The bill amends the Surprise Billing Protection Act to revise the method for calculating reimbursement rates for health care providers. Specifically, it mandates that health insurance carriers directly reimburse nonparticipating providers for services rendered based on a "surprise bill reimbursement rate." This rate will now be determined using claims data from the calendar year that is two years prior to the year in which the service was provided, rather than the previously used 2017 plan year data.

Additionally, the definition of the "surprise bill reimbursement rate" is updated to reflect the sixtieth percentile of the allowed commercial reimbursement rate for the specific health care service performed by a provider in the same specialty and geographic area. The bill also stipulates that no reimbursement rate shall be less than one hundred fifty percent of the approved and published Medicare reimbursement rate for the applicable service from the calendar year prior to when the service was provided. The previous requirement for a nonprofit organization to maintain a benchmarking database has been removed, and the superintendent will now specify the database after consulting with health care sector stakeholders.

Statutes affected:
introduced version: 59A-57A-13