant or beneficiary. In determining the median described in the preceding sentence, the |
6 | amount negotiated with each in-network provider is treated as a separate amount (even if the |
7 | same amount is paid to more than one provider). If there is no per-service amount negotiated with |
8 | in-network providers (such as under a capitation or other similar payment arrangement), the |
9 | amount under this subdivision (A) is disregarded. |
10 | (B) The amount for the emergency service shall be calculated using the same method the |
11 | plan generally uses to determine payments for out-of- in-network services (such as the usual, |
12 | customary, and reasonable amount), excluding any in-network copayment or coinsurance |
13 | imposed with respect to the participant or beneficiary. The amount in this subdivision (B) is |
14 | determined without reduction for out-of-network cost-sharing that generally applies under the |
15 | plan or health insurance coverage with respect to out-of-network services. |
16 | (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the |
17 | Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in- |
18 | network copayment or coinsurance imposed with respect to the participant or beneficiary. |
19 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement |
20 | (such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency |
21 | services provided out of network if the cost-sharing requirement generally applies to out-of- in- |
22 | network benefits. A deductible may be imposed with respect to out-of-network emergency |
23 | services only as part of a deductible that generally applies to out-of- in-network benefits. If an |
24 | out-of-pocket maximum generally applies to out-of-network benefits, that out-of-pocket |
25 | maximum must apply to out-of-network emergency services. |
26 | (f) The provisions of this section shall apply to grandfathered health plans. This section |
27 | shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; |
28 | (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) |
29 | Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by |
30 | accident or both; and (9) Other limited benefit policies. |
31 | SECTION 5. Section 27-41-79 of the General Laws in Chapter 27-41 entitled "Health |
32 | Maintenance Organizations" is hereby amended to read as follows: |
33 | 27-41-79. Emergency services. |
34 | (a) As used in this section: |
| LC003066 - Page 9 of 13 |
1 | (1) "Emergency medical condition" means a medical condition manifesting itself by acute |
2 | symptoms of sufficient severity (including severe pain) so that a prudent layperson, who |
3 | possesses an average knowledge of health and medicine, could reasonably expect the absence of |
4 | immediate medical attention to result in a condition: (i) Placing the health of the individual, or |
5 | with respect to a pregnant woman her unborn child in serious jeopardy; (ii) Constituting a serious |
6 | impairment to bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or |
7 | part. |
8 | (2) "Emergency services" means, with respect to an emergency medical condition: |
9 | (A) A medical screening examination (as required under section 1867 of the Social |
10 | Security Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a |
11 | hospital, including ancillary services routinely available to the emergency department to evaluate |
12 | such emergency medical condition, and |
13 | (B) Such further medical examination and treatment, to the extent they are within the |
14 | capabilities of the staff and facilities available at the hospital, as are required under section 1867 |
15 | of the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient. |
16 | (3) "Stabilize", with respect to an emergency medical condition has the meaning given in |
17 | section 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)). |
18 | (b) If a health maintenance organization offering group health insurance coverage |
19 | provides any benefits with respect to services in an emergency department of a hospital, it must |
20 | cover emergency services consistent with the rules of this section. |
21 | (c) A health maintenance organization shall provide coverage for emergency services in |
22 | the following manner: |
23 | (1) Without the need for any prior authorization determination, even if the emergency |
24 | services are provided on an out-of-network basis; |
25 | (2) Without regard to whether the health care provider furnishing the emergency services |
26 | is a participating network provider with respect to the services; |
27 | (3) If the emergency services are provided out of network, without imposing any |
28 | administrative requirement or limitation on coverage that is more restrictive than the requirements |
29 | or limitations that apply to emergency services received from in-network providers; |
30 | (4) If the emergency services are provided out of network, by complying with the cost- |
31 | sharing requirements of subsection (d) of this section; and |
32 | (5) Without regard to any other term or condition of the coverage, other than: |
33 | (A) The exclusion of or coordination of benefits; |
34 | (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of |
| LC003066 - Page 10 of 13 |
1 | title XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or |
2 | (C) Applicable cost sharing. |
3 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance |
4 | rate imposed with respect to a participant or beneficiary for out-of-network emergency services |
5 | cannot exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if |
6 | the services were provided in-network; provided, however, that a participant or beneficiary may |
7 | be required to pay, in addition to the in-network cost sharing, the excess of the amount the out-of- |
8 | network provider charges over the amount the plan or health maintenance organization is required |
9 | to pay under subdivision (1) of this subsection. A health maintenance organization complies with |
10 | the requirements of this subsection if it provides benefits with respect to an emergency service in |
11 | an amount equal to the greatest of the three amounts specified in subdivisions (A), (B), and (C) of |
12 | this subdivision (1) (which are adjusted for in-network cost-sharing requirements). |
13 | (A) The amount negotiated with in-network providers for the emergency service |
14 | furnished, excluding any in-network copayment or coinsurance imposed with respect to the |
15 | participant or beneficiary. If there is more than one amount negotiated with in-network providers |
16 | for the emergency service, the amount described under this subdivision (A) is the median of these |
17 | amounts, excluding any in-network copayment or coinsurance imposed with respect to the |
18 | participant or beneficiary. In determining the median described in the preceding sentence, the |
19 | amount negotiated with each in-network provider is treated as a separate amount (even if the |
20 | same amount is paid to more than one provider). If there is no per-service amount negotiated with |
21 | in-network providers (such as under a capitation or other similar payment arrangement), the |
22 | amount under this subdivision (A) is disregarded. |
23 | (B) The amount for the emergency service calculated using the same method the plan |
24 | generally uses to determine payments for out-of- in-network services (such as the usual, |
25 | customary, and reasonable amount), excluding any in-network copayment or coinsurance |
26 | imposed with respect to the participant or beneficiary. The amount in this subdivision (B) is |
27 | determined without reduction for out-of-network cost sharing that generally applies under the |
28 | plan or health insurance coverage with respect to out-of-network services. |
29 | (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the |
30 | Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in- |
31 | network copayment or coinsurance imposed with respect to the participant or beneficiary. |
32 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement |
33 | (such as a deductible or out-of-pocket maximum) may be imposed with respect to emergency |
34 | services provided out of network if the cost-sharing requirement generally applies to out-of- in- |
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1 | network benefits. A deductible may be imposed with respect to out-of-network emergency |
2 | services only as part of a deductible that generally applies to out-of- in-network benefits. If an |
3 | out-of-pocket maximum generally applies to out-of-network benefits, that out-of-pocket |
4 | maximum must apply to out-of-network emergency services. |
5 | (e) The provisions of this section apply for plan years beginning on or after September |
6 | 23, 2010. |
7 | (f) The provisions of this section shall apply to grandfathered health plans. This section |
8 | shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; |
9 | (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) |
10 | Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by |
11 | accident or both; and (9) Other limited benefit policies. |
12 | SECTION 6. This act shall take effect on January 1, 2021. |
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EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO HEALTH AND SAFETY -- LICENSING OF HEALTH CARE FACILITIES | |
*** | |
1 | This act would mandate that a hospital providing a planned procedure to a patient provide |
2 | notice of services proposed to be provided by out-of-network physician/provider. For emergency |
3 | services the medical provider shall be limited to charging fees equal to services provided to in- |
4 | network patients. |
5 | This act would take effect on January 1, 2021. |
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