2024 -- S 2176 | |
======== | |
LC004141 | |
======== | |
STATE OF RHODE ISLAND | |
IN GENERAL ASSEMBLY | |
JANUARY SESSION, A.D. 2024 | |
____________ | |
A N A C T | |
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES | |
| |
Introduced By: Senators DiMario, Lauria, Lawson, Pearson, Ujifusa, Valverde, Euer, | |
Date Introduced: January 24, 2024 | |
Referred To: Senate Health & Human Services | |
It is enacted by the General Assembly as follows: | |
1 | SECTION 1. Section 27-18-76 of the General Laws in Chapter 27-18 entitled "Accident |
2 | and Sickness Insurance Policies" is hereby amended to read as follows: |
3 | 27-18-76. Emergency services. |
4 | (a) As used in this section: |
5 | (1) “Emergency medical condition” means a medical condition manifesting itself by acute |
6 | symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses |
7 | an average knowledge of health and medicine, could reasonably expect the absence of immediate |
8 | medical attention to result in a condition: (i) Placing the health of the individual, or with respect to |
9 | a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious impairment to |
10 | bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part. |
11 | (2) “Emergency services” means, with respect to an emergency medical condition: |
12 | (A)(i) A medical screening examination (as required under section 1867 of the Social |
13 | Security Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a |
14 | hospital, including ancillary services routinely available to the emergency department to evaluate |
15 | such emergency medical condition, and ; |
16 | (B)(ii) Such further medical examination and treatment, to the extent they are within the |
17 | capabilities of the staff and facilities available at the hospital, as are required under section 1867 of |
18 | the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient; and |
19 | (iii) Transportation for emergency services by ambulance or rescue. |
| |
1 | (3) “Stabilize,” with respect to an emergency medical condition has the meaning given in |
2 | § 1867(e)(3) of the Social Security Act (42 U.S.C. § 1395dd(e)(3)). |
3 | (b) If a health insurance carrier offering health insurance coverage provides any benefits |
4 | with respect to services in an emergency department of a hospital, the carrier must cover emergency |
5 | services in compliance with this section. |
6 | (c) A health insurance carrier shall provide coverage for emergency services in the |
7 | following manner: |
8 | (1) Without the need for any prior authorization determination, even if the emergency |
9 | services are provided on an out-of-network basis; |
10 | (2) Without regard to whether the healthcare provider furnishing the emergency services is |
11 | a participating network provider with respect to the services; |
12 | (3) If the emergency services are provided out of network, without imposing any |
13 | administrative requirement or limitation on coverage that is more restrictive than the requirements |
14 | or limitations that apply to emergency services received from in-network providers; |
15 | (4) If the emergency services are provided out of network, by complying with the cost- |
16 | sharing requirements of subsection (d) of this section; and |
17 | (5) Without regard to any other term or condition of the coverage, other than: |
18 | (A) The exclusion of or coordination of benefits; |
19 | (B) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title |
20 | XXVII of the federal PHS Act, or chapter 100 of the federal Internal Revenue Code; or |
21 | (C) Applicable cost-sharing. |
22 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate |
23 | imposed with respect to a participant or beneficiary for out-of-network emergency services cannot |
24 | exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the |
25 | services were provided in-network; provided, however, that a participant or beneficiary may be |
26 | required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of- |
27 | network provider charges over the amount the health insurance carrier is required to pay under |
28 | subdivision (1) of this subsection. A health insurance carrier complies with the requirements of this |
29 | subsection if it provides benefits with respect to an emergency service in an amount equal to the |
30 | greatest of the three amounts specified in subdivisions (A), (B), and (C) of this subdivision (1) |
31 | (which are adjusted for in-network cost-sharing requirements). |
32 | (A) The amount negotiated with in-network providers for the emergency service furnished, |
33 | excluding any in-network copayment or coinsurance imposed with respect to the participant or |
34 | beneficiary. If there is more than one amount negotiated with in-network providers for the |
| LC004141 - Page 2 of 12 |
1 | emergency service, the amount described under this subdivision (A) is the median of these amounts, |
2 | excluding any in-network copayment or coinsurance imposed with respect to the participant or |
3 | beneficiary. In determining the median described in the preceding sentence, the amount negotiated |
4 | with each in-network provider is treated as a separate amount (even if the same amount is paid to |
5 | more than one provider). If there is no per-service amount negotiated with in-network providers |
6 | (such as under a capitation or other similar payment arrangement), the amount under this |
7 | subdivision (A) is disregarded. |
8 | (B) The amount for the emergency service shall be calculated using the same method the |
9 | plan generally uses to determine payments for out-of-network services (such as the usual, |
10 | customary, and reasonable amount), excluding any in-network copayment or coinsurance imposed |
11 | with respect to the participant or beneficiary. The amount in this subdivision (B) is determined |
12 | without reduction for out-of-network cost-sharing that generally applies under the plan or health |
13 | insurance coverage with respect to out-of-network services. |
14 | (C) The amount that would be paid under Medicare (part A or part B of title XVIII of the |
15 | Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in-network |
16 | copayment or coinsurance imposed with respect to the participant or beneficiary. |
17 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such |
18 | as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services |
19 | provided out of network if the cost-sharing requirement generally applies to out-of-network |
20 | benefits. A deductible may be imposed with respect to out-of-network emergency services only as |
21 | part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum |
22 | generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of- |
23 | network emergency services. |
24 | (e) The provisions of this section apply for plan years beginning on or after September 23, |
25 | 2010. |
26 | (f) This section shall not apply to grandfathered health plans. This section shall not apply |
27 | to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability |
28 | income; (3) accident only; (4) long term care; (5) Medicare supplement; (6) limited benefit health; |
29 | (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both; and (9) |
30 | other limited benefit policies. |
31 | SECTION 2. Section 27-19-66 of the General Laws in Chapter 27-19 entitled "Nonprofit |
32 | Hospital Service Corporations" is hereby amended to read as follows: |
33 | 27-19-66. Emergency services. |
34 | (a) As used in this section: |
| LC004141 - Page 3 of 12 |
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 possesses |
3 | an average knowledge of health and medicine, could reasonably expect the absence of immediate |
4 | medical attention to result in a condition: (i) Placing the health of the individual, or with respect to |
5 | a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious impairment to |
6 | bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part. |
7 | (2) “Emergency services” means, with respect to an emergency medical condition: |
8 | (i) A medical screening examination (as required under section 1867 of the Social Security |
9 | Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a hospital, |
10 | including ancillary services routinely available to the emergency department to evaluate such |
11 | emergency medical condition; and |
12 | (ii) Such further medical examination and treatment, to the extent they are within the |
13 | capabilities of the staff and facilities available at the hospital, as are required under section 1867 of |
14 | the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient; and |
15 | (iii) Transportation for emergency services by ambulance or rescue. |
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 nonprofit hospital service corporation provides any benefits to subscribers with |
19 | respect to services in an emergency department of a hospital, the plan must cover emergency |
20 | services consistent with the rules of this section. |
21 | (c) A nonprofit hospital service corporation shall provide coverage for emergency services |
22 | in 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 healthcare provider furnishing the emergency services is |
26 | 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 | (i) The exclusion of or coordination of benefits; |
34 | (ii) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title |
| LC004141 - Page 4 of 12 |
1 | XXVII of the federal Public Health Service Act, or chapter 100 of the federal Internal Revenue |
2 | Code; or |
3 | (iii) Applicable cost sharing. |
4 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate |
5 | imposed with respect to a participant or beneficiary for out-of-network emergency services cannot |
6 | exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the |
7 | services were provided in-network. However, a participant or beneficiary may be required to pay, |
8 | in addition to the in-network cost sharing, the excess of the amount the out-of-network provider |
9 | charges over the amount the plan or health insurance carrier is required to pay under subsection |
10 | (d)(1). A group health plan or health insurance carrier complies with the requirements of this |
11 | subsection (d) if it provides benefits with respect to an emergency service in an amount equal to |
12 | the greatest of the three amounts specified in subsections (d)(1)(i), (d)(1)(ii), and (d)(1)(iii) of this |
13 | section (which are adjusted for in-network cost-sharing requirements). |
14 | (i) The amount negotiated with in-network providers for the emergency service furnished, |
15 | excluding any in-network copayment or coinsurance imposed with respect to the participant or |
16 | beneficiary. If there is more than one amount negotiated with in-network providers for the |
17 | emergency service, the amount described under this subsection (d)(1)(i) 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 same |
21 | amount is paid to more than one provider). If there is no per-service amount negotiated with in- |
22 | network providers (such as under a capitation or other similar payment arrangement), the amount |
23 | under this subsection (d)(1)(i) is disregarded. |
24 | (ii) The amount for the emergency service shall be calculated using the same method the |
25 | plan generally uses to determine payments for out-of-network services (such as the usual, |
26 | customary, and reasonable amount), excluding any in-network copayment or coinsurance imposed |
27 | with respect to the participant or beneficiary. The amount in this subsection (d)(1)(ii) is determined |
28 | without reduction for out-of-network cost sharing that generally applies under the plan or health |
29 | insurance coverage with respect to out-of-network services. Thus, for example, if a plan generally |
30 | pays seventy percent (70%) of the usual, customary, and reasonable amount for out-of-network |
31 | services, the amount in this subsection (d)(1)(ii) for an emergency service is the total, that is, one |
32 | hundred percent (100%), of the usual, customary, and reasonable amount for the service, not |
33 | reduced by the thirty percent (30%) coinsurance that would generally apply to out-of-network |
34 | services (but reduced by the in-network copayment or coinsurance that the individual would be |
| LC004141 - Page 5 of 12 |
1 | responsible for if the emergency service had been provided in-network). |
2 | (iii) 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-network |
4 | copayment or coinsurance imposed with respect to the participant or beneficiary. |
5 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such |
6 | as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services |
7 | provided out of network if the cost-sharing requirement generally applies to out-of-network |
8 | benefits. A deductible may be imposed with respect to out-of-network emergency services only as |
9 | part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum |
10 | generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of- |
11 | network emergency services. |
12 | (e) The provisions of this section apply for plan years beginning on or after September 23, |
13 | 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) Medicare |
16 | supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or bodily |
17 | injury or death by accident or both; and (9) Other limited benefit policies. |
18 | SECTION 3. 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 possesses |
24 | an average knowledge of health and medicine, could reasonably expect the absence of immediate |
25 | medical attention to result in a condition: (i) Placing the health of the individual, or with respect to |
26 | a pregnant woman her unborn child, in serious jeopardy; (ii) Constituting a serious impairment to |
27 | bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part. |
28 | (2) “Emergency services” means, with respect to an emergency medical condition: |
29 | (i) A medical screening examination (as required under section 1867 of the Social Security |
30 | Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a hospital, |
31 | including ancillary services routinely available to the emergency department to evaluate the |
32 | emergency medical condition; and |
33 | (ii) Further medical examination and treatment, to the extent they are within the capabilities |
34 | of the staff and facilities available at the hospital, as are required under section 1867 of the Social |
| LC004141 - Page 6 of 12 |
1 | Security Act (42 U.S.C. § 1395dd) to stabilize the patient; and |
2 | (iii) Transportation for emergency services by ambulance or rescue. |
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 services |
9 | 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 healthcare provider furnishing the emergency services is |
13 | 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 | (i) The exclusion of or coordination of benefits; |
21 | (ii) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title |
22 | XXVII of the federal Public Health Service Act, or chapter 100 of the federal Internal Revenue |
23 | Code; or |
24 | (iii) Applicable cost sharing. |
25 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate |
26 | imposed with respect to a participant or beneficiary for out-of-network emergency services cannot |
27 | exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the |
28 | services were provided in-network. However, a participant or beneficiary may be required to pay, |
29 | in addition to the in-network cost sharing, the excess of the amount the out-of-network provider |
30 | charges over the amount the plan or health insurance carrier is required to pay under subsection |
31 | (d)(1). A group health plan or health insurance carrier complies with the requirements of this |
32 | subsection (d) if it provides benefits with respect to an emergency service in an amount equal to |
33 | the greatest of the three amounts specified in subsections (d)(1)(i), (d)(1)(ii), and (d)(1)(iii) of this |
34 | section (which are adjusted for in-network cost-sharing requirements). |
| LC004141 - Page 7 of 12 |
1 | (i) The amount negotiated with in-network providers for the emergency service furnished, |
2 | excluding any in-network copayment or coinsurance imposed with respect to the participant or |
3 | beneficiary. If there is more than one amount negotiated with in-network providers for the |
4 | emergency service, the amount described under this subsection (d)(1)(i) is the median of these |
5 | amounts, excluding any in-network copayment or coinsurance imposed with respect to the |
6 | participant or beneficiary. In determining the median described in the preceding sentence, the |
7 | amount negotiated with each in-network provider is treated as a separate amount (even if the same |
8 | amount is paid to more than one provider). If there is no per-service amount negotiated with in- |
9 | network providers (such as under a capitation or other similar payment arrangement), the amount |
10 | under this subsection (d)(1)(i) is disregarded. |
11 | (ii) The amount for the emergency service shall be calculated using the same method the |
12 | plan generally uses to determine payments for out-of-network services (such as the usual, |
13 | customary, and reasonable amount), excluding any in-network copayment or coinsurance imposed |
14 | with respect to the participant or beneficiary. The amount in this subsection (d)(1)(ii) is determined |
15 | without reduction for out-of-network cost sharing that generally applies under the plan or health |
16 | insurance coverage with respect to out-of-network services. |
17 | (iii) The amount that would be paid under Medicare (part A or part B of title XVIII of the |
18 | Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in-network |
19 | copayment or coinsurance imposed with respect to the participant or beneficiary. |
20 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such |
21 | as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services |
22 | provided out of network if the cost-sharing requirement generally applies to out-of-network |
23 | benefits. A deductible may be imposed with respect to out-of-network emergency services only as |
24 | part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum |
25 | generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of- |
26 | network emergency services. |
27 | (f) The provisions of this section shall apply to grandfathered health plans. This section |
28 | shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; |
29 | (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited |
30 | benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident |
31 | or both; and (9) Other limited benefit policies. |
32 | SECTION 4. Section 27-41-79 of the General Laws in Chapter 27-41 entitled "Health |
33 | Maintenance Organizations" is hereby amended to read as follows: |
34 | 27-41-79. Emergency services. |
| LC004141 - Page 8 of 12 |
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 possesses |
4 | an average knowledge of health and medicine, could reasonably expect the absence of immediate |
5 | medical attention to result in a condition: (i) Placing the health of the individual, or with respect to |
6 | a pregnant woman her unborn child in serious jeopardy; (ii) Constituting a serious impairment to |
7 | bodily functions; or (iii) Constituting a serious dysfunction of any bodily organ or part. |
8 | (2) “Emergency services” means, with respect to an emergency medical condition: |
9 | (i) A medical screening examination (as required under section 1867 of the Social Security |
10 | Act, 42 U.S.C. § 1395dd) that is within the capability of the emergency department of a hospital, |
11 | including ancillary services routinely available to the emergency department to evaluate such |
12 | emergency medical condition; and |
13 | (ii) 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 of |
15 | the Social Security Act (42 U.S.C. § 1395dd) to stabilize the patient; and |
16 | (iii) Transportation for emergency services by ambulance or rescue. |
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 health maintenance organization offering group health insurance coverage provides |
20 | any benefits with respect to services in an emergency department of a hospital, it must cover |
21 | emergency services consistent with the rules of this section. |
22 | (c) A health maintenance organization shall provide coverage for emergency services in |
23 | 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 healthcare provider furnishing the emergency services is |
27 | 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 | (i) The exclusion of or coordination of benefits; |
| LC004141 - Page 9 of 12 |
1 | (ii) An affiliation or waiting period permitted under part 7 of federal ERISA, part A of title |
2 | XXVII of the federal Public Health Service Act, or chapter 100 of the federal Internal Revenue |
3 | Code; or |
4 | (iii) Applicable cost sharing. |
5 | (d)(1) Any cost-sharing requirement expressed as a copayment amount or coinsurance rate |
6 | imposed with respect to a participant or beneficiary for out-of-network emergency services cannot |
7 | exceed the cost-sharing requirement imposed with respect to a participant or beneficiary if the |
8 | services were provided in-network; provided, however, that a participant or beneficiary may be |
9 | required to pay, in addition to the in-network cost sharing, the excess of the amount the out-of- |
10 | network provider charges over the amount the plan or health maintenance organization is required |
11 | to pay under subsection (d)(1). A health maintenance organization complies with the requirements |
12 | of this subsection (d) if it provides benefits with respect to an emergency service in an amount |
13 | equal to the greatest of the three amounts specified in subsections (d)(1)(i), (d)(1)(ii), and (d)(1)(iii) |
14 | of this section (which are adjusted for in-network cost-sharing requirements). |
15 | (i) The amount negotiated with in-network providers for the emergency service furnished, |
16 | excluding any in-network copayment or coinsurance imposed with respect to the participant or |
17 | beneficiary. If there is more than one amount negotiated with in-network providers for the |
18 | emergency service, the amount described under this subsection (d)(1)(i) is the median of these |
19 | amounts, excluding any in-network copayment or coinsurance imposed with respect to the |
20 | participant or beneficiary. In determining the median described in the preceding sentence, the |
21 | amount negotiated with each in-network provider is treated as a separate amount (even if the same |
22 | amount is paid to more than one provider). If there is no per-service amount negotiated with in- |
23 | network providers (such as under a capitation or other similar payment arrangement), the amount |
24 | under this subsection (d)(1)(i) is disregarded. |
25 | (ii) The amount for the emergency service calculated using the same method the plan |
26 | generally uses to determine payments for out-of-network services (such as the usual, customary, |
27 | and reasonable amount), excluding any in-network copayment or coinsurance imposed with respect |
28 | to the participant or beneficiary. The amount in this subsection (d)(1)(ii) is determined without |
29 | reduction for out-of-network cost sharing that generally applies under the plan or health insurance |
30 | coverage with respect to out-of-network services. |
31 | (iii) The amount that would be paid under Medicare (part A or part B of title XVIII of the |
32 | Social Security Act, 42 U.S.C. § 1395 et seq.) for the emergency service, excluding any in-network |
33 | copayment or coinsurance imposed with respect to the participant or beneficiary. |
34 | (2) Any cost-sharing requirement other than a copayment or coinsurance requirement (such |
| LC004141 - Page 10 of 12 |
1 | as a deductible or out-of-pocket maximum) may be imposed with respect to emergency services |
2 | provided out of network if the cost-sharing requirement generally applies to out-of-network |
3 | benefits. A deductible may be imposed with respect to out-of-network emergency services only as |
4 | part of a deductible that generally applies to out-of-network benefits. If an out-of-pocket maximum |
5 | generally applies to out-of-network benefits, that out-of-pocket maximum must apply to out-of- |
6 | network emergency services. |
7 | (e) The provisions of this section apply for plan years beginning on or after September 23, |
8 | 2010. |
9 | (f) The provisions of this section shall apply to grandfathered health plans. This section |
10 | shall not apply to insurance coverage providing benefits for: (1) Hospital confinement indemnity; |
11 | (2) Disability income; (3) Accident only; (4) Long-term care; (5) Medicare supplement; (6) Limited |
12 | benefit health; (7) Specified disease indemnity; (8) Sickness or bodily injury or death by accident |
13 | or both; and (9) Other limited benefit policies. |
14 | SECTION 5. This act shall take effect upon passage. |
======== | |
LC004141 | |
======== | |
| LC004141 - Page 11 of 12 |
EXPLANATION | |
BY THE LEGISLATIVE COUNCIL | |
OF | |
A N A C T | |
RELATING TO INSURANCE -- ACCIDENT AND SICKNESS INSURANCE POLICIES | |
*** | |
1 | This act would mandate health insurance coverage to include transportation for emergency |
2 | services by ambulance or rescue. |
3 | This act would take effect upon passage. |
======== | |
LC004141 | |
======== | |
| LC004141 - Page 12 of 12 |