Contains whereas clauses. 

Section 1.

Makes the following changes to Article 11B of Chapter 131E. Organizes the Article into two parts, Part I, consisting of the Health Care Cost Reduction Act of 2013 (2013 Act) and Part II, pertaining to Transparency in Healthcare Billing Practices (discussed in Section 2 below).  Makes clarifying, technical, and conforming changes.

Makes the following changes to the Act. Requires hospitals to submit quarterly reports (currently annual report) on DRG’s (diagnostic related groups), to submit to the Department of Health and Human Services (DHHS), as described, and adds new calculation required by the act on how to determine the amount that will be charged to each patient for each DRG. Removes outdated language.

Requires the following quarterly reports (currently, annual reports) to Department of Health and Human Services (DHHS) by: (1) certain qualifying hospitals on DRG’s (diagnostic related groups) as described, and with new calculation required by the act on how to determine the amount that will be charged to each patient for each DRG; (2) hospitals and ambulatory surgical facilities as described on the total costs for the most common surgical and imaging procedures as described and with the new calculation required by the act. Requires the NC Medical Care Commission (Commission) to adopt rules to accomplish the three listed directives, including to establish and define no fewer than ten quality measures for licensed hospitals and licensed ambulatory surgical facilities and the methodology that hospitals or ambulatory surgical facilities should use to determine the most common DRG’s or common surgical and imaging procedures, as appropriate.  Enacts new GS 131E-214.18 imposing a civil penalty for failure to comply with the Act, including penalties to be assessed for each violation day in the amounts described. Requires DHHS to remit the clear proceeds of any civil penalty to the Civil Penalty and Forfeiture Fund (Fund).

Defines health benefit plan, health service facility, healthcare provider, and insurer.

Effective on the later of January 1, 2026, or the date the rules adopted by the Commission take effect. Directs that GS 131E-214.18, as enacted by the act, applies to acts occurring on or after that date.

Section 2.

Enacts GS 131E-214.30, as follows.  Requires at the time a health service facility participating in an insurer's healthcare provider network (1) treats an insured individual for anything other than screening and stabilization; (2) admits an insured individual to receive emergency services; (3) schedules a procedure for nonemergency services for an insured individual; or (4) seeks prior authorization from an insurer for the provision of nonemergency services to an insured individual, to provide the insured individual with a written disclosure pertaining to billing, out-of-network services, and consumer protections, as described.  Requires, emergency services facilities to disclose to an insured individual if it does not have a contract for services with the insured’s insurer, and to provide information about consumer protections, as described.

Enacts GS 131E-214.31, as follows. Requires at the time a healthcare provider (1) treats an insured individual for anything other than screening and stabilization; (2) schedules a procedure for nonemergency services for an insured individual; or (3) seeks prior authorization from an insurer for the provision of nonemergency services to an insured individual, to provide the insured individual with a written disclosure that warns the insured that the healthcare provider is not in the insured’s healthcare provider network and provides consumer protection information, as described.

Designates failure to comply with the above requirements as an unfair trade practice.  Clarifies that nothing in Article 11B of GS Chapter 131E forecloses other remedies available under law or equity.

Repeals the definition of health benefit plan in GS 58-3-200(a)(1) and insurer in GS 58-3-200(a)(2) (definitions section of provisions pertaining to miscellaneous insurance and managed care coverages and networks).  Adds terms clinical laboratory, health service facility, and healthcare provider.

Requires an insurer upon request under GS 58-3-200(d) (services outside provider networks), to determine whether a healthcare provider able to meet the needs of the insured is available to the insured without unreasonable delay by reference to the insured's location and the specific medical needs of the insured.

Applies to healthcare services provided on or after October 1, 2026, and to contracts issued, renewed, or amended or after that date.

Section 3.

Adds new Article 11C to GS Chapter 131E, entitled “Fair Billing and Collection Practices for Hospitals and Ambulatory Surgical Facilities," as follows. Recodifies GS 131E-91(fair billing and collections practices for hospitals and ambulatory surgical facilities) as GS 131E-214.50, and reorganizes that provision into new Article 11C. Requires a hospital or ambulatory surgical facility to first present an itemized list of charges to the patient detailing the specific nature of the charges or expenses incurred by the patient before referring the bill to collection as another required collections practice under new GS 131E-214.50.  Enacts new GS 131E-215.52 (patient’s right to a good faith estimate) as part of new Article 11C, as follows. Defines CMS, facility (licensed hospital or ambulatory surgical facility), items and services, service package, and shoppable service (a non-urgent service that can be scheduled by the patient in advance).  Requires a facility to provide, upon request, a good faith estimate for a shoppable service as described.  Limits a patient’s final bill from exceeding more than 5% of the good faith estimate. Requires DHHS to adopt rules to implement the statute.

Effective on the later of January 1, 2026, or the date the rules adopted by DHHS become effect. Applies to acts occurring after the effective date. 

Section 4.

Adds new GS 131E-214.54 (concerning facility fees) to Article 11C, as follows.  Defines campus, facility fee (any fee charged or billed by a health care provider for outpatient services provided in a hospital-based facility that is (i) intended to compensate the health care provider for the operational expenses of the health care provider, (ii) separate and distinct from a professional fee, and (iii) charged regardless of the modality through which the health care services were provided), health care provider, health systems, hospital, hospital-based facility, professional fee, and remote location of a hospital.

Places the following limits on facility fees: (1) prevents a health care provider from assessing a charge, bill, or collecting a facility fee unless the services are provided on a hospital's main campus, at a remote location of a hospital, or at a facility that includes an emergency department and (2) regardless of where the services are provided, no health care provider from assessing a charge, bill, or collecting a facility fee for outpatient evaluation and management services, or any other outpatient, diagnostic, or imaging services identified by DHHS. Requires DHHS to annually identify those services. 

Requires each hospital and health system to submit a report to DHHS by July 1 on the six specified matters.  Specifies that all violations of the statute are an unfair trade practice. Subjects health care providers that violate the statute to a civil penalty of not more than $1,000 per occurrence.  Requires DHHS to adopt rules to implement new GS 131E-214.54. Effective on the later of January 1, 2026, or the date DHHS adopts the rules discussed above. 

Section 5.

Expands the State Auditor’s responsibilities under GS 147-64.6 to include a periodic review of health service facilities that receive State funds for information on the prices these facilities charge out-of-network or uninsured patients and their transparency about those prices.

Part 6.

Expands the obligations pertaining to expedited appeals under GS 58-50-61(k) to include utilization review organizations (currently just insurers). Makes clarifying and technical changes. Requires an insurer to provide its contact information for the insurer as part of the written information it must provide as part of a first-level grievance review (currently have to provide review contact information for the reviewer), and makes technical changes to GS 58-50-62(e) (concerning first-level grievance reviews). Requires the insurer to provide information on how and where to submit written material for a second-level grievance review (currently, just have to provide its contact information) in GS 58-50-62(f) (second-level grievance reviews).

Section 7.

Expands acts that are not considered the “unlawful practice of dentistry” under GS 90-29 to include the mechanism by which a management company (defined), and a licensee establish the fee in a management arrangement (defined). Specifies that a management fee established under this exception is a private business contract and is not evidence of a partnership under GS Chapter 59.

Section 8.

Amends GS 131E-176 (the definitions pertaining to certificates of need) so that rehabilitative health services; rehabilitation health service facilities; rehabilitation health service facility beds; rehabilitation facility hospitals for rehabilitation of injured, disabled, or sick persons; nursing provided at an at a non-inpatient rehabilitation facility for the rehabilitation of sick, injured, or disabled individuals are no longer included in the definitions. Amends term rehabilitation facility so that it means a facility that has been classified and designated as an inpatient rehabilitation facility by the Centers for Medicare and Medicaid Services (currently, means a public or private inpatient facility which is operated for the primary purpose of assisting in the rehabilitation of individuals with disabilities through an integrated program of medical and other services which are provided under competent, professional supervision).