This document includes House Floor Amendments incorporated into the bill on Mon, Mar 6, 2017 at 7:29 PM by jeyring.
Representative James A. Dunnigan proposes the following substitute bill:




Chief Sponsor: James A. Dunnigan

Senate Sponsor: Brian E. Shiozawa


8     General Description:
9          This bill amends the Insurance Code and health care provider licensing laws related to
10     health care provider network adequacy and payment for out of network emergency
11     department services.
12     Highlighted Provisions:
13          This bill:
14          ▸     effective January 1, 2018:
15               •     establishes provider network adequacy standards for managed care
16     organizations;
17               •     establishes standards for provider directories;
18               •     establishes standards for state regulated insurers to reimburse health care
19     providers who provide out of network emergency services or post stabilization
20     care to an enrollee;
21               •     prohibits a health care provider who provides out-of-network emergency
22     services to an enrollee of a state regulated plan, an ERISA plan, or a self funded
23     plan, and who receives payment directly from the payor, from balance billing in
24     excess of a cap;
25               •     requires a health care provider to give an enrollee notice of certain rights if the

26     health care provider sends an enrollee a bill for emergency services; and
27               •     makes it a violation of licensing laws for a health care provider to balance bill
28     an enrollee under certain circumstances;
29          ▸     exempts a non-network provider who does not balance bill as of January 1, 2017,
30     from the reimbursement and balance billing requirements;
31          ▸     exempts a health care provider from balance billing restrictions if the health care
32     provider is licensed under Title 58, Division of Occupational and Professional
33     Licensing, and if the provider's practice is substantially emergency services
34     provided in a hospital emergency department;
35          ▸     requires the insurance commissioner to report to the Legislature's Business and
36     Labor Interim Committee by November 2019 regarding emergency service
37     reimbursement and balance billing;
38          ▸     sunsets the non-network emergency services provisions on January 1, 2021; and
39          ▸     makes technical amendments and conforming amendments.
40     Money Appropriated in this Bill:
41          None
42     Other Special Clauses:
43          This bill provides a special effective date.
44     Utah Code Sections Affected:
45     AMENDS:
46          31A-8-101, as last amended by Laws of Utah 2002, Chapter 308
47          31A-8-105, as last amended by Laws of Utah 1998, Chapter 329
48          31A-8-213, as last amended by Laws of Utah 2007, Chapter 309
49          31A-22-618.5, as last amended by Laws of Utah 2014, Chapters 290 and 300
50          63I-2-231, as last amended by Laws of Utah 2016, Chapter 138
51     ENACTS:
52          26-21-30, Utah Code Annotated 1953
53          31A-22-645, Utah Code Annotated 1953
54          31A-22-646, Utah Code Annotated 1953
55          31A-22-647, Utah Code Annotated 1953
56          58-1-509, Utah Code Annotated 1953

57     REPEALS:
58          31A-8-104, as last amended by Laws of Utah 1997, Chapter 185
59          31A-8-408, as last amended by Laws of Utah 2002, Chapter 308

61     Be it enacted by the Legislature of the state of Utah:
62          Section 1. Section 26-21-30 is enacted to read:
63          26-21-30. Violation of chapter.
64          (1) For purposes of this section:
65          (a) "Balanced billing" means the same as that term is defined in Section 31A-22-645.
66          (b) "Emergency services" means the same as that term is defined in Section
67     31A-22-645.
68          (2) Beginning January 1, 2018, it is a violation of this chapter for a health care facility
69     to balance bill a patient for emergency services in violation of Section 31A-22-647.
70          (3) A health care facility that violates this section is subject to Section 26-21-11.
71          Section 2. Section 31A-8-101 is amended to read:
72          31A-8-101. Definitions.
73          For purposes of this chapter:
74          (1) "Basic health care services" means:
75          (a) emergency care;
76          (b) inpatient hospital and physician care;
77          (c) outpatient medical services; and
78          (d) out-of-area coverage.
79          (2) "Director of health" means:
80          (a) the executive director of the Department of Health; or
81          (b) the authorized representative of the executive director of the Department of Health.
82          (3) "Enrollee" means an individual:
83          (a) who has entered into a contract with an organization for health care; or
84          (b) in whose behalf an arrangement for health care has been made.
85          (4) "Health care" is as defined in Section 31A-1-301.
86          (5) "Health maintenance organization" means any person:
87          (a) other than:

88          (i) an insurer licensed under Chapter 7, Nonprofit Health Service Insurance
89     Corporations; or
90          (ii) an individual who contracts to render professional or personal services that the
91     individual directly performs; and
92          (b) that:
93          (i) furnishes at a minimum, either directly or through arrangements with others, basic
94     health care services to an enrollee in return for prepaid periodic payments agreed to in amount
95     prior to the time during which the health care may be furnished; and
96          (ii) is obligated to the enrollee to arrange for or to directly provide available and
97     accessible health care.
98          (6) (a) "Limited health plan" means, except as limited under Subsection (6)(b), any
99     person who furnishes, either directly or through arrangements with others, services:
100          (i) of:
101          (A) dentists;
102          (B) optometrists;
103          (C) physical therapists;
104          (D) podiatrists;
105          (E) psychologists;
106          (F) physicians;
107          (G) chiropractic physicians;
108          (H) naturopathic physicians;
109          (I) osteopathic physicians;
110          (J) social workers;
111          (K) family counselors;
112          (L) other health care providers; or
113          (M) reasonable combinations of the services described in this Subsection (6)(a)(i);
114          (ii) to an enrollee;
115          (iii) in return for prepaid periodic payments agreed to in amount prior to the time
116     during which the services may be furnished; and
117          (iv) for which the person is obligated to the enrollee to arrange for or directly provide
118     the available and accessible services described in this Subsection (6)(a).

119          (b) "Limited health plan" does not include:
120          (i) a health maintenance organization;
121          (ii) an insurer licensed under Chapter 7, Nonprofit Health Service Insurance
122     Corporations; or
123          (iii) an individual who contracts to render professional or personal services that the
124     individual performs.
125          (7) (a) "Nonprofit organization" or "nonprofit corporation" means an organization no
126     part of the income of which is distributable to its members, trustees, or officers, or a nonprofit
127     cooperative association, except in a manner allowed under Section 31A-8-406.
128          (b) "Nonprofit health maintenance organization" and "nonprofit limited health plan"
129     are used when referring specifically to one of the types of organizations with "nonprofit" status.
130          (8) "Organization" means a health maintenance organization and limited health plan,
131     unless used in the context of:
132          (a) "organization permit," which is described in Sections 31A-8-204 and 31A-8-206; or
133          (b) "organization expenses," which is described in Section 31A-8-208.
134          (9) "Participating provider" means a provider as defined in Subsection (10) who, under
135     a contract with the health maintenance organization, agrees to provide health care services to
136     enrollees with an expectation of receiving payment, directly or indirectly, from the health
137     maintenance organization, other than copayment.
138          (10) "Provider" means any person who:
139          (a) furnishes health care directly to the enrollee; and
140          (b) is licensed or otherwise authorized to furnish the health care in this state.
141          (11) "Uncovered expenditures" means the costs of health care services that are covered
142     by an organization for which an enrollee is liable in the event of the organization's insolvency.
143          [(12) "Unusual or infrequently used health services" means those health services that
144     are projected to involve fewer than 10% of the organization's enrollees' encounters with
145     providers, measured on an annual basis over the organization's entire enrollment.]
146          Section 3. Section 31A-8-105 is amended to read:
147          31A-8-105. General powers of organizations.
148          Organizations may:
149          (1) buy, sell, lease, encumber, construct, renovate, operate, or maintain hospitals,

150     health care clinics, other health care facilities, and other real and personal property incidental to
151     and reasonably necessary for the transaction of the business and for the accomplishment of the
152     purposes of the organization;
153          (2) furnish health care through providers which are under contract with the
154     organization;
155          (3) contract with insurance companies licensed in this state or with health service
156     corporations authorized to do business in this state for insurance, indemnity, or reimbursement
157     for the cost of health care furnished by the organization;
158          (4) offer to its enrollees, in addition to health care, insured indemnity benefits, but only
159     for emergency care, out-of-area coverage, [unusual or infrequently used health services as
160     defined in Section 31A-8-101,] and adoption benefits as provided in Section 31A-22-610.1;
161          (5) receive from governmental or private agencies payments covering all or part of the
162     cost of the health care furnished by the organization;
163          (6) lend money to a medical group under contract with it or with a corporation under its
164     control to acquire or construct health care facilities or for other uses to further its program of
165     providing health care services to its enrollees;
166          (7) be owned jointly by health care professionals and persons not professionally
167     licensed without violating Utah law; and
168          (8) do all other things necessary for the accomplishment of the purposes of the
169     organization.
170          Section 4. Section 31A-8-213 is amended to read:
171          31A-8-213. Certificate of authority.
172          (1) An organization may apply for a certificate of authority at any time prior to the
173     expiration of its organization permit. The application shall include:
174          (a) a detailed statement by a principal officer about any material changes that have
175     taken place or are likely to take place in the facts on which the issuance of the organization
176     permit was based; and
177          (b) if any material changes are proposed in the business plan, the information about the
178     changes that would be required if an organization permit were then being applied for.
179          (2) The commissioner shall issue a certificate of authority, if the commissioner finds
180     that:

181          (a) the organization's capital and surplus complies with the requirements of Section
182     31A-8-209 as to the operations proposed under the new certificate of authority;
183          (b) there is no basis for revoking the organization permit under Section 31A-8-207;
184          (c) the deposit required by Section 31A-8-211 has been made; and
185          [(d) the organization satisfies the requirements of Section 31A-8-104; and]
186          [(e)] (d) all other applicable requirements of the law have been met.
187          (3) The certificate of authority shall specify any limits imposed by the commissioner
188     upon the organization's business or methods of operation, including the general types of health
189     care services the organization is authorized to provide.
190          (4) Upon the issuance of the certificate of authority:
191          (a) the board shall authorize and direct the issuance of certificates for shares, bonds, or
192     notes subscribed to under the organization permit, and of insurance policies upon qualifying
193     applications obtained under the organization permit; and
194          (b) the commissioner shall authorize the release to the organization of all funds held in
195     escrow under Section 31A-5-208, as adopted by Section 31A-8-206.
196          (5) (a) An organization may at any time apply to the commissioner for a new or
197     amended certificate of authority altering the limits on its business or methods of operation.
198     The application shall contain or be accompanied by that information reasonably required by the
199     commissioner under Subsections 31A-5-204(2) and 31A-8-205(2). The commissioner shall
200     issue the new certificate as requested if the commissioner finds that the organization continues
201     to satisfy the requirements specified under Subsection (2).
202          (b) If the commissioner issues an order under Chapter 27, Part 5, Administrative
203     Actions, against an organization, the commissioner may also revoke the organization's
204     certificate and issue a new one with any limitation the commissioner considers necessary.
205          Section 5. Section 31A-22-618.5 is amended to read:
206          31A-22-618.5. Health benefit plan offerings.
207          (1) The purpose of this section is to increase the range of health benefit plans available
208     in the small group, small employer group, large group, and individual insurance markets.
209          (2) A health maintenance organization that is subject to Chapter 8, Health Maintenance
210     Organizations and Limited Health Plans:
211          (a) shall offer to potential purchasers at least one health benefit plan that is subject to

212     the requirements of Chapter 8, Health Maintenance Organizations and Limited Health Plans;
213     and
214          (b) may offer to a potential purchaser one or more health benefit plans that:
215          (i) are not subject to one or more of the following:
216          (A) the limitations on insured indemnity benefits in Subsection 31A-8-105(4);
217          [(B) the limitation on point of service products in Subsections 31A-8-408(3) through
218     (6);]
219          [(C)] (B) except as provided in Subsection (2)(b)(ii), basic health care services as
220     defined in Section 31A-8-101; or
221          [(D)] (C) coverage mandates enacted after January 1, 2009 that are not required by
222     federal law, provided that the insurer offers one plan under Subsection (2)(a) that covers the
223     mandate enacted after January 1, 2009; and
224          (ii) when offering a health plan under this section, provide coverage for an emergency
225     medical condition as required by Section 31A-22-627 as follows:
226          (A) within the organization's service area, covered services shall include health care
227     services from nonaffiliated providers when medically necessary to stabilize an emergency
228     medical condition; and
229          (B) outside the organization's service area, covered services shall include medically
230     necessary health care services for the treatment of an emergency medical condition that are
231     immediately required while the enrollee is outside the geographic limits of the organization's
232     service area.
233          (3) An insurer that offers a health benefit plan that is not subject to Chapter 8, Health
234     Maintenance Organizations and Limited Health Plans:
235          (a) may offer a health benefit plan that is not subject to Section 31A-22-618;
236          (b) when offering a health plan under this Subsection (3), shall provide coverage of
237     emergency care services as required by Section 31A-22-627; and
238          (c) is not subject to coverage mandates enacted after January 1, 2009 that are not
239     required by federal law, provided that an insurer offers one plan that covers a mandate enacted
240     after January 1, 2009.
241          (4) Section 31A-8-106 does not prohibit the offer of a health benefit plan under
242     Subsection (2)(b).

243          (5) (a) Any difference in price between a health benefit plan offered under Subsections
244     (2)(a) and (b) shall be based on actuarially sound data.
245          (b) Any difference in price between a health benefit plan offered under Subsection
246     (3)(a) shall be based on actuarially sound data.
247          (6) Nothing in this section limits the number of health benefit plans that an insurer may
248     offer.
249          Section 6. Section 31A-22-645 is enacted to read:
250          31A-22-645. Access to managed care organization health care providers.
251          (1) As used in this section and Sections 31A-22-646 and 31A-22-647:
252          (a) (i) "Balance billing" means the practice of a health care provider billing an enrollee
253     for the difference between the health care provider's charge and the managed care
254     organization's allowed amount.
255          (ii) "Balance billing" does not include billing an enrollee for cost sharing required by
256     the enrollee's plan, such as copayments, coinsurance, and deductibles.
257          (b) "Covered benefit" or "benefit" means the health care services to which a covered
258     person is entitled under the terms of a health benefit plan.
259          (c) "Emergency medical condition" means the same as that term is defined in Section
260     31A-22-627.
261          (d) "Emergency services" means, with respect to an emergency condition:
262          (i) a medical or mental health screening examination that is within the capability of the
263     emergency department of a hospital, including ancillary services routinely available to the
264     emergency department to evaluate the emergency medical condition; and
265          (ii) any further medical or mental health examination and treatment, to the extent the
266     treatment or examination is within the capabilities of the emergency department and the staff,
267     to stabilize the patient.
268          (e) "Managed care organization" means:
269          (i) a managed care organization as that term is defined in Section 31A-1-103; and
270          (ii) a third-party administrator as that term is defined in Section 31A-1-103.
271          (f) (i) "Post stabilization care" includes services related to emergency services that:
272          (A) are provided by a health care provider other than providers listed in Subsection
273     (1)(f)(ii), and are provided after an enrollee's condition is no longer considered an emergency

274     medical condition;
275          (B) maintain a stabilized condition or improve or resolve the enrollee's condition; and
276          (C) are provided within 90 consecutive days after the day the enrollee experienced the
277     emergency medical condition.
278          (ii) "Post stabilization care" does not include health care facility charges or laboratory
279     charges.
280          (g) "Stabilize" means the same as that term is defined in 42 U.S.C. Sec. 1395dd(e)(3).
281          (2) A managed care organization offering or administering a network plan shall
282     maintain a network that is sufficient in numbers and appropriate types of providers, including
283     those that serve predominantly low-income, medically underserved individuals, to ensure that
284     all services to enrollees, including children and adults, will be accessible without unreasonable
285     travel or delay.
286          (3) An enrollee under a managed care organization's network plan shall have access to
287     emergency services 24 hours per day, seven days per week.
288          (4) (a) Upon the request of the commissioner, a managed care organization providing a
289     network plan shall demonstrate to the commissioner, in accordance with Subsection (4)(b), that
290     the managed care organization is able to provide adequate access to current and potential
291     enrollees through a contracted network of providers and facilities for all counties within the
292     managed care organization's filed service area.
293          (b) Adequate access is demonstrated if the managed care organization demonstrates
294     compliance with Subsection (4)(c) or (d).
295          (c) A managed care organization demonstrates network adequacy if the managed care
296     network meets the maximum travel time and distance standards in, and has sufficient numbers
297     of, health care professionals, providers, and facilities to meet the minimum number of
298     requirements set forth by:
299          (i) the Centers for Medicare and Medicaid Services for Medicare Advantage Plans; and
300          (ii) modifications to the standards in Subsection (4)(c)(i), adopted by the commissioner
301     by administrative rule, as necessary to reflect the age demographics of the enrollees in the plans
302     and availability of rural health care providers, and based on nationally recognized standards.
303          (d) A managed care organization demonstrates network adequacy if the managed care
304     organization meets adequacy and sufficiency standards established by the commissioner by

305     administrative rule made in accordance with Title 63G, Chapter 3, Utah Administrative
306     Rulemaking Act, and this Subsection (4)(d).
307          (e) The commissioner shall adopt administrative rules in compliance with Title 63G,
308     Chapter 3, Utah Administrative Rulemaking Act, to establish reasonable standards under
309     Subsection (4)(d) for:
310          (i) provider-covered person ratios by specialty;
311          (ii) primary care professional-covered person ratios;
312          (iii) geographic accessibility of providers;
313          (iv) geographic variation and population dispersion;
314          (v) waiting times for an appointment with participating providers;
315          (vi) hours of operation;
316          (vii) the ability of the network to meet the needs of covered persons, which may
317     include low-income persons, children and adults with serious, chronic, or complex health
318     conditions or physical or mental disabilities, or persons with limited English proficiency;
319          (viii) other health care service delivery system options, such as telemedicine or
320     telehealth, mobile clinics, centers of excellence, and other ways of delivering health care;
321          (ix) the volume of technological and specialty care services available to serve the needs
322     of covered persons requiring technologically advanced or specialty care services;
323          (x) the extent to which participating providers are accepting new patients;
324          (xi) the regionalization of specialty care, which may require some children and adults
325     to cross state lines for care;
326          (xii) a number of providers within a specified area, including rural or urban areas, that
327     takes into consideration an insured's travel time and distance to providers; and
328          (xiii) the manner in which a managed care organization demonstrates compliance with
329     the criteria established under this Subsection (4).
330          (5) A managed care organization shall provide notice in writing to enrollees that for a
331     covered benefit to be provided at a facility in the enrollee's health benefit plan network, there is
332     the possibility that the enrollee could be treated by a health care provider that is not in the same
333     network, which could result in higher cost-sharing and balance billing.
334          Section 7. Section 31A-22-646 is enacted to read:
335          31A-22-646. Managed care organization provider directories.

336          (1) (a) A managed care organization shall post electronically a current and accurate
337     provider directory for each of the organization's network plans.
338          (b) In making the directory available electronically, the managed care organization
339     shall ensure the general public is able to view all of the current providers for a plan through a
340     clearly identifiable link or tab and without creating or accessing an account or entering a policy
341     or contract number.
342          (c) The managed care organization shall update each network plan provider directory at
343     least monthly. A managed care organization does not violate the requirements of this
344     Subsection (1)(c) if a provider fails to notify the managed care organization of a change to the
345     provider's information.
346          (2) A managed care organization shall make available through an electronic provider
347     directory, for each network plan, the information under this Subsection (2) in a searchable
348     format:
349          (a) for a health care provider who is licensed under Title 58, Occupations and
350     Professions:
351          (i) the health care provider's name;
352          (ii) the health care provider's gender;
353          (iii) participating office locations;
354          (iv) specialty and board certifications;
355          (v) medical group affiliations, if applicable;
356          (vi) participating facility affiliations, if applicable;
357          (vii) languages spoken, other than English, if applicable;
358          (viii) whether accepting new patients; and
359          (ix) contact information; and
360          (b) for facilities licensed under Title 26, Chapter 21, Health Care Facility Licensing
361     and Inspection Act, or Title 62A, Chapter 2, Licensure of Programs and Facilities:
362          (i) the facility name;
363          (ii) the type of facility;
364          (iii) participating facility locations;
365          (iv) facility accreditation status; and
366          (v) type of services performed for facilities other than hospitals.

367          (3) A managed care organization shall make a print copy of a current provider directory
368     available upon request of an enrollee or a prospective enrollee at least annually.
369          (4) A provider directory, whether in electronic or print format, shall accommodate the
370     communication needs of individuals with disabilities, and include a link to or information
371     regarding available assistance for persons with limited English proficiency.
372          Section 8. Section 31A-22-647 is enacted to read:
373          31A-22-647. Managed care organization out-of-network services -- Emergency
374     services -- Post stabilization care -- Balance billing.
375          (1) (a) A managed care organization shall have a process to ensure that an enrollee
376     obtains covered services at a network level of benefits, including a network level of cost
377     sharing, from a non-network provider, or shall make other arrangements acceptable to the
378     commissioner:
379          (i) in accordance with Section 31A-22-645; and
380          (ii) (A) when an enrollee is diagnosed with a condition or disease that requires
381     specialized health care services; and
382          (B) when the managed care organization does not have a network provider of the
383     required specialty with the professional training and expertise to treat or provide the health care
384     services for the condition or disease, or cannot provide reasonable access to a network provider
385     with the required training or expertise to treat or provide health care services for the condition
386     or disease.
387          (b) A managed care organization shall:
388          (i) inform an enrollee of the process the enrollee may use to request access to obtain a
389     covered benefit from a non-network provider in accordance with Subsection (1)(a);
390          (ii) have a system in place that documents all requests to obtain covered benefits from
391     a non-network provider under Subsection (1)(a); and
392          (iii) ensure that requests to obtain a covered benefit from a non-network provider under
393     Subsection (1)(a) are addressed in a timely fashion appropriate to the covered person's
394     condition.
395          (2) (a) Except for a health care provider who is exempt under Subsection (8), a
396     managed care organization shall reimburse a non-network provider for emergency services and
397     post stabilization care in accordance with this section.

398          (b) A managed care organization shall:
399          (i) accept assignment of benefits from an enrollee for emergency services and post
400     stabilization care provided by a non-network provider; and
401          (ii) send an explanation of benefits to the non-network provider with the information
402     required under Subsection (5)(a).
403          (c) A managed care organization shall pay a non-network provider for emergency
404     services the greater of the amount required in 45 C.F.R. Sec. 147.138 Ĥ→ [
, plus 5% of that
404a     amount
] ←Ĥ .
405          (d) Payment to a non-network provider for post stabilization care shall be the greater
406     of:
407          (i) the payment required under the applicable provisions of 45 C.F.R. Sec. 147.138; or
408          (ii) 100% of the in-network allowed amount for the patient's managed care
409     organization plan.
410          (3) Ĥ→ [
(a) Except as provided in Subsection (8), a non-network provider who receives
411     payment directly from a payor may not balance bill that payor's enrollee in excess of the
412     amount under this Subsection (3).
413          (b) A non-network provider may balance bill an enrollee for emergency services in an
414     amount that is the lesser of:
415          (i) 10% above the amount allowed under Subsection (2)(c) for the emergency services;
416     or
417          (ii) $5,000.
] (a) As used in this Subsection (3), "allowed charges benchmark" means the

417a     70th percentile of the distribution of payments made by insurers for an emergency service
417b     provided within a market area, as determined by a database of insurance claims designated by
417c     the commissioner.
417d          (b) Except as provided in Subsection (8), a non-network provider who is reimbursed
417e     under Subsection (2)(c) may not balance bill an enrollee in excess of the amount under this
417f     Subsection (3).
417g          (c) A non-network provider may balance bill an enrollee for an emergency service in an
417h     amount not to exceed the allowed charges benchmark for the service for the market area in
417i     which the service was performed less any amounts already paid for the service by the managed
417j     care organization or the enrollee.
417k          (d) The commissioner shall make rules in accordance with Title 63G, Chapter 3, Utah
417l     Administrative Rulemaking Act:
417m               (i) designating a database of insurance claims data to be used for determining
417n     allowed charges benchmarks, which shall be a database:
417o               (A) developed and maintained in accordance with sound methodologies; and
417p               (B) provided by an independent nonprofit corporation that collects medical and
417q     dental insurance claims data nationwide and is able to provide allowed charges benchmarks
417r     for multiple market areas within Utah; and
417s               (ii) specifying how market areas shall be determined for purposes of establishing
417t     allowed charges benchmarks for emergency services provided within Utah. ←Ĥ
418          (c) A non-network provider may not balance bill an enrollee for post stabilization care.
419          (4) (a) A managed care organization may elect to pay a non-network provider for
420     emergency services or post stabilization care:
421          (i) as submitted by the provider;
422          (ii) in accordance with the benchmark established in Subsection (2)(c) or (2)(d); or
423          (iii) in an amount mutually agreed upon by the managed care organization and the
424     provider.
425          (b) This section does not preclude a managed care organization and a non-network
426     provider from agreeing to a different payment arrangement if:
427          (i) except as provided in Subsection (8), the enrollee is responsible for no more than:
428          (A) the applicable in-network cost-sharing amount; and

429          (B) the balance bill amount allowed under Subsection (3); and
430          (ii) except as provided in Subsection (8), the enrollee has no legal obligation to pay the
431     balance for emergency services or post stabilization care remaining after the payments under
432     Subsection (4)(b)(i).
433          (c) If a non-network provider sends a bill directly to an enrollee for emergency services
434     or post stabilization care, the bill shall notify the enrollee:
435          (i) that the emergency services or post stabilization care were performed by a provider
436     who is not a network provider for the enrollee's health benefit plan;
437          (ii) that the enrollee is responsible for paying the enrollee's applicable in-network cost
438     sharing amount and the additional balance bill allowed under Subsection (3);
439          (iii) whether the enrollee has an obligation to pay the remaining balance for the
440     emergency services;
441          (iv) whether the non-network provider claims an exemption under Subsection (8); and
442          (v) that the enrollee may contact the state insurance commissioner's office for
443     assistance, which notice shall include contact information for the insurance department.
444          (5) A non-network provider who receives payment from the managed care organization
445     under Subsection (2)(c) or (2)(d):
446          (a) may rely on the explanation of benefits provided by the managed care organization
447     to the enrollee and the non-network provider, informing the non-network provider of:
448          (i) the amount the non-network provider may attempt to collect from the enrollee for
449     the enrollee's cost sharing, including unmet deductibles, copayments, and coinsurance; and
450          (ii) the managed care organization's allowed amount under Subsection (2)(c) for the
451     emergency services or Subsection (2)(d) for post stabilization care;
452          (b) except as provided in Subsection (8), shall accept the following payment from the
453     enrollee as payment in full for the emergency services and post stabilization care:
454          (i) payment of cost sharing from the enrollee; and
455          (ii) payment of the additional balance bill allowed under Subsection (3); and
456          (c) may not attempt to collect payment from an enrollee for emergency services or post
457     stabilization care in excess of the amount under Subsection (5)(b).
458          (6) The rights and remedies provided under this section to an enrollee shall be in
459     addition to, and may not preempt, any other rights and remedies available to an enrollee under

460     state or federal law.
461          (7) On or before November 30, 2019, the commissioner shall report to the Business
462     and Labor Interim Committee regarding:
463          (a) the benchmarks established in Subsection (2);
464          (b) the balance billing allowed under Subsection (3);
465          (c) whether the payment benchmarks and allowed balance billing should be modified;
466          (d) how many health care providers claimed an exemption under Subsection (8)(a), the
467     number of requests for assistance under Subsection (8)(b), and information about
468     determinations under Subsection (8)(c); and
469          (e) market conduct of managed care organizations regarding contracts with health care
470     providers for non-network emergency services and post stabilization care.
471          (8) A non-network provider is not subject to Subsections (2), (3), (4)(b), and (5)(b) of
472     this section if:
473          (a) (i) as of January 1, 2017, for the past calendar year, the non-network provider, by
474     practice or as a result of a contract, has not balance billed more than 10% of the provider's
475     insured patients who received out-of-network emergency services or post stabilization care;
476     and
477          (ii) the non-network provider, before January 1, 2018, submits a statement to the
478     commissioner:
479          (A) indicating that the provider is in compliance with Subsection (8)(a) and is not
480     subject to Subsections (2), (3), (4)(b), and (5)(b); or
481          (B) providing information required by the commissioner to verify that the health care
482     provider is in compliance with this Subsection (8)(a) and is not subject to Subsections (2), (3),
483     (4)(b), and (5)(b); or
484          (b) (i) the health care provider is licensed under Title 58, Division of Occupational and
485     Professional Licensing Act;
486          (ii) 95% or more of the health care provider's practice is the delivery of emergency
487     services in a hospital emergency department, as that term is defined in Section 31A-22-627;
488     and
489          (iii) the health care provider provides information required by the commissioner to
490     verify the health care provider is in compliance with this Subsection (8)(b).

491          (9) (a) The commissioner shall make administrative rules under Title 63G, Chapter 3,
492     Utah Administrative Rulemaking Act, to establish the information a health care provider shall
493     submit under Subsections (8)(a) and (b) to verify compliance with this Subsection (8).
494          (b) After a health care provider submits the information to verify the exemption under
495     Subsections (8)(a) and (b), the commissioner shall notify the health care provider whether the
496     health care provider is exempt under Subsection (8)(a) or (b).
497          (10) An enrollee who receives a bill from a non-network provider for emergency
498     services or post stabilization care, and who believes that the provisions of this section apply to
499     the emergency services or post stabilization care, may request the assistance of the
500     commissioner to determine if the health care provider met the requirements of Subsection
501     (8)(a) or (b).
502          (11) The commissioner may ask a health care provider who submitted a statement
503     under Subsection (8)(a)(ii)(A) to demonstrate compliance with Subsection (8)(a) if an enrollee
504     who receives a balance bill requests assistance from the commissioner. The commissioner may
505     not ask a health care provider who verified compliance under Subsection (8)(a)(ii)(B) or (8)(b)
506     to reverify compliance under this Subsection (9)(d).
507          (12) If the commissioner determines that the health care provider who submitted a
508     statement under Subsection (8)(a)(ii)(A) did not meet the requirements of Subsection (8)(a),
509     the managed care organization shall reimburse the non-network provider in accordance with
510     this section and the non-network provider is subject to the balance billing restrictions of this
511     section.
512          Section 9. Section 58-1-509 is enacted to read:
513          58-1-509. Health care provider -- Emergency services -- Balance billing --
514     Unprofessional conduct.
515          (1) For purposes of this section:
516          (a) "Balance billing" means the same as that term is defined in Section 31A-22-645.
517          (b) "Emergency services" means the same as that term is defined in Section
518     31A-22-645.
519          (c) "Health care provider" means an individual who is:
520          (i) defined as a health care provider under Section 78B-3-403; and
521          (ii) licensed under this title.

522          (2) Beginning January 1, 2018, it is unprofessional conduct for a health care provider
523     to balance bill a patient for emergency services in violation of Section 31A-22-647.
524          (3) A health care provider who violates this section is subject to Section 58-1-502.
525          Section 10. Section 63I-2-231 is amended to read:
526          63I-2-231. Repeal dates, Title 31A.
527          (1) Section 31A-22-315.5 is repealed July 1, 2019.
528          (2) Section 31A-22-647 is repealed January 1, 2021.
529          [(2)] (3) Title 31A, Chapter 42, Defined Contribution Risk Adjuster Act, is repealed
530     December 31, 2018.
531          Section 11. Repealer.
532          This bill repeals:
533          Section 31A-8-104, Determination of ability to provide services.
534          Section 31A-8-408, Organizations offering point of service or point of sales
535     products.
536          Section 12. Effective date.
537          This bill takes effect on January 1, 2018.