7 LONG TITLE
8 General Description:
9 This bill regulates the reimbursement and billing for certain emergency services.
10 Highlighted Provisions:
11 This bill:
12 ▸ applies to health benefit plans entered into or renewed on or after January 1, 2018;
13 ▸ requires a health insurer to pay non-network health care providers for emergency
14 services provided to an enrollee;
15 ▸ establishes a benchmark for payment for emergency services provided by a
16 non-network health care provider;
17 ▸ prohibits a non-network health care provider who receives payment from the health
18 insurer for emergency services from balance billing the enrollee;
19 ▸ requires a health care provider to give an enrollee notice of assistance the enrollee
20 may receive from the insurance commissioner if the enrollee receives a bill from a
21 non-network heath care provider for emergency services;
22 ▸ makes balanced billing for emergency services unprofessional conduct under health
23 care provider licensing laws; and
24 ▸ requires a sunset review of the benchmark for payment of emergency services by
25 July 1, 2022.
26 Money Appropriated in this Bill:
28 Other Special Clauses:
30 Utah Code Sections Affected:
32 31A-22-627, as last amended by Laws of Utah 2016, Chapter 295
33 63I-2-231, as last amended by Laws of Utah 2016, Chapter 138
35 26-21-30, Utah Code Annotated 1953
36 31A-22-627.5, Utah Code Annotated 1953
37 58-1-509, Utah Code Annotated 1953
39 Be it enacted by the Legislature of the state of Utah:
40 Section 1. Section 26-21-30 is enacted to read:
41 26-21-30. Emergency medical services -- Balance billing -- Violation of chapter.
42 (1) For purposes of this section:
43 (a) "Balance billing" means the same as that term is defined in Section 31A-22-627.5.
44 (b) "Emergency services" means the same as that term is defined in Section
46 (2) Beginning January 1, 2018, it is a violation of this chapter for a health care facility
47 to balance bill a patient for emergency services in violation of Section 31A-22-627.5.
48 (3) A health care facility that violates this section is subject to Section 26-21-11.
49 Section 2. Section 31A-22-627 is amended to read:
50 31A-22-627. Coverage of emergency medical services.
51 (1) A health insurance policy or health maintenance organization contract:
52 (a) shall provide, at a minimum, coverage of emergency services:
53 (i) as required in 29 C.F.R. Sec. 2590.715-2719A; and
54 (ii) for plans entered into or renewed on or after January 1, 2018, as required in
55 Subsection (1)(a)(i) and in Section 31A-22-627.5; and
56 (b) may not:
57 (i) require any form of preauthorization for treatment of an emergency medical
58 condition until after the insured's condition has been stabilized; or
59 (ii) deny a claim for any covered evaluation, covered diagnostic test, or other covered
60 treatment considered medically necessary to stabilize the emergency medical condition of an
62 (2) A health insurance policy or health maintenance organization contract may require
63 authorization for the continued treatment of an emergency medical condition after the insured's
64 condition has been stabilized. If such authorization is required, an insurer who does not accept
65 or reject a request for authorization may not deny a claim for any evaluation, diagnostic testing,
66 or other treatment considered medically necessary that occurred between the time the request
67 was received and the time the insurer rejected the request for authorization.
68 (3) For purposes of this section:
69 (a) "emergency medical condition" means a medical condition manifesting itself by
70 acute symptoms of sufficient severity, including severe pain, such that a prudent layperson,
71 who possesses an average knowledge of medicine and health, would reasonably expect the
72 absence of immediate medical attention at a hospital emergency department to result in:
73 (i) placing the insured's health, or with respect to a pregnant woman, the health of the
74 woman or her unborn child, in serious jeopardy;
75 (ii) serious impairment to bodily functions; or
76 (iii) serious dysfunction of any bodily organ or part; and
77 (b) "hospital emergency department" means that area of a hospital in which emergency
78 services are provided on a 24-hour-a-day basis.
79 (4) Nothing in this section may be construed as:
80 (a) altering the level or type of benefits that are provided under the terms of a contract
81 or policy; or
82 (b) restricting a policy or contract from providing enhanced benefits for certain
83 emergency medical conditions that are identified in the policy or contract.
84 (5) Notwithstanding Section 31A-2-308, if the commissioner finds an insurer has
85 violated this section, the commissioner may:
86 (a) work with the insurer to improve the insurer's compliance with this section; or
87 (b) impose the following fines:
88 (i) not more than $5,000; or
89 (ii) twice the amount of any profit gained from violations of this section.
90 Section 3. Section 31A-22-627.5 is enacted to read:
91 31A-22-627.5. Emergency services -- Non-network providers -- Balance billing.
92 (1) For purposes of this section:
93 (a) (i) "Balance billing" means the practice of a health care provider billing an enrollee
94 for the difference between the health care provider's charge and the amount of reimbursement
95 by the managed care organization under Subsection (2)(c).
96 (ii) "Balance billing" does not include billing an enrollee for copayments, coinsurance,
97 or deductibles.
98 (b) "Emergency medical condition" means the same as that term is defined in Section
100 (c) "Emergency services" means, with respect to an emergency medical condition:
101 (i) a medical or mental health screening examination that is within the capability of the
102 emergency department of a hospital, including ancillary services routinely available to the
103 emergency department to evaluate the emergency medical condition; and
104 (ii) any further medical or mental health examination and treatment, to the extent the
105 treatment or examination is within the capabilities of the emergency department and the staff,
106 to stabilize the patient.
107 (d) "Managed care organization" means a third-party administrator as that term is
108 defined in Section 31A-1-103, or a person:
109 (i) licensed:
110 (A) under Chapter 5, Domestic Stock and Mutual Insurance Corporations;
111 (B) under Chapter 7, Nonprofit Health Service Insurance Corporation;
112 (C) as a health maintenance organization under Chapter 8, Health Maintenance
113 Organizations and Limited Health Plans; or
114 (D) under Chapter 14, Foreign Insurers; and
115 (ii) that requires an enrollee to use, or offers incentives, including financial incentives,
116 for an enrollee to use, network providers.
117 (e) "Network provider" means a health care provider who has an agreement with a
118 managed care organization to provide health care services to an enrollee with an expectation of
119 receiving payment, other than coinsurance, copayments, or deductibles, directly from the
120 managed care organization.
121 (2) (a) For plans entered into or renewed on or after January 1, 2018, a managed care
122 organization shall reimburse a non-network provider for emergency services in accordance
123 with this section.
124 (b) A managed care organization shall accept assignment of benefits from an enrollee
125 for emergency services provided by a non-network provider.
126 (c) Except as provided in Subsection (2)(f), payment to a non-network provider for
127 emergency services shall be the greater of:
128 (i) the median amount negotiated by the managed care organization with the network
129 providers for the emergency services furnished, without regard to copayments or coinsurance
130 obligations of the enrollee;
131 (ii) the amount for the emergency services calculated using the same method generally
132 used by managed care organizations to determine payments for non-network services, without
133 regard to copayments or coinsurance obligations of the enrollee; or
134 (iii) the eightieth percentile of the charges for a particular emergency service performed
135 by a health care provider in the same or similar specialty in Utah, as reported in a
136 benchmarking database maintained by an organization selected by the commissioner under
137 Subsection (2)(d).
138 (d) The commissioner shall designate, by administrative rule, a national database of
139 charges under Subsection (2)(c), which database shall be established and maintained by a
140 national independent not-for-profit corporation that collects private medical and dental claims,
141 contributed by payers nationwide, developed with the support of independent academic
142 experts, and not affiliated with an insurer.
143 (e) A managed care organization shall pay a non-network provider for emergency
145 (i) as submitted by the provider; or
146 (ii) in accordance with the benchmark established in Subsection (2)(c).
147 (f) This section does not preclude a managed care organization and a non-network
148 provider from agreeing to a different payment arrangement.
149 (3) When a non-network provider sends a bill directly to an enrollee for emergency
150 services, the non-network provider shall include a statement on the bill informing the enrollee:
151 (a) that the emergency services were performed by a provider who is not a network
152 provider for the enrollee's health benefit plan;
153 (b) that the enrollee:
154 (i) is responsible for paying the enrollee's applicable in-network cost-sharing amount;
155 (ii) has no legal obligation to pay the remaining balance for the emergency services;
156 (iii) shall either:
157 (A) accept and pay the remaining balance for the emergency services provided by the
158 non-network provider; or
159 (B) forward the bill for the remaining balance to the enrollee's managed care
160 organization; and
161 (iv) may contact the state insurance commissioner's office for assistance; and
162 (c) of the online address and telephone number for the insurance department's
163 consumer assistance office.
164 (4) A non-network provider who receives payment from the managed care organization
165 under Subsection (2)(c):
166 (a) shall accept the payment under Subsection (2)(c) and the cost-sharing payment from
167 the enrollee as payment in full for the emergency services; and
168 (b) may not attempt to collect payment from an enrollee for emergency services,
169 excluding appropriate cost-sharing payment from the enrollee.
170 (5) The rights and remedies provided under this section to an enrollee shall be in
171 addition to, and may not preempt, any other rights and remedies available to an enrollee under
172 state or federal law.
173 (6) (a) On or before November 30, 2021, the commissioner shall report to the Business
174 and Labor Interim Committee regarding the benchmark established under Subsections (2)(c)
175 and (d) and whether the payment benchmarks should be modified.
176 (b) This section is repealed in accordance with Section 63I-2-231.
177 Section 4. Section 58-1-509 is enacted to read:
178 58-1-509. Health care provider -- Emergency services -- Balance billing-
179 Unprofessional conduct.
180 (1) For purposes of this section:
181 (a) "Balance billing" means the same as that term is defined in Section 31A-22-627.5.
182 (b) "Emergency services" means the same as that term is defined in Section
184 (c) "Health care provider" means an individual who is:
185 (i) defined as a health care provider under Section 78B-3-403; and
186 (ii) licensed under this title.
187 (2) Beginning January 1, 2018, it is unprofessional conduct for a health care provider
188 to balance bill a patient for emergency services in violation of Section 31A-22-627.5.
189 (3) A health care provider who violates this section is subject to Section 58-1-502.
190 Section 5. Section 63I-2-231 is amended to read:
191 63I-2-231. Repeal dates, Title 31A.
192 (1) Section 31A-22-315.5 is repealed July 1, 2019.
193 (2) Title 31A, Chapter 42, Defined Contribution Risk Adjuster Act, is repealed
194 December 31, 2018.
195 (3) Section 31A-22-627.5 is repealed July 1, 2022.
Legislative Review Note
Office of Legislative Research and General Counsel