1 AN ACT
2 RELATING TO HEALTH COVERAGE; ENACTING THE SURPRISE BILLING
3 PROTECTION ACT; PROVIDING FOR PROTECTION OF COVERED PERSONS
4 FROM UNEXPECTED BILLING FROM PROVIDERS THAT DO NOT
5 PARTICIPATE IN THE COVERED PERSON'S HEALTH BENEFITS PLAN;
6 PROHIBITING SURPRISE BILLING AS AN UNFAIR PRACTICE;
7 ESTABLISHING PENALTIES; PROVIDING FOR A CONTINGENT REPEAL.
8
9 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
10 SECTION 1. A new section of the New Mexico Insurance
11 Code is enacted to read:
12 "SHORT TITLE.--Sections 1 through 13 of this act may be
13 cited as the "Surprise Billing Protection Act"."
14 SECTION 2. A new section of the New Mexico Insurance
15 Code is enacted to read:
16 "DEFINITIONS.--As used in the Surprise Billing
17 Protection Act:
18 A. "allowed amount" means the maximum portion of
19 a billed charge that a health insurance carrier will pay,
20 including any applicable covered person cost-sharing
21 responsibility, for a covered health care service or item
22 rendered by a participating provider or by a nonparticipating
23 provider;
24 B. "balance billing" means a nonparticipating
25 provider's practice of issuing a bill to a covered person for SCORC/SB 337 Page 1 1 the difference between the nonparticipating provider's billed
2 charges on a claim and any amount paid by the health
3 insurance carrier as reimbursement for that claim, excluding
4 any cost-sharing amount due from the covered person;
5 C. "claim" means a request from a provider for
6 payment for health care services rendered;
7 D. "co-insurance" means a cost-sharing method that
8 requires a covered person to pay a stated percentage of
9 medical expenses after any deductible amount is paid;
10 provided that co-insurance rates may differ for different
11 types of services under the same health benefits plan;
12 E. "copayment" means a cost-sharing method that
13 requires a covered person to pay a fixed dollar amount when
14 health care services are received, with the health insurance
15 carrier paying the balance allowable amount; provided that
16 there may be different copayment requirements for different
17 types of services under the same health benefits plan;
18 F. "cost sharing" means a copayment, co-insurance,
19 deductible or any other form of financial obligation of a
20 covered person other than premium or share of premium, or any
21 combination of any of these financial obligations as defined
22 by the terms of a health benefits plan;
23 G. "covered benefits" means those health care
24 services to which a covered person is entitled under the
25 terms of a health benefits plan; SCORC/SB 337 Page 2 1 H. "covered person" means:
2 (1) an enrollee, policyholder or subscriber;
3 (2) the enrolled dependent of an enrollee,
4 policyholder or subscriber; or
5 (3) another individual participating in a
6 health benefits plan;
7 I. "deductible" means a fixed dollar amount that a
8 covered person may be required to pay during the benefit
9 period before the health insurance carrier begins payment for
10 covered benefits; provided that a health benefits plan may
11 have both individual and family deductibles and separate
12 deductibles for specific services;
13 J. "emergency care" means a health care procedure,
14 treatment or service, excluding ambulance transportation
15 service, which procedure, treatment or service is delivered
16 to a covered person after the sudden onset of what reasonably
17 appears to be a medical or behavioral health condition that
18 manifests itself by symptoms of sufficient severity,
19 including severe pain, that the absence of immediate medical
20 attention, regardless of eventual diagnosis, could be
21 expected by a reasonable layperson to result in jeopardy to a
22 person's physical or mental health or to the health or safety
23 of a fetus or pregnant person, serious impairment of bodily
24 function, serious dysfunction of a bodily organ or part or
25 disfigurement to a person; SCORC/SB 337 Page 3 1 K. "facility" means an entity providing a health
2 care service, including:
3 (1) a general, special, psychiatric or
4 rehabilitation hospital;
5 (2) an ambulatory surgical center;
6 (3) a cancer treatment center;
7 (4) a birth center;
8 (5) an inpatient, outpatient or residential
9 drug and alcohol treatment center;
10 (6) a laboratory, diagnostic or other
11 outpatient medical service or testing center;
12 (7) a health care provider's office or
13 clinic;
14 (8) an urgent care center;
15 (9) a freestanding emergency room; or
16 (10) any other therapeutic health care
17 setting;
18 L. "freestanding emergency room" means a facility
19 licensed by the department of health that is separate from an
20 acute care hospital and that provides twenty-four-hour
21 emergency care to patients at the same level of care that a
22 hospital-based emergency room delivers;
23 M. "health benefits plan" means a policy or
24 agreement entered into or offered or issued by a health
25 insurance carrier to provide, deliver, arrange for, pay for SCORC/SB 337 Page 4 1 or reimburse any of the costs of health care services;
2 provided that "health benefits plan" does not include any of
3 the following:
4 (1) an accident-only policy;
5 (2) a credit-only policy;
6 (3) a long- or short-term care or disability
7 income policy;
8 (4) a specified disease policy;
9 (5) coverage provided pursuant to Title 18
10 of the federal Social Security Act, as amended;
11 (6) coverage provided pursuant to Title 19
12 of the federal Social Security Act and the Public Assistance
13 Act;
14 (7) a federal TRICARE policy, including a
15 federal civilian health and medical program of the uniformed
16 services supplement;
17 (8) a fixed or hospital indemnity policy;
18 (9) a dental-only policy;
19 (10) a vision-only policy;
20 (11) a workers' compensation policy;
21 (12) an automobile medical payment policy;
22 or
23 (13) any other policy specified in rules of
24 the superintendent;
25 N. "health care services": SCORC/SB 337 Page 5 1 (1) means any service, supply or procedure
2 for the diagnosis, prevention, treatment, cure or relief of a
3 health condition, illness, injury or other disease, including
4 physical or behavioral health services, to the extent offered
5 by a health benefits plan; and
6 (2) does not mean ambulance transportation
7 services;
8 O. "health insurance carrier" means an entity
9 subject to state insurance laws, including a health insurance
10 company, a health maintenance organization, a hospital and
11 health service corporation, a provider service network, a
12 nonprofit health care plan or any other entity that contracts
13 or offers to contract, or enters into agreements to provide,
14 deliver, arrange for, pay for or reimburse any costs of
15 health care services or that provides, offers or administers
16 a health benefit policy or managed health care plan in the
17 state;
18 P. "hospital" means a facility offering inpatient
19 health care services, nursing care and overnight care for
20 three or more individuals on a twenty-four-hours-per-day,
21 seven-days-per-week basis for the diagnosis and treatment of
22 physical, behavioral or rehabilitative health conditions;
23 Q. "inducement" means the act or process of
24 enticing or persuading another person to take a certain
25 course of action; SCORC/SB 337 Page 6 1 R. "network" means the group or groups of
2 participating providers that have been contracted to provide
3 health care services under a network plan;
4 S. "network plan" means a health benefits plan
5 that either requires a covered person to use or creates
6 incentives, including financial incentives, for a covered
7 person to use providers and facilities managed, owned, under
8 contract with or employed by the health insurance carrier
9 offering the health benefits plan;
10 T. "nonparticipating provider" means a provider
11 who is not a participating provider;
12 U. "participating provider" means a provider or
13 facility that, under express contract with a health insurance
14 carrier or with a health insurance carrier's contractor or
15 subcontractor, has agreed to provide health care services to
16 covered persons, with an expectation of receiving payment
17 directly or indirectly from the health insurance carrier,
18 subject to cost sharing;
19 V. "prior authorization" means a pre-service
20 determination made by a health insurance carrier regarding a
21 covered person's eligibility for services, medical necessity,
22 benefit coverage and the location or appropriateness of
23 services, pursuant to the terms of a health benefits plan
24 that the health insurance carrier offers;
25 W. "provider" means a health care professional, SCORC/SB 337 Page 7 1 hospital or other facility licensed to furnish health care
2 services;
3 X. "stabilize" means to provide emergency care to
4 a patient as may be necessary to ensure, within reasonable
5 medical probability, that no material deterioration of the
6 condition is likely to result from or occur during the
7 transfer of the patient to a facility or, with respect to
8 emergency labor, to deliver, including the delivery of a
9 placenta; and
10 Y. "surprise bill":
11 (1) means a bill that a nonparticipating
12 provider issues to a covered person for health care services
13 rendered in the following circumstances, in an amount that
14 exceeds the covered person's cost-sharing obligation that
15 would apply for the same health care services if these
16 services had been provided by a participating provider:
17 (a) emergency care provided by the
18 nonparticipating provider; or
19 (b) health care services, that are not
20 emergency care, rendered by a nonparticipating provider at a
21 participating facility where: 1) a participating provider is
22 unavailable; 2) a nonparticipating provider renders
23 unforeseen services; or 3) a nonparticipating provider
24 renders services for which the covered person has not given
25 specific consent for that nonparticipating provider to render SCORC/SB 337 Page 8 1 the particular services rendered; and
2 (2) does not mean a bill:
3 (a) for health care services received
4 by a covered person when a participating provider was
5 available to render the health care services and the covered
6 person knowingly elected to obtain the services from a
7 nonparticipating provider without prior authorization; or
8 (b) received for health care services
9 rendered by a nonparticipating provider to a covered person
10 whose coverage is provided pursuant to a preferred provider
11 plan; provided that the health care services are not provided
12 as emergency care or for services rendered pursuant to
13 Subparagraph (b) of Paragraph (1) of this subsection."
14 SECTION 3. A new section of the New Mexico Insurance
15 Code is enacted to read:
16 "EMERGENCY CARE--REIMBURSEMENT--LIMITATION ON CHARGES.--
17 A. A health insurance carrier shall reimburse a
18 nonparticipating provider for emergency care necessary to
19 evaluate and stabilize a covered person if a prudent
20 layperson would reasonably believe that emergency care is
21 necessary, regardless of eventual diagnosis.
22 B. A health insurance carrier shall not require
23 that prior authorization for emergency care be obtained by,
24 or on behalf of, a covered person prior to the point of
25 stabilization of that covered person if a prudent layperson SCORC/SB 337 Page 9 1 would reasonably believe that the covered person requires
2 emergency care.
3 C. A health insurance carrier may impose a
4 cost-sharing or limitation of benefits requirement for
5 emergency care performed by a nonparticipating provider only
6 to the same extent that the copayment, co-insurance or
7 limitation of benefits requirement applies for participating
8 providers and is documented in the policy.
9 D. A health insurance carrier may require an
10 emergency care provider to notify a health insurance carrier
11 of a covered person's admission to the hospital within a
12 reasonable time period after the covered person has been
13 stabilized."
14 SECTION 4. A new section of the New Mexico Insurance
15 Code is enacted to read:
16 "NON-EMERGENCY CARE--LIMITATION ON CHARGES.--
17 A. Other than applicable cost sharing that would
18 apply if a participating provider had rendered the same
19 services, a health insurance carrier shall provide
20 reimbursement for and a covered person shall not be liable
21 for charges and fees for covered non-emergency care rendered
22 by a nonparticipating provider that are delivered when:
23 (1) the covered person at an in-network
24 facility does not have the ability or opportunity to choose a
25 participating provider who is available to provide the SCORC/SB 337 Page 10 1 covered services; or
2 (2) medically necessary care is unavailable
3 within a health benefits plan's network; provided that
4 "medical necessity" shall be determined by a covered person's
5 provider in conjunction with the covered person's health
6 benefits plan and health insurance carrier.
7 B. Except as set forth in Subsection A of this
8 section, nothing in this section shall preclude a
9 nonparticipating provider from balance billing for non-
10 emergency care provided by a nonparticipating provider to an
11 individual who has knowingly chosen to receive services from
12 that nonparticipating provider."
13 SECTION 5. A new section of the New Mexico Insurance
14 Code is enacted to read:
15 "CREDIT AGAINST MAXIMUM OUT-OF-POCKET COST-SHARING
16 AMOUNT--COMMUNICATION BY HOSPITALS--ADVANCE NOTIFICATION OF
17 CHARGES FOR HEALTH CARE SERVICES.--
18 A. A nonparticipating provider shall not knowingly
19 submit a surprise bill to a covered person.
20 B. In accordance with the hearing procedures
21 established pursuant to the Patient Protection Act, a covered
22 person may appeal a health insurance carrier's determination
23 made regarding a surprise bill.
24 C. By July 1, 2020, the department of health shall
25 require each health facility licensed pursuant to the Public SCORC/SB 337 Page 11 1 Health Act to post the following on the health facility's
2 website in a publicly accessible manner:
3 (1) the names and hyperlinks for direct
4 access to the websites of all health insurance carriers with
5 which the hospital has a contract for services;
6 (2) a statement that sets forth the
7 following:
8 (a) services may be performed in the
9 hospital by participating providers as well as
10 nonparticipating providers who may separately bill the
11 patient;
12 (b) providers that perform health care
13 services in the hospital may or may not participate in the
14 same health benefits plans as the hospital; and
15 (c) prospective patients should contact
16 their health insurance carriers in advance of receiving
17 services at that hospital to determine whether the scheduled
18 health care services provided in that hospital will be
19 covered at in-network rates;
20 (3) the rights of covered persons under the
21 Surprise Billing Protection Act; and
22 (4) instructions for contacting the
23 superintendent.
24 D. Any written communication, other than a receipt
25 of payment, from a provider or health insurance carrier SCORC/SB 337 Page 12 1 pertaining to a surprise bill, shall clearly state that the
2 covered person is responsible only for payment of applicable
3 in-network cost-sharing amounts under the covered person's
4 health benefits plan. A collection agency collecting medical
5 debt from New Mexico residents shall post a notice of
6 consumer rights pursuant to the Surprise Billing Protection
7 Act on its website.
8 E. When a nonparticipating provider under
9 nonemergency circumstances has advance knowledge that the
10 nonparticipating provider is not contracted with the covered
11 person's health insurance carrier, the nonparticipating
12 provider shall inform the covered person of the
13 nonparticipating provider's nonparticipating status and
14 advise the covered person to contact the covered person's
15 health insurance carrier to discuss the covered person's
16 options."
17 SECTION 6. A new section of the New Mexico Insurance
18 Code is enacted to read:
19 "COVERED PERSONS--PROVIDERS--OVERPAYMENT.--
20 A. If a covered person pays a nonparticipating
21 provider more than the in-network cost-sharing amount for
22 services provided under circumstances giving rise to a
23 surprise bill, the nonparticipating provider shall refund to
24 the covered person within forty-five calendar days of receipt
25 of payment from the health insurance carrier any amount paid SCORC/SB 337 Page 13 1 in excess of the in-network cost-sharing amount.
2 B. If a nonparticipating provider has not made a
3 full refund to the covered person of any amount paid in
4 excess of the in-network cost-sharing amount to the covered
5 person within forty-five calendar days of receipt, interest
6 shall accrue at the rate set for payment of interest on a
7 health plan's liability for clean claims submitted by
8 eligible providers to a health plan pursuant to Chapter 59A,
9 Article 16 NMSA 1978.
10 C. A covered person may seek recovery of the
11 refund of the amount the covered person has paid in excess of
12 the in-network cost-sharing amount that a nonparticipating
13 provider owes, plus interest, pursuant to Subsection B of
14 this section by filing an appeal with the office of
15 superintendent of insurance. The superintendent of insurance
16 shall develop an appeals process pursuant to this section."
17 SECTION 7. A new section of the New Mexico Insurance
18 Code is enacted to read:
19 "NONPARTICIPATING PROVIDERS--REBATES AND
20 INDUCEMENTS--PROHIBITION.--A nonparticipating provider shall
21 not, either directly or indirectly, knowingly waive, rebate,
22 give, pay or offer to waive, rebate, give or pay all or part
23 of a cost-sharing amount owed by a covered person pursuant to
24 the terms of the covered person's health benefits plan as an
25 inducement for the covered person to seek a health care SCORC/SB 337 Page 14 1 service from that nonparticipating provider. The
2 superintendent may impose fines on providers for unlawful
3 rebates and inducements; provided that a provider on which
4 the superintendent intends to impose a fine shall be entitled
5 to a hearing in accordance with the provisions of Section
6 59A-4-15 NMSA 1978."
7 SECTION 8. A new section of the New Mexico Insurance
8 Code is enacted to read:
9 "HEALTH CARE PROVIDER REIMBURSEMENT RATES--SURPRISE
10 BILLING.--
11 A. The superintendent shall convene appropriate
12 stakeholders, including rural providers, insurers and
13 consumer advocates, and review the reimbursement rate for
14 surprise bills annually to ensure fairness to providers and
15 to evaluate the impact on health insurance premiums and
16 health benefits plan networks.
17 B. Calculation of the date of health insurance
18 carrier receipt of a claim shall align with requirements for
19 prompt payment established pursuant to Section 59A-16-21.1
20 NMSA 1978.
21 C. A health insurance carrier shall make available
22 to providers access to claims status information."
23 SECTION 9. A new section of the New Mexico Insurance
24 Code is enacted to read:
25 "REASONABLE HEALTH CARE COST MANAGEMENT SCORC/SB 337 Page 15 1 PERMITTED.--Nothing in the Surprise Billing Protection Act
2 shall be construed to prohibit a health insurance carrier
3 from appropriately using reasonable health care cost
4 management techniques."
5 SECTION 10. A new section of the New Mexico Insurance
6 Code is enacted to read:
7 "PRIVATE CAUSE OF ACTION.--Except as provided in
8 Subsection C of Section 6 of the Surprise Billing Protection
9 Act, nothing in that act shall be construed to create or
10 imply a private cause of action for a violation of that act."
11 SECTION 11. A new section of the New Mexico Insurance
12 Code is enacted to read:
13 "INFORMATION FROM PROVIDER NETWORKS.--The
14 superintendent:
15 A. may require that health insurance carriers
16 report the annual percentage of claims and expenditures paid
17 to nonparticipating providers for health care services; and
18 B. may require by rule a report on changes to the
19 percent of claims paid as an emergency claim."
20 SECTION 12. A new section of the New Mexico Insurance
21 Code is enacted to read:
22 "APPLICABILITY.--The provisions of the Surprise Billing
23 Protection Act apply to the following types of health
24 coverage delivered or issued for delivery in this state:
25 A. group health coverage governed by the SCORC/SB 337 Page 16 1 provisions of the Health Care Purchasing Act;
2 B. individual health insurance policies, health
3 benefits plans and certificates of insurance governed by the
4 provisions of Chapter 59A, Article 22 NMSA 1978;
5 C. multiple-employer welfare arrangements governed
6 by the provisions of Section 59A-15-20 NMSA 1978;
7 D. group and blanket health insurance policies,
8 health benefits plans and certificates of insurance governed
9 by the provisions of Chapter 59A, Article 23 NMSA 1978;
10 E. individual and group health maintenance
11 organization contracts governed by the provisions of the
12 Health Maintenance Organization Law; and
13 F. individual and group nonprofit health benefits
14 plans governed by the provisions of the Nonprofit Health Care
15 Plan Law."
16 SECTION 13. A new section of the New Mexico Insurance
17 Code is enacted to read:
18 "PROVIDERS--REIMBURSEMENT FOR A SURPRISE BILL.--
19 A. For services provided pursuant to Section 3 or
20 4 of the Surprise Billing Protection Act, a health insurance
21 carrier shall directly reimburse a nonparticipating provider
22 for care rendered the surprise bill reimbursement rate for
23 services.
24 B. The surprise bill reimbursement rate shall be
25 calculated using claims data reflecting the allowed amounts SCORC/SB 337 Page 17 1 paid for claims paid in the 2017 plan year.
2 C. As used in this section, "surprise bill
3 reimbursement rate" means the sixtieth percentile of the
4 allowed commercial reimbursement rate for the particular
5 health care service performed by a provider in the same or
6 similar specialty in the same geographic area, as reported in
7 a benchmarking database maintained by a nonprofit
8 organization specified by the superintendent after
9 consultation with health care sector stakeholders; provided
10 that no surprise bill reimbursement rate shall be paid at
11 less than one hundred fifty percent of the 2017 medicare
12 reimbursement rate for the applicable health care service
13 provided.
14 D. The nonprofit organization shall be
15 conflict-free and unaffiliated with any stakeholder in the
16 health care sector."
17 SECTION 14. A new section of Chapter 59A, Article 16
18 NMSA 1978 is enacted to read:
19 "HEALTH CARE PROVIDERS--SURPRISE BILLING PROHIBITED.--
20 A. A provider shall not knowingly submit to a
21 covered person a surprise bill for health care services,
22 which surprise bill demands payment for any amount in excess
23 of the cost-sharing amounts that would have been imposed by
24 the covered person's health benefits plan if the health care
25 service from which the surprise bill arises had been rendered SCORC/SB 337 Page 18 1 by a participating provider.
2 B. It shall be an unfair practice for a health
3 care provider to knowingly submit a surprise bill to a
4 collection agency.
5 C. As used in this section:
6 (1) "covered person" means:
7 (a) an enrollee, policyholder or
8 subscriber;
9 (b) the enrolled dependent of an
10 enrollee, policyholder or subscriber; or
11 (c) another individual participating in
12 a health benefits plan;
13 (2) "emergency care" means a health care
14 procedure, treatment or service, excluding ambulance
15 transportation service, which procedure, treatment or service
16 is delivered to a covered person after the sudden onset of
17 what reasonably appears to be a medical or behavioral health
18 condition that manifests itself by symptoms of sufficient
19 severity, including severe pain, that the absence of
20 immediate medical attention, regardless of eventual
21 diagnosis, could be expected by a reasonable layperson to
22 result in jeopardy to a person's physical or mental health or
23 to the health or safety of a fetus or pregnant person,
24 serious impairment of bodily function, serious dysfunction of
25 a bodily organ or part or disfigurement to a person; SCORC/SB 337 Page 19 1 (3) "facility" means an entity providing a
2 health care service, including:
3 (a) a general, special, psychiatric or
4 rehabilitation hospital;
5 (b) an ambulatory surgical center;
6 (c) a cancer treatment center;
7 (d) a birth center;
8 (e) an inpatient, outpatient or
9 residential drug and alcohol treatment center;
10 (f) a laboratory, diagnostic or other
11 outpatient medical service or testing center;
12 (g) a health care provider's office or
13 clinic;
14 (h) an urgent care center;
15 (i) a freestanding emergency room; or
16 (j) any other therapeutic health care
17 setting;
18 (4) "freestanding emergency room" means a
19 facility licensed by the department of health that is
20 separate from an acute care hospital and that provides
21 twenty-four-hour emergency care to patients at the same level
22 of care that a hospital-based emergency room delivers;
23 (5) "health benefits plan" means a policy or
24 agreement entered into, offered or issued by a health
25 insurance carrier to provide, deliver, arrange for, pay for SCORC/SB 337 Page 20 1 or reimburse any of the costs of health care services;
2 provided that "health benefits plan" does not include any of
3 the following:
4 (a) an accident-only policy;
5 (b) a credit-only policy;
6 (c) a long- or short-term care or
7 disability income policy;
8 (d) a specified disease policy;
9 (e) coverage provided pursuant to Title
10 18 of the federal Social Security Act, as amended;
11 (f) coverage provided pursuant to Title
12 19 of the federal Social Security Act and the Public
13 Assistance Act;
14 (g) a federal TRICARE policy, including
15 a federal civilian health and medical program of the
16 uniformed services supplement;
17 (h) a fixed or hospital indemnity
18 policy;
19 (i) a dental-only policy;
20 (j) a vision-only policy;
21 (k) a workers' compensation policy;
22 (l) an automobile medical payment
23 policy; or
24 (m) any other policy specified in rules
25 of the superintendent; SCORC/SB 337 Page 21 1 (6) "health care services":
2 (a) means any service, supply or
3 procedure for the diagnosis, prevention, treatment, cure or
4 relief of a health condition, illness, injury or other
5 disease, including physical or behavioral health services, to
6 the extent offered by a health benefits plan; and
7 (b) does not mean ambulance
8 transportation services;
9 (7) "health insurance carrier" means an
10 entity subject to state insurance laws, including a health
11 insurance company, a health maintenance organization, a
12 hospital and health service corporation, a provider service
13 network, a nonprofit health care plan or any other entity
14 that contracts or offers to contract, or enters into
15 agreements to provide, deliver, arrange for, pay for or
16 reimburse any costs of health care services or that provides,
17 offers or administers a health benefit policy or managed
18 health care plan in the state;
19 (8) "hospital" means a facility offering
20 inpatient health care services, nursing care and overnight
21 care for three or more individuals on a
22 twenty-four-hours-per-day, seven-days-per-week basis for the
23 diagnosis and treatment of physical, behavioral or
24 rehabilitative health conditions;
25 (9) "nonparticipating provider" means a SCORC/SB 337 Page 22 1 provider who is not a participating provider;
2 (10) "participating provider" means a
3 provider or facility that, under express contract with a
4 health insurance carrier or with a health insurance carrier's
5 contractor or subcontractor, has agreed to provide health
6 care services to covered persons, with an expectation of
7 receiving payment directly or indirectly from the health
8 insurance carrier, subject to cost sharing;
9 (11) "prior authorization" means a
10 pre-service determination made by a health insurance carrier
11 regarding a covered person's eligibility for health care
12 services, medical necessity, benefit coverage and the
13 location or appropriateness of services, pursuant to the
14 terms of a health benefits plan that the health insurance
15 carrier offers;
16 (12) "provider" means a health care
17 professional, hospital or other facility licensed to furnish
18 health care services; and
19 (13) "surprise bill":
20 (a) means a bill that a
21 nonparticipating provider issues to a covered person for
22 health care services rendered in the following circumstances,
23 in an amount that exceeds the covered person's cost-sharing
24 obligation that would apply for the same health care services
25 if these services had been provided by a participating SCORC/SB 337 Page 23 1 provider: 1) emergency care provided by the nonparticipating
2 provider; or 2) health care services, that are not emergency
3 care, rendered by a nonparticipating provider at a
4 participating facility where a: participating provider is
5 unavailable; a nonparticipating provider renders unforeseen
6 services; or a nonparticipating provider renders services for
7 which the covered person has not given specific consent for
8 that nonparticipating provider to render the particular
9 services rendered; and
10 (b) does not mean a bill: 1) for
11 health care services received by a covered person when a
12 participating provider was available to render the health
13 care services and the covered person knowingly elected to
14 obtain the services from a nonparticipating provider without
15 prior authorization; or 2) received for health care services
16 rendered by a nonparticipating provider to a covered person
17 whose coverage is provided pursuant to a preferred provider
18 plan; provided that the health care services are not provided
19 as emergency care."
20 SECTION 15. DELAYED REPEAL.--Section 13 of this act is
21 repealed effective July 1, 2023.
22 SECTION 16. EFFECTIVE DATE.--The effective date of the
23 provisions of this act is January 1, 2020. SCORC/SB 337 Page 24 24
25