Chief Sponsor: James A. Dunnigan

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 health care
19     professional must follow if there is a dispute regarding payment for certain
20     emergency services.
21     Money Appropriated in this Bill:
22          None
23     Other Special Clauses:
24          None
25     Utah Code Sections Affected:
26     ENACTS:
27          31A-22-653, Utah Code Annotated 1953

28          31A-22-654, Utah Code Annotated 1953
29          31A-22-655, Utah Code Annotated 1953
30          58-1-510, Utah Code Annotated 1953

32     Be it enacted by the Legislature of the state of Utah:
33          Section 1. Section 31A-22-653 is enacted to read:
34          31A-22-653. Access to managed care organization health care providers.
35          (1) As used in this section:
36          (a) (i) "Balance billing" means the practice of a licensed provider billing a managed
37     care organization enrollee for the difference between a licensed provider's charge and the
38     managed care organization's allowed amount.
39          (ii) "Balance billing" does not include billing an enrollee for cost sharing required by
40     the enrollee's health benefit plan, including copayments, coinsurance, and deductibles.
41          (b) "Covered benefit" means a health care service covered under the terms of a health
42     benefit plan.
43          (c) "Emergency services" means the same as that term is defined in 42 C.F.R. Sec.
44     2590.715-2719A.
45          (d) "Licensed provider" means an individual who is licensed under Title 58,
46     Occupations and Professions, to provide health care.
47          (e) "Managed care organization" means:
48          (i) a managed care organization as defined in Section 31A-27a-403; and
49          (ii) a third party administrator.
50          (f) (i) "Post stabilization care" means services related to emergency services that:
51          (A) are provided by the physician who performed the emergency services;
52          (B) are provided after an enrollee's condition is no longer considered an emergency
53     medical condition as defined in Section 31A-22-627;
54          (C) stabilize as defined in 42 U.S.C. Sec. 1395dd(e)(3) or improve or resolve the
55     enrollee's condition; and
56          (D) are provided within 90 days after the day on which the enrollee's condition is no
57     longer considered an emergency medical condition as defined in Section 31A-22-627.
58          (ii) "Post stabilization care" does not include health care facility charges or laboratory

59     charges.
60          (2) A managed care organization that offers or administers a network plan shall
61     maintain a network that is sufficient in number and appropriate types of licensed providers,
62     including those that serve predominantly low-income, medically underserved individuals, to
63     ensure that all services to enrollees, including children and adults, will be accessible without
64     unreasonable travel or delay.
65          (3) An enrollee under a managed care organization's network plan shall have access to
66     emergency services 24 hours per day, seven days per week.
67          (4) (a) A managed care organization that provides a network plan shall provide
68     adequate access to current and potential enrollees through a contracted network of health care
69     providers, including health care facilities, for each county within the managed care
70     organization's filed service area.
71          (b) Adequate access under Subsection (4)(a) is demonstrated if the managed care
72     organization:
73          (i) has a network of health care providers that meets the maximum travel time and
74     distance standards in, and has sufficient numbers of, health care providers to meet the
75     minimum number of requirements set forth by:
76          (A) the Centers for Medicare and Medicaid Services for Medicare Advantage plans;
77     and
78          (B) modifications to and extensions of the standards in Subsection (4)(b)(i)(A) adopted
79     by the commissioner by administrative rule based on nationally recognized standards and as
80     necessary to reflect the age and demographics of the enrollees in the network plan and the
81     availability of rural health care providers; and
82          (ii) meets adequacy and sufficiency standards established by the commissioner by
83     administrative rule made in accordance with this Subsection (4) and Title 63G, Chapter 3, Utah
84     Administrative Rulemaking Act.
85          (c) The commissioner shall adopt administrative rules in accordance with Title 63G,
86     Chapter 3, Utah Administrative Rulemaking Act, to establish reasonable standards under
87     Subsection (4)(b)(ii).
88          Section 2. Section 31A-22-654 is enacted to read:
89          31A-22-654. Managed care organization provider directories.

90          (1) As used in this section:
91          (a) "Licensed provider" means the same as that term is defined in Section 31A-22-653.
92          (b) "Managed care organization" means the same as that term is defined in Section
93     31A-22-653.
94          (2) (a) A managed care organization shall post electronically a current and accurate
95     directory of licensed providers for each of the organization's network plans.
96          (b) In making the directory available electronically, the managed care organization
97     shall ensure the general public is able to view all of the current licensed providers for a plan
98     through a clearly identifiable link or tab and without creating or accessing an account or
99     entering a policy or contract number.
100          (c) The managed care organization shall update each network plan provider directory at
101     least monthly.
102          (d) A managed care organization does not violate the requirement of Subsection (2)(c)
103     if the managed care organization fails to update the directory because a licensed provider has
104     failed to notify the managed care organization of a change to the licensed provider's
105     information.
106          (3) A managed care organization shall make available through a searchable electronic
107     directory, for each network plan, the following information about each licensed provider in the
108     managed care organization's network plan, as submitted to the managed care organization by
109     the licensed provider:
110          (a) the licensed provider's name;
111          (b) the licensed provider's gender;
112          (c) participating office locations;
113          (d) specialty;
114          (e) medical group affiliations, if applicable;
115          (f) participating facility affiliations, if applicable;
116          (g) languages spoken other than English, if applicable;
117          (h) whether the licensed provider is accepting new patients; and
118          (i) contact information.
119          (4) The provider directory under this section shall accommodate the communication
120     needs of individuals with disabilities and include a link to or information regarding available

121     assistance for individuals with limited English proficiency.
122          Section 3. Section 31A-22-655 is enacted to read:
123          31A-22-655. Managed care organization out-of-network services -- Emergency
124     services -- Post stabilization care -- Balance billing.
125          (1) As used in this section:
126          (a) "Balance billing" means the same as that term is defined in Section 31A-22-653.
127          (b) "Covered benefit" means the same as that term is defined in Section 31A-22-653.
128          (c) "Emergency services" means the same as that term is defined in Section
129     31A-22-653.
130          (d) "Licensed provider" means the same as that term is defined in Section 31A-22-653.
131          (e) "Managed care organization" means the same as that term is defined in Section
132     31A-22-653.
133          (f) "Post stabilization care" means the same as that term is defined in Section
134     31A-22-653.
135          (2) Upon receiving a bill from a non-network licensed provider with the applicable
136     benchmark rate described in Subsection (5)(b)(i), a managed care organization shall:
137          (a) reimburse a non-network licensed provider for emergency services and post
138     stabilization care in accordance with this section;
139          (b) (i) pay a non-network licensed provider directly for emergency services and post
140     stabilization care provided to an enrollee; and
141          (ii) send an explanation of benefits to the non-network licensed provider with the
142     information required under Subsection (2)(f);
143          (c) pay a non-network licensed provider for emergency services in accordance with
144     Subsection (5);
145          (d) pay a non-network licensed provider for post stabilization care at the in-network
146     allowed amount for the patient's managed care organization plan if:
147          (i) the patient and the licensed provider agree to the post stabilization care;
148          (ii) the non-network licensed provider agrees to abide by the managed care
149     organization's terms and conditions of care that would apply to a network licensed provider;
150     and
151          (iii) the licensed provider submits a single claim for all post stabilization care with a

152     written request for payment under this Subsection (2)(d);
153          (e) ensure that the enrollee is responsible for no more than the applicable in-network
154     cost sharing amount; and
155          (f) provide an explanation of benefits to the enrollee and a remittance to the
156     non-network licensed provider that includes:
157          (i) the amount the non-network licensed provider may attempt to collect from the
158     enrollee for the enrollee's cost sharing, including unmet deductibles, copayments, and
159     coinsurance; and
160          (ii) the managed care organization's allowed amount under Subsection (2)(c) for the
161     emergency services or Subsection (2)(d) for post stabilization care.
162          (3) If a non-network licensed provider sends a bill directly to an enrollee for emergency
163     services or post stabilization care, the bill shall notify the enrollee:
164          (a) that the emergency services or post stabilization care were performed by a licensed
165     provider who is not a network licensed provider for the enrollee's health benefit plan; and
166          (b) that the enrollee is responsible for paying the enrollee's applicable in-network cost
167     sharing amount.
168          (4) A non-network licensed provider who receives payment from the managed care
169     organization under Subsection (2)(c) or (d):
170          (a) may rely on the remittance provided by the managed care organization to the
171     non-network licensed provider under Subsection (2)(f);
172          (b) shall accept the payment from the enrollee under Subsection (3)(b) as payment in
173     full for the emergency services and post stabilization care from the enrollee; and
174          (c) may not attempt to collect payment from an enrollee for emergency services or post
175     stabilization care in excess of the amount under Subsection (3)(b).
176          (5) (a) When a managed care organization receives a bill for emergency services from a
177     non-network licensed provider, the managed care organization shall:
178          (i) ensure that the enrollee is responsible for no more than the applicable in-network
179     cost sharing amount; and
180          (ii) may elect to pay a non-network licensed provider for emergency services:
181          (A) as submitted by the licensed provider;
182          (B) the applicable benchmark rate described in Subsection (5)(b); or

183          (C) in an amount mutually agreed upon by the managed care organization and the
184     licensed provider.
185          (b) (i) The benchmark rate under this section is:
186          (A) for an emergency room physician, the median of the emergency room physician's
187     contracted in-network rates with all managed care organizations in the state; and
188          (B) for a licensed provider who is not an emergency room physician, the 80th
189     percentile of all total amounts paid for the particular health care service performed by a
190     licensed provider in the state in the same or similar specialty as reported in the all payer claims
191     database maintained by the Department of Health.
192          (ii) A managed care organization may submit a request to the department to verify the
193     benchmark rate submitted by a licensed provider under this section.
194          (iii) A licensed provider may request the information described in Subsection
195     (5)(b)(i)(B) from the department for the purpose of providing a bill under Subsection (2).
196          (c) This section does not preclude a managed care organization and a non-network
197     licensed provider from agreeing to a different payment arrangement if:
198          (i) the enrollee is responsible for no more than the applicable in-network cost sharing
199     amount; and
200          (ii) the enrollee has no legal obligation to pay the balance for emergency services
201     remaining after the payments under Subsection (4).
202          Section 4. Section 58-1-510 is enacted to read:
203          58-1-510. Health care provider -- Unprofessional conduct to balance bill for
204     emergency services.
205          (1) As used in this section:
206          (a) "Balance billing" means the same as that term is defined in Section 31A-22-653.
207          (b) "Emergency services" means the same as that term is defined in Section
208     31A-22-653.
209          (c) "Licensed provider" means the same as that term is defined in Section 31A-22-653.
210          (2) It is unprofessional conduct for a licensed provider to engage in balance billing for
211     emergency services in violation of Section 31A-22-655.