2017 -- S 0494

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LC001557

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     STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2017

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A N   A C T

RELATING TO INSURANCE -- SURPRISE OUT-OF-NETWORK BILLS FOR

EMERGENCY AND OTHER MEDICAL SERVICES

     

     Introduced By: Senators Archambault, Satchell, Sheehan, Nesselbush, and Sosnowski

     Date Introduced: March 02, 2017

     Referred To: Senate Health & Human Services

     It is enacted by the General Assembly as follows:

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     SECTION 1. Title 27 of the General Laws entitled "INSURANCE" is hereby amended

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by adding thereto the following chapter:

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CHAPTER 82

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SURPRISE OUT-OF-NETWORK BILLS FOR EMERGENCY AND OTHER MEDICAL

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SERVICES

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     27-82-1. Short title.

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     This chapter shall be known and may be cited as the "Surprise Out-of-Network Bills for

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Emergency and other Medical Services".

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     27-82-2. Applicability.

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     This chapter does not apply to health care services, including emergency services, where

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health care provider fees are subject to schedules or other monetary limitations under any other

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law, including the workers' compensation law, and does not preempt any such law.

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     27-82-3. Definitions.

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     As used in this chapter, the following words and terms shall have the following meanings

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unless the context shall clearly indicate another or different meaning or intent:

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     (1) "Alternative dispute resolution entity" means a person or organization, independent of

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the disputing parties, identified by the health insurance commissioner to resolve disputes pursuant

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to this chapter.

 

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     (2) "Emergency condition" means a medical or behavioral condition that manifests itself

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by acute symptoms of sufficient severity, including severe pain, such that a prudent person,

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possessing an average knowledge of medicine and health, could reasonably expect the absence of

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immediate medical attention to result in:

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     (i) Placing the health of the person afflicted with such condition in serious jeopardy, or in

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the case of a behavioral condition, placing the health of such person or others in serious jeopardy;

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     (ii) Serious impairment to such person's bodily functions;

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     (iii) Serious dysfunction of any bodily organ or part of such person;

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     (iv) Serious disfigurement of such person; or

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     (v) A condition described in §1867 of the Social Security Act, 42 U.S.C. §1395dd

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(e)(1)(A) (i), (ii), or (iii));

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     (3) "Emergency services" means, with respect to an emergency condition:

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     (i) A medical screening examination as required under §1867 of the Social Security Act,

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42 U.S.C. §1395dd, which is within the capability of the emergency department of a hospital,

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including ancillary services routinely available to the emergency department to evaluate such

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emergency medical condition; and

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     (ii) Within the capabilities of the staff and facilities available at the hospital, such further

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medical examination and treatment as are required under §1867 of the Social Security Act, 42

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U.S.C. §1395dd, to stabilize the patient;

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     (4) "Facility" means any institution, place, building, or agency, or portion thereof,

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engaged in providing health care services. This includes, but is not limited to, hospitals,

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ambulatory surgical centers, clinics, outpatient surgery or care centers, laboratories and diagnostic

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centers, and specialized care centers, such as birthing centers and psychiatric care centers.

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     (5) "Health care plan", "health plan", "health benefits", or "health benefit plan" means

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health insurance coverage and a group health plan, pursuant to §§27-18-1.1, 27-19-1, 27-20-1 and

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27-41-2.

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     (6) "Health insurance carrier" means an insurer licensed to write accident and health

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insurance pursuant to chapter 18 of title 27; a nonprofit hospital service corporation licensed to

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write insurance pursuant to chapter 19 of title 27; a nonprofit medical service corporation licensed

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to write insurance pursuant to chapter 20 of title 27; a health maintenance organization licensed to

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write insurance pursuant to chapter 41 of title 27.

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     (7) "Insured" means a patient covered under a health insurance carrier's policy or

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contract.

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     (8) "Out-of-network" or "nonparticipating" means not having a contract with a health

 

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insurance plan to provide health care services to an insured.

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     (9) "In-network" or "participating" means having a contract with a health insurance plan

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to provide health care services to an insured.

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     (10) "Patient" means a person who receives health care services, including emergency

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services, in this state.

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     (11)(i) "Surprise out-of-network bill" means a bill for health care services, other than

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emergency services, received by an insured for services rendered by an out-of-network provider

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at an in-network facility, during a service or procedure performed by an in-network provider or

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during a service or procedure previously approved or authorized by the health carrier and the

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insured did not knowingly elect to obtain such services from such out-of-network provider; and

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     (ii) "Surprise out-of-network bill" does not include a bill for health care services received

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by an insured when an in-network health care provider was available to render such services and

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the insured knowingly elected to obtain such services from another health care provider who was

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out-of-network.

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     27-82-4. Billing and reimbursement.

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     (a) No health insurance plan shall require prior authorization for rendering emergency

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services to an insured.

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     (b) No health insurance plan shall impose, for emergency services rendered to an insured

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by an out-of-network health care provider, a coinsurance, copayment, deductible, or other out-of-

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pocket expense that is greater than the coinsurance copayment, deductible, or other out-of-pocket

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expense that would be imposed if such emergency services were rendered by an in-network

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health care provider.

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     (c) If emergency services were rendered to an insured by an out-of-network health care

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provider, such health care provider shall bill the health carrier directly and the health carrier shall

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reimburse such health care provider the eightieth percentile of all charges for the particular health

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care service performed by a health care provider in the same or similar specialty and provided in

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the same geographical area, as reported in a benchmarking database maintained by a nonprofit

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organization specified by the health insurance commissioner. Such organization shall not be

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affiliated with any health carrier. Nothing in this subsection shall be construed to prohibit such

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health carrier and out-of-network health care provider from agreeing to a greater reimbursement

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amount.

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     (d) With respect to a surprise out-of-network bill:

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     (1) An insured shall only be required to pay the applicable coinsurance, copayment,

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deductible or other out-of-pocket expense that would be imposed for such health care services if

 

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such services were rendered by an in-network health care provider; and

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     (2) The out-of-network health care provider shall bill the health carrier directly and the

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health carrier shall reimburse the out-of-network health care provider for health care services

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rendered at the eightieth percentile of all charges for the particular health care service performed

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by a health care provider in the same or similar specialty and provided in the same geographical

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area, as reported in a benchmarking database maintained by a nonprofit organization specified by

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the health insurance commissioner. Such organization shall not be affiliated with any health

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carrier. Nothing in this subsection shall be construed to prohibit such health carrier and out-of-

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network health care provider from agreeing to a greater reimbursement amount.

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     (e) If health care services were rendered to an insured by an out-of-network health care

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provider and the health carrier failed to inform such insured, if such insured was required to be

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informed, of the network status of such health care provider pursuant to the general laws, the

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health carrier shall not impose a coinsurance, copayment, deductible or other out-of-pocket

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expense that is greater than the coinsurance copayment, deductible or other out-of-pocket expense

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that would be imposed if such services were rendered by an in-network health care provider.

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     27-82-5. Hold harmless for surprise out-of-network bills for insureds.

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     When an insured is subject to a surprise out-of-network bill from a nonparticipating

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health care provider that knows the insured is insured under a health care plan, the

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nonparticipating health care provider shall not bill the insured except for any applicable

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copayment, coinsurance or deductible that would be owed if the insured utilized a participating

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health care provider.

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     27-82-6. Dispute resolution for emergency service.

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     Emergency services for an insured:

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     (1) When a health insurance carrier receives a bill for emergency services from a

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nonparticipating health care provider, the health insurance carrier shall reimburse the

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nonparticipating health care provider pursuant to §27-82-4(c).

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     (2) A nonparticipating health care provider or a health insurance carrier may submit a

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dispute regarding a fee or payment for emergency services for review to an alternative dispute

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resolution entity, provided that the disputed surprise out-of-network bill totals more than six

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hundred dollars ($600).

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     (3) The alternative dispute resolution entity shall make a determination within thirty (30)

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days of the receipt of the dispute for review.

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     (4) The determination of the alternative dispute resolution entity shall be binding on the

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patient, health care provider and health insurance carrier, and shall be admissible in any court

 

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proceeding between the patient or insured, health care provider or health insurance carrier, or in

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any administrative proceeding between this state and the health care provider.

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     27-82-7. Dispute resolution for surprise out-of-network bills.

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     (a) When a health insurance carrier receives a surprise out-of-network bill from

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nonparticipating health care provider, the health insurance carrier shall reimburse the

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nonparticipating health care provider pursuant to §27-82-4(d).

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     (b) Either the health insurance carrier or the nonparticipating health care provider may

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submit a dispute regarding a surprise out-of-network bill for review to an alternative dispute

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resolution entity, provided that the disputed surprise out-of-network bill totals more than six

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hundred dollars ($600).

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     (c) The alternative dispute resolution entity shall make a determination within thirty (30)

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days of receipt of the dispute for review.

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     (d) The determination of the alternative dispute resolution entity shall be binding on the

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patient, health care provider and health insurance carrier, and shall be admissible in any court

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proceeding between the patient or insured, health care provider or health insurance carrier, or in

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any administrative proceeding between this state and the health care provider.

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     27-82-8. Payment for alternative dispute resolution.

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     For disputes involving an insured, when the alternative dispute resolution entity makes a

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determination in favor of the health insurance carrier, payment for the dispute resolution process

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shall be the responsibility of the nonparticipating health care provider. When the alternative

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dispute resolution entity makes a determination in favor of the nonparticipating health care

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provider, payment for the dispute resolution process shall be the responsibility of the health

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insurance carrier. When a good faith negotiation directed by the alternative dispute resolution

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entity results in a settlement between the health insurance carrier and nonparticipating health care

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provider, the health insurance carrier and the nonparticipating health care provider shall evenly

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divide and share the prorated cost for dispute resolution.

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     SECTION 2. This act shall take effect upon passage.

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LC001557

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EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N   A C T

RELATING TO INSURANCE -- SURPRISE OUT-OF-NETWORK BILLS FOR

EMERGENCY AND OTHER MEDICAL SERVICES

***

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     This act would protect people with health insurance from surprise medical bills for

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emergency and other services by requiring a nonparticipating health care provider to bill an

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insured party only for a copayment, or deductible. The nonparticipating health care provider

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would instead be required to directly bill the health insurance carrier for the remainder. This act

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would include detailed steps for billing and reimbursement as well as dispute resolution between

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the health care provide and the insurance carrier. This act would not apply to health care services,

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where health care provider fees are subject to fee schedules.

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     This act would take effect upon passage.

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LC001557

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