Amendments	Fiscal Memos
SA0416	Amendment 1-0 to SB0001
SA0469	Amendment 2-0 to SB0001

No amendments for HB0002.

NOTE: Each fiscal memorandum applies only to the amendment(s) identified in the memorandum. The fiscal memorandum must be matched to any amendments that have been adopted.

Fiscal Summary

NOT SIGNIFICANT

Bill Summary

This bill requires the commissioner of commerce and insurance to establish an independent dispute resolution process by which a dispute for a bill for out-of-network billing emergency services or balance bill may be resolved, as discussed below. This bill requires the commissioner to promulgate rules that establish standards for the resolution process, including a process for selecting independent dispute resolution entities to conduct the resolution process. Independent dispute resolution entities must use licensed physicians in the same or similar specialty as the physician providing the service in dispute.

FACTORS DETERMINING REASONABLE FEES (Section 56-33-105)

This bill sets out in detail certain factors that an independent dispute resolution entity must consider to determine the appropriate amount to pay for a healthcare service. The factors include:

(1) Whether there is a gross disparity between the fee charged and the services rendered as compared to:

(A) Fees paid to the physician for the same services to other patients in health carrier networks; and

(B) Fees paid by health carriers to reimburse physicians in the same or similar specialty for the same services but who are not participating in the network; and

(2) A case's circumstances and complexity including patient's characteristics, usual rate of the service, and fiftieth percentile of rates for the service or supply paid to participating physicians and provided in the same geographical area as reported to the benchmarking database.

DISPUTE RESOLUTION FOR EMERGENCIES

Under this bill, when a health carrier receives a bill for emergency services from an out-of-network facility-based physician or an out-of-network healthcare facility, the health carrier must pay a fee it finds reasonable for the emergency services, not including the enrollee's co-payment, coinsurance, or deductible. The health carrier must pay the fee in accordance with present law which is generally no later than 30 days after the date the health carrier actually receives the claim submitted on paper from a provider or no later than 21 days after receiving the claim by electronic submission. This bill requires the health carrier to ensure that the enrollee does not pay more for the out-of-network emergency services than the enrollee would pay if the services were performed with a participating facility or physician.

Further, if there is a dispute with the payment of the emergency services, this bill creates a dispute resolution process. An out-of-network physician, facility, or health carrier may submit a dispute regarding a fee or payment for emergency services to an independent dispute resolution entity for review. The independent dispute resolution entity will decide within 30 days. This bill requires the independent dispute resolution entity to select the health carrier's payment or the out-of-network facility or physician's fee. For the purposes of deciding, the independent dispute resolution entity uses the factors referred to above. This bill authorizes the independent dispute resolution entity to direct the parties to negotiate if settlement is likely or both parties present unreasonable extremes. The parties will have up to 10 days to negotiate, and the 10 days will run concurrently with the 30-day period for dispute resolution.

If a patient is uninsured, this bill authorizes the patient to submit a dispute regarding an emergency services fee for resolution upon approval of the commissioner. An independent dispute resolution entity will determine the reasonable fee subject to the factors referred to above. This bill does not require the uninsured patient to pay the out-of-network physician's fee prior to submitting a dispute with the independent dispute resolution entity.

This bill declares the independent dispute resolution entity's holding as binding on the health carrier, physician, and patient.

DISPUTE RESOLUTION FOR BALANCE BILLS

Under this bill, if benefits are assigned in a nonemergency, then the health carrier must pay the out-of-network facility or physician in accordance with this bill and the timeframes under present law (discussed above). The out-of-network physician may bill the health carrier for services rendered, and the health carrier is required to either pay for the billed amount or attempt to negotiate. If negotiation fails, the health carrier must pay the physician an amount the health carrier determines as reasonable, excluding the enrollee's obligations, in accordance to present law. If negotiation succeeds, then the carrier must pay in accordance with present law (discussed above).

If there is a dispute regarding the payment, this bill authorizes either the health carrier or the out-of-network physician to submit the dispute for review to an independent dispute resolution entity. This bill sets out in detail the requirements for such a review (see Section 56-33-107). Additionally, this bill creates a dispute resolution process for patients who are not experiencing an emergency and have not assigned benefits. Further, this bill creates a dispute resolution process for uninsured patients in non-emergency situations. A patient will not be required to pay the physician's fee prior to submitting the dispute. The determination of the independent dispute resolution will be binding on the patient, physician, and health carrier.

PAYMENT OF RESOLVED BALANCE BILL

Under this bill, if the independent dispute resolution entity finds one party's fee or payment to be reasonable, the opposing party is responsible for paying for the dispute resolution process. If there is a good faith negotiation between the parties resulting in a settlement, the cost of the resolution process will be split evenly between the parties. If the patient is uninsured and the independent dispute resolution entity finds the out-of-network physician or entity's fee to be reasonable, the patient will be responsible for paying for the dispute resolution process unless it is a hardship to the patient. This bill authorizes the commissioner to determine payment in such cases.

HOLD HARMLESS AND ASSIGNMENT OF BENEFITS FOR INSURED PERSONS

This bill requires that an enrollee only be responsible for co-payments, coinsurance, or deductibles when an enrollee assigns benefits to an out-of-network facility in writing and the physician is aware the enrollee is with an out-of-network benefit. If the enrollee receives emergency services from an out-of-network facility, assigns benefits to the facility, and the facility knows the enrollee is enrolled in an out-of-network plan, the enrollee is only responsible for co-payment, coinsurance, or deductibles that would be normally owed in the enrollee's participating plan. These provisions will not apply to services provided in-network and services provided to enrollees who choose to receive services from an out-of-network facility or physician, except for emergency services.

ON JANUARY 27, 2022, THE SENATE ADOPTED AMENDMENT #2, AND PASSED SENATE BILL 1, AS AMENDED.

AMENDMENT #2 rewrites this bill to adopt the federal No Surprises Act for application within this state to hold patients harmless from incurring a surprise medical bill. This amendment authorizes the commissioner of commerce and insurance to promulgate rules to effectuate the purposes of this amendment.