The proposed bill seeks to amend existing laws related to healthcare provider reimbursement, specifically for licensed ambulatory surgical centers, outpatient psychiatric centers, and outpatient imaging facilities. It aims to establish fair reimbursement rates, ensuring these facilities receive compensation comparable to hospital-based outpatient departments for similar services. The bill addresses current disparities in reimbursement rates that can limit competition and access to affordable care, particularly in light of a recent court ruling that permitted insurers to reimburse these centers at lower rates. Key provisions include a requirement for insurers to reimburse these facilities at no less than 90% of the average hospital-based outpatient rate and to disclose their reimbursement methodologies, with retroactive application to relevant claims and contracts.

Furthermore, the bill enhances transparency in reimbursement practices by mandating insurers to provide a detailed schedule of reimbursement rates and the factors influencing payment determinations. It prohibits insurers from increasing costs or reducing reimbursement rates without meeting specific conditions, such as maintaining a certain medical loss ratio and obtaining approval from the Insurance Commissioner. The legislation emphasizes the protection of patient access to healthcare services by preventing insurers from limiting coverage for outpatient services provided by nonhospital facilities. It also includes enforcement provisions by the Insurance Commissioner, categorizing violations as deceptive acts under existing trade practices laws, and features an emergency clause to address the urgent need for these changes to safeguard the financial viability of healthcare providers and ensure patient access to care.

Statutes affected:
Old version SB626 Original - 4-3-2025 05:45 PM: 23-79-101, 23-79-115, 20-9-201, 20-10-213, 20-9-214, 20-9-215, 23-99-201, 23-99-801, 23-66-201, 4-88-101
SB 626: 23-79-101, 23-79-115, 20-9-201, 20-10-213, 20-9-214, 20-9-215, 23-99-201, 23-99-801, 23-66-201, 4-88-101