Chief Sponsor: Brady Brammer

Senate Sponsor: ____________


8     General Description:
9          This bill enacts requirements related to billing and provider networks for certain health
10     insurance plans.
11     Highlighted Provisions:
12          This bill:
13          ▸     defines terms;
14          ▸     requires a managed care organization to provide adequate coverage of certain health
15     care services in the managed care organization's network;
16          ▸     requires a managed care organization to publish and maintain a provider directory
17     of health care providers that are in the managed care organization's network; and
18          ▸     enacts procedures that a managed care organization and a non-network physician
19     must follow if there is a dispute regarding payment for certain emergency services.
20     Money Appropriated in this Bill:
21          None
22     Other Special Clauses:
23          None
24     Utah Code Sections Affected:
25     ENACTS:
26          31A-22-653, Utah Code Annotated 1953
27          31A-22-654, Utah Code Annotated 1953

28          31A-22-655, Utah Code Annotated 1953

30     Be it enacted by the Legislature of the state of Utah:
31          Section 1. Section 31A-22-653 is enacted to read:
32          31A-22-653. Access to managed care organization health care providers.
33          (1) As used in this section:
34          (a) (i) "Balance billing" means the practice of a physician billing a managed care
35     organization enrollee for the difference between a physician's charge and the managed care
36     organization's allowed amount.
37          (ii) "Balance billing" does not include billing an enrollee for cost sharing required by
38     the enrollee's health benefit plan, including copayments, coinsurance, and deductibles.
39          (b) "Covered benefit" means a health care service covered under the terms of a health
40     benefit plan.
41          (c) "Emergency medical condition" means the same as that term is defined in Section
42     31A-22-627.
43          (d) "Emergency services" means, with respect to an emergency medical condition,
44     services rendered by a physician billable by or on behalf of the physician for:
45          (i) a medical or mental health screening examination that is within the capability of an
46     emergency department of a hospital, including ancillary services routinely available to the
47     emergency department to evaluate the emergency medical condition; and
48          (ii) any further medical or mental health examination and treatment, to the extent the
49     treatment or examination is within the capabilities of the emergency department and is
50     necessary to stabilize the patient.
51          (e) "Licensed provider" means an individual who is licensed under Title 58,
52     Occupations and Professions, to provide health care.
53          (f) "Managed care organization" means:
54          (i) a managed care organization as defined in Section 31A-27a-403; and
55          (ii) a third-party administrator.
56          (g) "Physician" means the same as that term is defined in Section 58-67-102.
57          (h) (i) "Post stabilization care" means services related to emergency services that:
58          (A) are provided by the physician who performed the emergency services;

59          (B) are provided after an enrollee's condition is no longer considered an emergency
60     medical condition;
61          (C) maintain a stabilized condition or improve or resolve the enrollee's condition; and
62          (D) are provided within 90 days after the day on which the enrollee's condition is no
63     longer considered an emergency medical condition.
64          (ii) "Post stabilization care" does not include health care facility charges or laboratory
65     charges.
66          (i) "Stabilize" means to stabilize as defined in 42 U.S.C. Sec. 1395dd(e)(3).
67          (2) A managed care organization that offers or administers a network plan shall
68     maintain a network that is sufficient in number and appropriate types of licensed providers,
69     including those that serve predominantly low-income, medically underserved individuals, to
70     ensure that all services to enrollees, including children and adults, will be accessible without
71     unreasonable travel or delay.
72          (3) An enrollee under a managed care organization's network plan shall have access to
73     emergency services 24 hours per day, seven days per week.
74          (4) (a) At least one time each year, a managed care organization that provides a
75     network plan shall demonstrate to the commissioner that the managed care organization is able
76     to provide adequate access to current and potential enrollees through a contracted network of
77     health care providers, including health care facilities, for each county within the managed care
78     organization's filed service area.
79          (b) Adequate access under Subsection (4)(a) is demonstrated if the managed care
80     organization:
81          (i) has a network of health care providers that meets the maximum travel time and
82     distance standards in, and has sufficient numbers of, health care providers to meet the
83     minimum number of requirements set forth by:
84          (A) the Centers for Medicare and Medicaid Services for Medicare Advantage plans;
85     and
86          (B) modifications to and extensions of the standards in Subsection (4)(b)(i)(A) adopted
87     by the commissioner by administrative rule based on nationally recognized standards and as
88     necessary to reflect the age and demographics of the enrollees in the network plan and the
89     availability of rural health care providers; and

90          (ii) meets adequacy and sufficiency standards established by the commissioner by
91     administrative rule made in accordance with this Subsection (4) and Title 63G, Chapter 3, Utah
92     Administrative Rulemaking Act.
93          (c) The commissioner shall adopt administrative rules in accordance with Title 63G,
94     Chapter 3, Utah Administrative Rulemaking Act, to establish reasonable standards under
95     Subsection (4)(b)(ii) regarding:
96          (i) the ratio of enrollees to licensed providers, by specialty;
97          (ii) the ratio of enrollees to primary care licensed providers;
98          (iii) the geographic accessibility of health care providers;
99          (iv) geographic variation and population dispersion;
100          (v) waiting times for an appointment with participating health care providers;
101          (vi) hours of operation;
102          (vii) the availability of the network to meet the needs of enrollees, which may include
103     low-income individuals, children and adults with serious, chronic, or complex health
104     conditions or physical or mental disabilities, or individuals with limited English proficiency;
105          (viii) other health care service delivery system options, such as telemedicine or
106     telehealth, mobile clinics, centers of excellence, and other ways of delivering health care;
107          (ix) the volume of technological and specialty care services available to serve the needs
108     of enrollees requiring technologically advanced or specialty care services;
109          (x) the extent to which participating health care providers are accepting new patients;
110          (xi) the regionalization of specialty care, which may require some children and adults
111     to cross state lines for care;
112          (xii) the number of health care providers within a specified area, including rural or
113     urban areas, that takes into consideration an insured's travel time and distance to health care
114     providers; and
115          (xiii) the manner in which a managed care organization demonstrates compliance with
116     the criteria established under this Subsection (4).
117          Section 2. Section 31A-22-654 is enacted to read:
118          31A-22-654. Managed care organization provider directories.
119          (1) As used in this section:
120          (a) "Licensed provider" means the same as that term is defined in Section 31A-22-653.

121          (b) "Managed care organization" means the same as that term is defined in Section
122     31A-22-653.
123          (2) (a) A managed care organization shall post electronically a current and accurate
124     directory of licensed providers for each of the organization's network plans.
125          (b) In making the directory available electronically, the managed care organization
126     shall ensure the general public is able to view all of the current licensed providers for a plan
127     through a clearly identifiable link or tab and without creating or accessing an account or
128     entering a policy or contract number.
129          (c) The managed care organization shall update each network plan provider directory at
130     least monthly.
131          (d) A managed care organization does not violate the requirement of Subsection (2)(c)
132     if the managed care organization fails to update the directory because a licensed provider has
133     failed to notify the managed care organization of a change to the licensed provider's
134     information.
135          (3) A managed care organization shall make available through a searchable electronic
136     directory, for each network plan, the following information about each licensed provider in the
137     managed care organization's network plan:
138          (a) the licensed provider's name;
139          (b) the licensed provider's gender;
140          (c) participating office locations;
141          (d) specialty and board certifications;
142          (e) medical group affiliations, if applicable;
143          (f) participating facility affiliations, if applicable;
144          (g) languages spoken other than English, if applicable;
145          (h) whether the licensed provider is accepting new patients; and
146          (i) contact information.
147          (4) The provider directory under this section shall accommodate the communication
148     needs of individuals with disabilities and include a link to or information regarding available
149     assistance for individuals with limited English proficiency.
150          Section 3. Section 31A-22-655 is enacted to read:
151          31A-22-655. Managed care organization out-of-network services -- Emergency

152     services -- Post stabilization care -- Balance billing.
153          (1) As used in this section:
154          (a) "Balance billing" means the same as that term is defined in Section 31A-22-653.
155          (b) "Covered benefit" means the same as that term is defined in Section 31A-22-653.
156          (c) "Emergency medical condition" means the same as that term is defined in Section
157     31A-22-627.
158          (d) "Emergency services" means the same as that term is defined in Section
159     31A-22-653.
160          (e) "Managed care organization" means the same as that term is defined in Section
161     31A-22-653.
162          (f) "Physician" means the same as that term is defined in Section 58-67-102.
163          (g) "Post stabilization care" means the same as that term is defined in Section
164     31A-22-653.
165          (h) "Stabilize" means to stabilize as defined in 42 U.S.C. Sec. 1395dd(e)(3).
166          (2) A managed care organization shall have a process to ensure that an enrollee is able
167     to obtain health care for a covered benefit from a non-network physician:
168          (a) at an in-network level of benefit, including an in-network level of cost sharing, or
169     under an arrangement approved by the commissioner;
170          (b) in accordance with Section 31A-22-653; and
171          (c) (i) when an enrollee is diagnosed with a condition or disease that requires
172     specialized health care services; and
173          (ii) when the managed care organization does not have an in-network physician of the
174     required specialty with the professional training and expertise to treat or provide health care for
175     the condition or disease, or cannot provide reasonable access to an in-network physician with
176     the required training or expertise to treat or provide health care services for the condition or
177     disease.
178          (3) A managed care organization shall:
179          (a) reimburse a non-network physician for emergency services and post stabilization
180     care in accordance with this section;
181          (b) (i) pay a non-network physician directly for emergency services and post
182     stabilization care provided to an enrollee; and

183          (ii) send an explanation of benefits to the non-network physician with the information
184     required under Subsection (3)(f);
185          (c) pay a non-network physician for emergency services in accordance with Subsection
186     (6);
187          (d) pay a non-network physician for post stabilization care at the in-network allowed
188     amount for the patient's managed care organization plan if the patient and the provider agree to
189     post stabilization care;
190          (e) count toward any deductible or out-of-pocket maximum applied under the enrollee's
191     plan any cost sharing payments made by the enrollee with respect to emergency services or post
192     stabilization care reimbursed under this section in the same manner as if such cost sharing
193     payments were paid for services or care furnished by an in-network physician; and
194          (f) provide to an enrollee who has received emergency services and to the non-network
195     physician an explanation of benefits that includes:
196          (i) whether payment for the emergency services and post stabilization care is subject to
197     any regulation under state or federal law;
198          (ii) the amount the non-network physician may attempt to collect from the enrollee for
199     the enrollee's cost sharing, including unmet deductibles, copayments, and coinsurance; and
200          (iii) the managed care organization's allowed amount under Subsection (3)(c) for the
201     emergency services or Subsection (3)(d) for post stabilization care.
202          (4) If a non-network physician sends a bill directly to an enrollee for emergency
203     services or post stabilization care, the bill shall notify the enrollee:
204          (a) that the emergency services or post stabilization care were performed by a physician
205     who is not a network physician for the enrollee's health benefit plan; and
206          (b) that the enrollee is responsible for paying the enrollee's applicable in-network cost
207     sharing amount.
208          (5) A non-network physician who receives payment from the managed care
209     organization under Subsection (3)(c) or (d):
210          (a) may rely on the explanation of benefits provided by the managed care organization
211     to the enrollee and the non-network physician under Subsection (3)(f);
212          (b) shall accept the payment from the enrollee under Subsection (4)(b) as payment in
213     full for the emergency services and post stabilization care from the enrollee; and

214          (c) may not attempt to collect payment from an enrollee for emergency services or post
215     stabilization care in excess of the amount under Subsection (5)(b).
216          (6) (a) When a managed care organization receives a bill for emergency services from a
217     non-network physician, the managed care organization shall:
218          (i) ensure that the enrollee shall incur no greater out-of-pocket costs for the emergency
219     services than the enrollee would have incurred with an in-network physician; and
220          (ii) may elect to pay a non-network physician for emergency services:
221          (A) as submitted by the provider;
222          (B) in accordance with Subsection (6)(b); or
223          (C) in an amount mutually agreed upon by the managed care organization and the
224     physician.
225          (b) This section does not preclude a managed care organization and a non-network
226     physician from agreeing to a different payment arrangement if:
227          (i) the enrollee is responsible for no more than the applicable in-network cost sharing
228     amount; and
229          (ii) the enrollee has no legal obligation to pay the balance for emergency services
230     remaining after the payments under Subsection (5).
231          (c) A managed care organization that does not pay in accordance with Subsection
232     (6)(a)(ii)(A) or (B) shall pay a commercially reasonable amount for the emergency services
233     rendered by the non-network physician, based on the criteria described in Subsection (8),
234     except for the enrollee's copayment, coinsurance, or deductible, if applicable.
235          (d) If the managed care organization pays the non-network physician under Subsection
236     (6)(c), the physician and the managed care organization may, no later than 30 days after the day
237     on which the payment is made, negotiate an amount of payment for the emergency services,
238     other than the amount paid by the managed care organization.
239          (e) If the managed care organization and the non-network physician have not agreed to
240     a negotiated amount under Subsection (6)(d), the managed care organization or the
241     non-network physician may initiate an independent dispute resolution process under
242     Subsection (7) to determine the amount of payment.
243          (7) (a) An arbitrator's determination under this Subsection (7) shall be to select, based
244     on an evaluation of what is a commercially reasonable fee for the services rendered, either:

245          (i) the managed care organization's payment; or
246          (ii) the non-network physician's reimbursement request.
247          (b) The arbitrator shall determine which amount to select based upon the conditions
248     and factors set forth in Subsection (8).
249          (c) The determination of the arbitrator shall be binding on the managed care
250     organization, physician, and patient, and is admissible in:
251          (i) a court proceeding between the managed care organization, physician, or patient;
252     and
253          (ii) an administrative proceeding between the state and the physician.
254          (d) The arbitrator shall make a determination within 30 days after the day on which the
255     arbitrator receives the dispute for review.
256          (e) (i) For disputes involving an insured, when the arbitrator determines the managed
257     care organization's payment is commercially reasonable, payment for the dispute resolution
258     process shall be the responsibility of the non-network physician.
259          (ii) When the arbitrator determines the non-network physician's reimbursement request
260     is commercially reasonable, payment for the dispute resolution process shall be the
261     responsibility of the managed care organization.
262          (iii) When a good faith negotiation directed by the arbitrator under this Subsection (7)
263     results in a settlement between the managed care organization and non-network physician, the
264     managed care organization and the non-network physician shall evenly divide and share the
265     prorated cost of the dispute resolution under this Subsection (7).
266          (f) Claims may be grouped under this Subsection (7) if each of the claims that is
267     grouped involves:
268          (i) the same managed care organization and health care provider group;
269          (ii) claims with the same or related current procedural terminology codes relevant to a
270     particular procedure for the patient; and
271          (iii) claims that occur within 90 days of each other.
272          (8) (a) In determining what is a commercially reasonable fee to pay for a health care
273     service, an arbitrator shall consider all relevant factors, including:
274          (i) the usual and customary reimbursement for the service; and
275          (ii) other factors that may be submitted at the discretion of either party, which may

276     include:
277          (A) the physician's usual payment for comparable services with regard to patients in
278     health care plans in which the physician is in-network and patients in health care plans in
279     which the physician is not in-network;
280          (B) the circumstances and complexity of the particular case, including time and place
281     of the service;
282          (C) individual patient characteristics; and
283          (D) other relevant clinical and economic factors, including payment by third-party
284     private payors.
285          (b) (i) The usual and customary reimbursement for a health care service under
286     Subsection (8)(a) means the 80th percentile of all total amounts paid for the particular health
287     care service performed by a physician in the same or similar specialty and provided in the same
288     geographical area of the state as reported in a benchmarking database maintained by a
289     nonprofit or government organization specified by the Department of Health by rule made in
290     accordance with Title 63G, Chapter 3, Utah Administrative Rulemaking Act, and in
291     consultation with:
292          (A) a state physician association representing all physician specialties; and
293          (B) a state association representing health insurers in the state.
294          (ii) The database described in Subsection (8)(b)(i) may be the all payer claims database
295     maintained by the Department of Health if the database can produce the necessary data in a
296     form approved by the department in consultation with:
297          (A) the Department of Health;
298          (B) a state physician association representing all physician specialties; and
299          (C) a state association representing health insurers in the state.
300          (iii) If the benchmarking database described in Subsection (8)(b)(i) is maintained by a
301     nonprofit organization, the nonprofit organization may not be affiliated with a managed care
302     organization or health insurer.