THE SENATE

S.B. NO.

2668

TWENTY-EIGHTH LEGISLATURE, 2016

S.D. 1

STATE OF HAWAII

 

 

 

 

 

 

A BILL FOR AN ACT

 

 

RELATING TO INSURANCE.

 

 

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 


SECTION 1. The legislature finds that consumers with health insurance who receive treatment from an out-of-network provider may receive a bill for the difference between an insurer's payments to a health care provider and the out-of-network provider's charges. These bills, known as balance bills or surprise bills, occur most often when consumers receive medical services from out-of-network providers. Out-of-network providers may not have a contracted rate with an insurer for services and therefore, the prices these providers may charge may be much greater than the price charged by in-network providers for similar services.

The legislature further finds that balance bills can be an unwelcome surprise to consumers who may not have knowingly decided to obtain health care outside of their provider network. Currently, there is no broad protection from surprise bills or balance bills at the federal level or in most states. In Hawaii, the restriction on balance billing applies to health maintenance organizations and mutual benefit societies only, which must include a provision in provider contracts that states a subscriber or member will not be liable to the provider for amounts owed by the organization or society. The legislature also finds that additional consumer protections are necessary to increase transparency for patients billed for medical services and protect consumers from the need to pay balance bills.

Accordingly, the purpose of this Act is to specify:

(1) Disclosure requirements for health care providers, health care facilities, and hospitals who are nonparticipating providers in a patient's health care plan;

(2) The amount a nonparticipating provider may bill for services performed without prior or subsequent authorization from a patient's health care plan;

(3) That an insured shall not be liable to a health care provider for any sums owed by an insurer; and

(4) That an insured who receives emergency services from a nonparticipating provider shall not incur greater out-of-pocket costs for the emergency services than the insured would have incurred with a participating provider.

SECTION 2. Chapter 321, Hawaii Revised Statutes, is amended by adding two new sections to be appropriately designated and to read as follows:

"321-A Disclosure required. (a) A health care provider, health care facility, or hospital shall disclose the following information in writing to patients or prospective patients prior to the provision of nonemergency services that are not authorized by the patients' health care plan:

(1) That certain health care facility-based providers may be called upon to render care to a covered person during the course of treatment;

(2) That those health care facility-based providers may not have contracts with the covered person's health care plan and are therefore considered to be out-of-network providers;

(3) That the services will therefore be provided on an out-of-network basis and the cost may be substantially higher than if the services were provided in-network;

(4) A notification that the covered person may either agree to accept and pay the charges for the out-of-network services, contact the covered person's health care plan for additional assistance, or rely on any other rights and remedies that may be available under state or federal law; and

(5) A statement indicating that the covered person may obtain a list of health care facility-based providers from the covered person's health care plan that are participating providers and the covered person may request those participating facility-based providers.

(b) If a health care provider, health care facility, or hospital is not a participating provider in a patient's or prospective patient's health care plan network, the health care provider, health care facility, or hospital shall:

(1) Inform a patient or prospective patient of the amount or estimated amount the health care provider will bill the patient for health care services prior to the provision of non-emergency services; and

(2) Disclose to the patient or prospective patient in writing the amount or estimated amount that the health care provider, health care facility, or hospital will bill the patient or prospective patient for health care services provided or anticipated to be provided to the patient or prospective patient, not including unforeseen medical circumstances that may arise when the health care services are provided.

(c) For purposes of this section:

"Health care facility" means any institution, place, building, or agency, or portion thereof, licensed or otherwise authorized by the State, whether organized for profit or not, used, operated, or designed to provide medical diagnosis, treatment, rehabilitative, or preventive care to any person or persons.

"Health care plan" means a health insurance company, mutual benefit society governed by article 1 of chapter 432, health care service plan or health maintenance organization governed by chapter 432D, or any other entity delivering or issuing for delivery in the State accident and health or sickness insurance as defined in section 431:1-205, other than disability insurance that replaces lost income.

"Health care provider" means an individual who is licensed or otherwise authorized by the State to provide health care services.

"Hospital" means:

(1) An institution with an organized medical staff, regulated under section 321-11(10), that admits patients for inpatient care, diagnosis, observation, and treatment; and

(2) A health facility under chapter 323F.

321-B Health care provider responsibility. (a) A health care provider, health care facility, or hospital who is a nonparticipating provider with a patient's health care plan shall bill no more than one hundred twenty per cent of the amount medicare would pay for the service to the patient's health care plan if the services were performed without the prior or subsequent authorization of the patient's health care plan.

(b) For purposes of this section:

"Health care facility" shall have the same meaning as in section 321-A.

"Health care plan" shall have the same meaning as in section 321-A.

"Health care provider" shall have the same meaning as in section 321-A.

"Hospital" shall have the same meaning as in section 321-A."

SECTION 3. Chapter 431, Hawaii Revised Statutes, is amended by adding a new section to article 10A to be appropriately designated and to read as follows:

"431:10A-   Balance billing; hold harmless; emergency services. (a) Every contract between an insurer and a participating provider of health care services shall be in writing and shall set forth that in the event the insurer fails to pay for health care services as set forth in the contract, the insured shall not be liable to the provider for any sums owed by the insurer.

(b) When an insured receives emergency services from a provider that is not a participating provider in the provider network of an insurer, the insured shall not incur greater out-of-pocket costs for the emergency services than the insured would have incurred with a participating provider of health care services.

(c) If a contract with a participating provider has not been reduced to writing as required by this section, or if a contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the insured sums owed by the insurer. No participating provider, or agent, trustee, or assignee thereof, may maintain any action at law against an insured to collect sums owed by the insurer.

(d) When an insured receives emergency services from a provider that is not a participating provider in the provider network of the insured, the insurer shall make certain that the insured shall incur no greater out-of-pocket costs for emergency services than the insured would have incurred with a participating provider of health care services.

(e) For purposes of this section:

"Emergency condition" means a medical or behavioral condition that manifests itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

(1) Placing the health of the person afflicted with the condition in serious jeopardy;

(2) Serious impairment to the person's bodily functions;

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

(4) Serious disfigurement of the person.

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

(1) A medical screening examination as required under section 1867 of the Social Security Act, 42 United States Code section 1395dd; and

(2) Any further medical examination and treatment, as required under section 1867 of the Social Security Act, title 42 United States Code section 1395dd, to stabilize the patient."

SECTION 4. Section 432:1-407, Hawaii Revised Statutes, is amended by amending subsection (d) to read as follows:

"(d) Every contract between a mutual benefit society and a participating provider of health care services shall be in writing and shall set forth that in the event the society fails to pay for health care services as set forth in the contract, the subscriber or member shall not be liable to the provider for any sums owed by the society. When a subscriber or member receives emergency services from a provider that is not a participating provider in the provider network of the mutual benefit society, the mutual benefit society shall ensure that the subscriber or member shall incur no greater out-of-pocket costs for emergency services than the subscriber or member would have incurred with a participating provider of health care services. If a contract with a participating provider has not been reduced to writing as required by this subsection, or if a contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or member sums owed by the society. No participating provider, or agent, trustee, or assignee thereof, may maintain any action at law against a subscriber or member to collect sums owed by the society.

For purposes of this subsection, "emergency services" shall have the same meaning as in section 431:10A-  ."

SECTION 5. Section 432D-8, Hawaii Revised Statutes, is amended by amending subsection (d) to read as follows:

"(d) Every contract between a health maintenance organization and a participating provider of health care services shall be in writing and shall set forth that in the event the health maintenance organization fails to pay for health care services as set forth in the contract, the subscriber or enrollee shall not be liable to the provider for any sums owed by the health maintenance organization. When a subscriber or enrollee receives emergency services from a provider that is not a participating provider in the provider network of the health maintenance organization, the health maintenance organization shall ensure that the subscriber or enrollee shall incur no greater out-of-pocket costs for emergency services than the subscriber or enrollee would have incurred with a participating provider of health care services. In the event that a contract with a participating provider has not been reduced to writing as required by this subsection or that a contract fails to contain the required prohibition, the participating provider shall not collect or attempt to collect from the subscriber or enrollee sums owed by the health maintenance organization. No participating provider, or agent, trustee, or assignee thereof, may maintain any action at law against a subscriber or enrollee to collect sums owed by the health maintenance organization.

For purposes of this subsection, "emergency services" shall have the same meaning as in section 431:10A-  ."

SECTION 6. In codifying the new sections added by section 2 of this Act, the revisor of statutes shall substitute appropriate section numbers for the letters used in designating the new sections in this Act.

SECTION 7. New statutory material is underscored.

SECTION 8. This Act shall take effect on July 1, 2050.

 


 


 

Report Title:

Insurance; Out-of-Network Providers; Balance Bills; Surprise Bills; Disclosure; Hold Harmless; Emergency Services; Health Care Providers; Health Care Facilities; Hospitals

 

Description:

Specifies disclosure requirements for health care providers, health care facilities, and hospitals who are nonparticipating providers in a patient's health care plan. Specifies the amount a nonparticipating provider may bill for services performed without prior or subsequent authorization from a patient's health care plan. Specifies an insured shall not be liable to a health care provider for any sums owed by an insurer. Specifies that an insured who receives emergency services from a nonparticipating provider shall not incur greater out-of-pocket costs for the emergency services than the insured would have incurred with a participating provider. Effective 7/1/2050. (SD1)

 

 

 

The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.