Chief Sponsor: Norman K. Thurston

Senate Sponsor: ____________


8     General Description:
9          This bill amends the Insurance Code.
10     Highlighted Provisions:
11          This bill:
12          ▸     creates a definition;
13          ▸     prohibits a health care provider from misrepresenting that the provider is a
14     contracted provider under a health benefit plan when that is not the case; and
15          ▸     specifies that a violation is a violation of the Utah Consumer Sales Practices Act.
16     Money Appropriated in this Bill:
17          None
18     Other Special Clauses:
19          None
20     Utah Code Sections Affected:
21     AMENDS:
22          31A-45-301, as enacted by Laws of Utah 2017, Chapter 292

24     Be it enacted by the Legislature of the state of Utah:
25          Section 1. Section 31A-45-301 is amended to read:
26          31A-45-301. Written contracts -- Limited liability of enrollee -- Provider claim
27     disputes -- Leased networks.

28          (1) As used in this section, "health care provider" means a person licensed to provide
29     health care under:
30          (a) Title 26, Chapter 21, Health Care Facility Licensing and Inspection Act; or
31          (b) Title 58, Occupations and Professions.
32          [(1)] (2) A managed care organization may not contract with a health care provider for
33     treatment of illness or injury unless the health care provider is licensed to perform that
34     treatment. Every contract between a managed care organization and a network provider shall be
35     in writing and shall set forth that if the managed care organization:
36          (a) fails to pay for health care services as set forth in the contract, the enrollee is not
37     liable to the health care provider for any sums owed by the managed care organization; and
38          (b) becomes insolvent, the rehabilitator or liquidator may require the network provider
39     to:
40          (i) continue to provide health care services under the contract between the network
41     provider and the managed care organization until the earlier of:
42          (A) 90 days after the date of the filing of a petition for rehabilitation or a petition for
43     liquidation; or
44          (B) the date the term of the contract ends; and
45          (ii) subject to Subsection [(3)] (4), reduce the fees the network provider is otherwise
46     entitled to receive from the managed care organization under the contract between the network
47     provider and the managed care organization during the time period described in Subsection
48     [(1)] (2)(b)(i).
49          [(2)] (3) If the conditions of Subsection [(3)] (4) are met, the network provider:
50          (a) shall accept the reduced payment as payment in full; and
51          (b) as provided in Subsection [(1)] (2)(a), may not collect additional amounts from the
52     insolvent managed care organization's enrollee, except as may be owed under Subsection [(3)]
53     (4)(b).
54          [(3)] (4) Notwithstanding Subsection [(1)] (2)(b)(ii):
55          (a) the rehabilitator or liquidator may not reduce a fee to less than 75% of the regular
56     fee set forth in the network provider contract; and
57          (b) the enrollee shall continue to pay the same copayments, deductibles, and other
58     payments for services received from the network provider that the enrollee was required to pay

59     before the filing of:
60          (i) the petition for rehabilitation; or
61          (ii) the petition for liquidation.
62          [(4)] (5) A network provider may not collect or attempt to collect from the enrollee
63     sums owed by the managed care organization or the amount of the regular fee reduction
64     authorized under Subsection [(1)] (2)(b)(ii) if the network provider contract:
65          (a) is not in writing as required in Subsection [(1)] (2); or
66          (b) fails to contain the language required by Subsection [(1)] (2).
67          [(5)] (6) (a) A person listed in Subsection [(5)] (6)(b) may not bill or maintain any
68     action at law against an enrollee to collect:
69          (i) sums owed by the organization; or
70          (ii) the amount of the regular fee reduction authorized under Subsection [(1)] (2)(b)(ii).
71          (b) Subsection [(5)] (6)(a) applies to:
72          (i) a network provider;
73          (ii) an agent;
74          (iii) a trustee; or
75          (iv) an assignee of a person described in Subsections [(5)] (6)(b)(i) through (iii).
76          (c) In any dispute involving a network provider's claim for reimbursement, the network
77     provider's claim shall be determined in accordance with applicable law, the network provider
78     contract, the enrollee contract, and the managed care organization's written payment policies in
79     effect at the time services were rendered.
80          (d) If the parties are unable to resolve their dispute, the matter shall be subject to
81     binding arbitration by a jointly selected arbitrator. Each party shall bear its own expense except
82     that the cost of the jointly selected arbitrator shall be equally shared. This Subsection [(5)]
83     (6)(d) does not apply to the claim of a general acute hospital to the extent the claim is
84     inconsistent with the hospital's provider agreement.
85          (e) A managed care organization may not penalize a network provider solely for
86     pursuing a claims dispute or otherwise demanding payment for a sum believed owing.
87          [(6)] (7) If a managed care organization permits another private entity with which the
88     managed care organization does not share common ownership or control to use or otherwise
89     lease one or more of the organization's networks that include network providers, the managed

90     care organization shall ensure, at a minimum, that the entity pays the network providers
91     included in the managed care organization's network in accordance with the same fee schedule
92     and general payment policies as the managed care organization would pay for those network
93     providers, unless payment for services is governed by a public program's fee schedule.
94          (8) (a) Neither a health care provider, nor a health care provider's representative, may
95     represent to an enrollee that the health care provider is a contracted provider under the
96     enrollee's health benefit plan if the health care provider is not a contracted provider under the
97     enrollee's health benefit plan.
98          (b) A violation of Subsection (8)(a) is a deceptive act or practice under Section
99     13-11-4.