ON FEBRUARY 23, 2023, THE SENATE ADOPTED AMENDMENT #1 AND PASSED SENATE BILL 266, AS AMENDED.
AMENDMENT #1 deletes the present law regarding the collection of out-of-network charges by healthcare facilities, as described below.
WRITTEN NOTICE
Present law prohibits healthcare facilities, which includes licensed hospitals and ambulatory surgical treatment centers, from collecting out-of-network charges from an insured, or the insurer on behalf of the insured, in excess of the cost sharing amount required in accordance with the insured’s health benefits coverage for the items and services, unless the healthcare facility provides written notice to the insured or the insured’s personal representative, prior to medical services being provided, that contains the following:
(1) A statement that the insured agrees to receive medical services by the out-of-network facility and will receive a bill for the amount unpaid by the insured’s insurer;
(2) A statement that the nonparticipating out-of-network facility-based physician may not have a current contract provider agreement with the insured’s insurer and is an out-of-network provider;
(3) A statement that the insured agrees to receive medical services by an out-of-network provider and will receive a bill for the amount unpaid by the insured’s insurer;
(4) If the healthcare facility is out of network or otherwise a nonparticipating provider, the estimated amount that the facility will charge the insured for items and services;
(5) A listing of anesthesiologists, radiologists, emergency room physicians, and pathologists or the groups of such healthcare providers with which the facility has contracted, including the healthcare provider or group name, phone number, and website, along with including the statement:
The physicians and other healthcare providers that may treat the patient at this facility may not be employed by this facility and may not participate in the patient’s insurance network. Anesthesiologists, radiologists, emergency room physicians, and pathologists are not employed by this facility. Services provided by those specialists, among others, will be billed separately. Before receiving services, the patient should check with his or her insurance carrier to find out if the patient’s providers are in-network. Otherwise, the patient may be at risk of higher out-of-network charges; and
(6) The written notice must also provide information about the possibility of a transfer to an in-network facility if the in-network facility has similar treatment available and will not risk the insured’s health.
The insured or the insured’s personal representative must then sign the written notice, acknowledging agreement to receive medical services by an out-of-network provider or, should the insured or insured’s personal representative refuse to sign the written notice, the healthcare facility must document in the patient’s medical record that it provided the notice and that the patient refused to sign the notice.
Present law also requires that this written notice be provided to the insured or the insured’s personal representative at the time of admission. If the insured is receiving medical services through a hospital emergency department and is incapacitated or unconscious at the time of receiving those services, the notice will not be required at that time. If that is the case, the written notice must be provided after receiving medical services and within 12 hours following stabilization. Information about a transfer to an in-network facility must accompany the written notice. Present law provides that a stabilized condition means, with respect to an emergency medical condition, where no material deterioration of the condition is likely, within a reasonable medical probability to result from or occur during transfer of the individual from a facility.
Present law further requires that when treated at an out-of-network facility, the insured or the insured’s personal representative must receive the written notice from the facility before being transferred by an ambulance to another facility for treatment of medical services unless the insured would be at risk of bodily injury by the facility giving the insured the notice.
INFORMATION REQUIREMENTS
Prior to admission for a scheduled medical procedure, a healthcare facility must provide the insured with informational materials that include the following:
(1) The estimated amount of copay, deductible, or coinsurance, or range of estimates, that the facility will charge the insured for scheduled items and/or services provided by the facility in accordance with the insured’s health benefit coverage for the items and services or as estimated by the insurance company on its website for its insured or through the available information to the facility at the time of the prior authorization;
(2) A listing of anesthesiologists, radiologists, emergency room physicians, and pathologists or the groups of such healthcare providers with which the facility is contracted, including the healthcare provider or group name, phone number, and website; and
(3) The following statement: The patient will be billed for additional charges, including out-of-network charges, if the patient is provided medical services by a healthcare provider that is not in-network. In particular, the patient should ask the facility if he or she will be provided any medical services by anesthesiologists, radiologists, emergency room physicians, or pathologists who are not in the patient’s network.
BILL
A bill to an insured from a healthcare provider or healthcare facility is required to contain a telephone number for the department and a clear and concise statement that the insured may call the department to complain about any out-of-network charges.
NON-COMPLIANCE
Present law provides that the failure of the healthcare facility to provide both the notice and information enumerated above does not give rise to any right of indemnification or private cause of action against the healthcare facility by an out-of-network facility-based physician for an insurer’s disregard of an insured’s assignment of benefit.
IN-NETWORK HEALTHCARE FACILITIES
An in-network healthcare facility does not need to provide an insured with the written notice if the healthcare facility employs all facility-based physicians or requires all facility-based physicians to participate in all of the insurance networks in which the healthcare facility is a participating provider or if the healthcare facility contractually prohibits all facility-based physicians from balance billing patients in excess of the cost sharing amount required in accordance with the insured’s health benefits coverage of the items and services provided.

Statutes affected:
Introduced: 56-7-120