AN ACT TO PROVIDE FOR GREATER TRANSPARENCY IN HEALTH CARE SERVICES BILLING.
Amends GS 58-3-200. Defines clinical laboratory, health care provider, and health services facility as they are used in the statute. Directs insurers to determine whether a health care provider able to meet the health care needs of an insured is reasonably available without unreasonable delay by reference to the insured's location and specific medical needs. Provides for the amount to be provided by the insurer to an out-of-network healthcare provider under subsection (d), as described below.
Enacts new GS 58-3-201 (Limitation on balance billing). Provides for the calculation of a benchmark amount for the provision of health care services. Provides that a health care provider's total payment for services provided outside an insurer's health care provider networks under GS 58-3-200(d) or for emergency care services under GS 58-3-190 is presumed reasonable if the payment is equal to or higher than the benchmark amount. A benchmark amount applied to an insured's deductible, co-payment, or coinsurance is considered payment for the services of this statute. Payment of the benchmark amount forecloses the health care provider from collecting any additional amount from the insured or any third party. Nothing in this statute requires an insurer to make any direct payment to a health care provider. Provides that regular willful violations of this statute constitute unfair and deceptive trade practices.
Enacts new GS Chapter 131E, Article 11B (Transparency in Health Services Billing practices).
Requires health services facilities participating in an insurer's health care provider network to submit a written disclosure containing listed information to an insured individual when the facility (1) admits to receive emergency services, (2) schedules a procedure for nonemergency services for, or (3) seeks prior authorization from an insurer for the provision of nonemergency services to the insured individual. Requires health services facilities without a contract with an insured individual's insurer to provide the insured individual with a written notice containing listed information when the facility admits the insured individual to receive emergency services.
Prohibits health services facilities from billing for services at a rate greater than the benchmark amount in GS 58-3-201 unless contracting health care providers able to meet the needs of the insured are reasonably available to the insured without unreasonable delay. Specifies what is included as services and definesservicesto exclude bills received for health care services if a provider participating in an insurer's provider network is available and the insured individual has elected to obtain services from a nonparticipating provider. Provides that a health care provider's payment for services under GS 58-3-200(d) or GS 58-3-190 is reasonable if it is equal to or higher than the benchmark under GS 58-3-201. A benchmark amount applied to an insured's deductible, co-payment, or coinsurance is considered payment for the purposes of this statute. Payment of the benchmark amount forecloses the health care provider from collecting any additional amount from the insured or any third party. Nothing in this statute requires an insurer to make any direct payment to a health care provider. Requires health care facilities that contract with health care providers outside an insured's network to ensure the provider complies with this statute.
Provides that regular willful violations of this article are unfair and deceptive trade practices.
Enacts new GS Chapter 90, Article 41A (Transparency in Health Care Provider Billing Practices).
Requires health care providers outside of an individual's insurance network, including hospital-based providers, to include a statement on any billing notice sent to an insured individual that the individual is responsible for paying the applicable in-network cost-sharing amount but is not obligated to pay the remaining balance when the benchmark in GS 58-3-201 applies.
Imposes the same fair billing requirements on health care providers that new GS 131E, Article 11B, imposes on health services facilities; however, does not defineservices.
Regular willful violations of this statute are unfair and deceptive trade practices.
Effective October 1, 2017, and applies to services provided on or after that date.
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