Repeals GS 58-3-200(a), which sets out definitions for the terms health benefit plan and insurer as used in the statute (Miscellaneous insurance and managed care coverage and network provisions). Instead, enacts GS 58-2-200(a1) (appears to intend GS 58-3-300(a1)), setting forth defined terms clinical laboratory, health care provider, and health services facility, as they apply to the statue.
Amends GS 58-3-200(d) regarding services by outside provider networks. Now requires the insurer, upon notice from the insured, to determine whether a health care provider able to meet the needs of the insured is reasonably available to the insured without unreasonable delay by reference to the insured's location and the specific medical needs of the insured. Requires the amount allowed for services provided under subsection (d) to be calculated using the benchmark amount under GS 58-3-201, as enacted, unless otherwise agreed to by the health care provider and the insurer. Does not require an insurer to make any direct payment to a health care provider. Prohibits health care providers from subjecting an insured to or otherwise requiring prior payment of an amount in excess of the applicable reasonable payment under GS 58-3-201, as enacted, prior to services being rendered to the insured.
Enacts GS 58-3-201, setting a benchmark amount, to be calculated at least annually, which is presumed to be a reasonable total payment for services provided by a health care provider outside an insurer's health care provider network, or for emergency care services provided. Details the calculation of the benchmark amount, and provides for the application of the benchmark amount, deeming payment of the amount to foreclose the health care provider from collecting additional amounts from the insured or any third party. Specifies that the insurer is not required to make payment of any amount owed directly to a health care provider. Deems noncompliance an unfair and deceptive trade practice and actionable under GS Chapter 75. Specifies that the provisions do not foreclose other remedies available.
Enacts Article 11B, Transparency in Health Services Billing Practices, to GS Chapter 11B. Sets forth defined terms health benefit plan, health care provider, health services facility, and insurer. Requires a health services facility or a health care provider participating in the insurer's health care network to provide the insured with a written disclosure containing five specific components at the time the facility or provider: (1) treats the insured for anything other than screening and stabilization, (2) admits an insured to receive emergency services, (3) schedules a procedure for nonemergency services for an insured, or (4) seeks prior authorization from an insurer for the provisions of nonemergency services to an insured. Additionally requires health services facilities to provide a written disclosure to the insured containing four specified components at the time the facility begins the provision of emergency services to an insured when the facility does not have a contract with the applicable insurer.
Prohibits health services facilities and health care providers from collecting an amount for services in excess of the benchmark amount calculated pursuant to GS 58-3-201, as enacted, unless the insurer does not have contracted health care providers or health services facilities in its health care provider network that are able to meet the needs of the insured and that are reasonably available to the insured without unreasonable delay. Defines services and provides for exclusions. Provides for what is considered a reasonable payment and total payment under the statute, mirroring provisions of GS 58-3-201, as enacted. Requires health services facilities contracting with providers that do not participate in an insurer's health care provider network to require the nonparticipating health care providers to comply with the billing and collections practices set out in the statute. Provides for situations where insurers can recover overpayments upon 30 days' notice and demand.
Deems noncompliance an unfair and deceptive trade practice and actionable under GS Chapter 75. Specifies that the provisions do not foreclose other remedies available.
Enacts Article 41A, Transparency in Health Care Provider Billing Practices, in GS Chapter 90. Sets forth defined terms health care provider, health services facility, hospital-based health care provider, and insurer. Requires a nonparticpating health care provider that does not participate in the health care provider network of the insured's insurer to include a statement on any billing notice to an insured that the insured is not responsible for paying any more than the applicable in-network deductible, co-payment, or coinsurance amounts and has no legal obligation to pay any remaining balance in excess of the benchmark amount calculated in GS 58-3-201, as enacted, that applies. Details fair billing and collection practices and what constitutes reasonable payments and total payment, similar to those set forth in Article 11B, GS Chapter 58, as enacted. Deems noncompliance an unfair and deceptive trade practice and actionable under GS Chapter 75. Specifies that the provisions do not foreclose other remedies available.
Applies to health care services provided to insured individuals on or after October 1, 2019.
Bill S 386 (2019-2020)Summary date: Mar 27 2019 - View summary