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
Shanley

     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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