8 LONG TITLE
9 General Description:
10 This bill enacts provisions relating to balance billing for emergency services by a health
11 care facility.
12 Highlighted Provisions:
13 This bill:
14 ▸ defined terms; and
15 ▸ enacts procedures that managed care organizations and a health care facility must
16 follow if there is a dispute regarding payment for certain emergency services.
17 Money Appropriated in this Bill:
19 Other Special Clauses:
21 Utah Code Sections Affected:
23 26-21-33, Utah Code Annotated 1953
24 31A-22-653, Utah Code Annotated 1953
26 Be it enacted by the Legislature of the state of Utah:
27 Section 1. Section 26-21-33 is enacted to read:
28 26-21-33. Balance billing for emergency services prohibited -- Violation of
30 (1) As used in this section:
31 (a) "Balance billing" means the same as that term is defined in Section 31A-22-653.
32 (b) "Emergency services" means the same as that term is defined in Section
34 (2) Beginning January 1, 2021, it is a violation of this chapter for a health care facility
35 to balance bill a patient for emergency services in violation of Section 31A-22-653.
36 (3) A health care facility that violates Subsection (2) is subject to Section 26-21-11.
37 Section 2. Section 31A-22-653 is enacted to read:
38 31A-22-653. Managed care organization out-of-network services -- Health care
39 facilities -- Emergency services -- Balance billing.
40 (1) As used in this section:
41 (a) (i) "Balance billing" means the practice of a health care facility billing a managed
42 care organization enrollee for the difference between a health care facility charge and the
43 managed care organization's allowed amount.
44 (ii) "Balance billing" does not include billing an enrollee for cost sharing required by
45 the enrollee's health benefit plan, including copayments, coinsurance, and deductibles.
46 (b) "Covered benefit" means a health care service covered under the terms of a health
47 benefit plan.
48 (c) "Emergency services" means the same as that term is defined in 42 C.F.R. Sec.
50 (d) "Health care facility" means the same as that term is defined in Section 26-21-2.
51 (e) "Managed care organization" means:
52 (i) a managed care organization as defined in Section 31A-27a-403; and
53 (ii) a third party administrator.
54 (2) Upon receiving a bill from a non-network health care facility with the benchmark
55 rate described in Subsection (5)(b)(i), a managed care organization shall:
56 (a) reimburse a non-network health care facility for emergency services in accordance
57 with this section;
58 (b) (i) pay a non-network health care facility directly for emergency services provided
59 to an enrollee; and
60 (ii) send a remittance to the non-network health care facility with the information
61 required under Subsection (2)(e);
62 (c) pay a non-network health care facility for emergency services in accordance with
63 Subsection (5);
64 (d) count toward any deductible or out-of-pocket maximum applied under the
65 enrollee's plan any cost sharing payments made by the enrollee with respect to emergency
66 services reimbursed under this section in the same manner as if such cost sharing payments
67 were paid for services or care furnished by an in-network health care facility; and
68 (e) provide to the non-network health care facility a remittance that includes:
69 (i) the amount the non-network health care facility may attempt to collect from the
70 enrollee for the enrollee's cost sharing, including unmet deductibles, copayments, and
71 coinsurance; and
72 (ii) the managed care organization's allowed amount under Subsection (2)(c) for the
73 emergency services.
74 (3) If a non-network health care facility sends a bill directly to an enrollee for
75 emergency services, the bill shall notify the enrollee:
76 (a) that the emergency services were performed by a health care facility that is not a
77 network health care facility for the enrollee's health benefit plan; and
78 (b) that the enrollee is responsible for paying the enrollee's applicable in-network cost
79 sharing amount.
80 (4) A non-network health care facility that receives payment from the managed care
81 organization under Subsection (2)(c):
82 (a) may rely on the remittance provided by the managed care organization to the
83 enrollee and the non-network health care facility under Subsection (2)(b)(ii);
84 (b) shall accept the payment from the enrollee under Subsection (3)(b) as payment in
85 full for the emergency services from the enrollee; and
86 (c) may not attempt to collect payment from an enrollee for emergency services in
87 excess of the amount under Subsection (4)(b).
88 (5) (a) When a managed care organization receives a bill for emergency services from a
89 non-network health care facility, the managed care organization shall:
90 (i) ensure that the enrollee is responsible for no more than the applicable in-network
91 cost sharing amount; and
92 (ii) may elect to pay a non-network health care facility for emergency services:
93 (A) as submitted by the health care facility;
94 (B) the benchmark rate described in Subsection (5)(b)(i); or
95 (C) in an amount mutually agreed upon by the managed care organization and the
96 health care facility.
97 (b) (i) The benchmark rate under this section is the median of the health care facility's
98 contracted in-network rates with all managed care organizations in the state.
99 (ii) A managed care organization may submit a request to the department to verify the
100 benchmark rate submitted by a health care facility under this section.
101 (c) This section does not preclude a managed care organization and a non-network
102 health care facility from agreeing to a different payment arrangement if:
103 (i) the enrollee is responsible for no more than the applicable in-network cost sharing
104 amount; and
105 (ii) the enrollee has no legal obligation to pay the balance for emergency services
106 remaining after the payments under Subsection (4).