LB569 LB569
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LEGISLATURE OF NEBRASKA
ONE HUNDRED SIXTH LEGISLATURE
FIRST SESSION
LEGISLATIVE BILL 569
Introduced by Morfeld, 46.
Read first time January 22, 2019
Committee: Banking, Commerce and Insurance
1 A BILL FOR AN ACT relating to health care benefits; to adopt the Out-of-
2 Network Consumer Protection, Transparency, and Accountability Act.
3 Be it enacted by the people of the State of Nebraska,
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1 Section 1. Sections 1 to 19 of this act shall be known and may be
2 cited as the Out-of-Network Consumer Protection, Transparency, and
3 Accountability Act.
4 Sec. 2. For purposes of the Out-of-Network Consumer Protection,
5 Transparency, and Accountability Act, the definitions found in sections 3
6 to 13 of this act apply.
7 Sec. 3. Carrier means an entity that contracts to provide, deliver,
8 arrange for, pay for, or reimburse any of the costs of health care
9 services under a health benefits plan.
10 Sec. 4. Covered person means a person on whose behalf a carrier is
11 obligated to pay health care expense benefits or provide health care
12 services.
13 Sec. 5. (1) Health benefits plan means a benefits plan which pays
14 or provides hospital and medical expense benefits for covered services
15 and is delivered or issued for delivery in this state by or through a
16 carrier.
17 (2) Health benefits plan does not include the medical assistance
18 program, medicare, medicare advantage, accident-only, credit, disability,
19 or long-term care coverage, TRICARE supplement coverage, coverage arising
20 out of a workers' compensation or similar law, automobile medical payment
21 insurance, personal injury protection insurance, and hospital confinement
22 indemnity coverage.
23 Sec. 6. Health care facility means a general acute hospital,
24 satellite emergency department, or ambulatory surgical center licensed
25 pursuant to the Health Care Facility Licensure Act.
26 Sec. 7. Health care professional means an individual who is
27 credentialed pursuant to the Uniform Credentialing Act, who is acting
28 within the scope of his or her credential, and who provides a covered
29 service defined by the health benefits plan.
30 Sec. 8. Health care provider means a health care professional or
31 health care facility.
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1 Sec. 9. (1) Inadvertent out-of-network services means health care
2 services that are covered under a health benefits plan which provides a
3 network and that are provided by an out-of-network health care provider
4 in the event that a covered person utilizes an in-network health care
5 facility for covered health care services and, for any reason, in-network
6 health care services are unavailable in that facility.
7 (2) Inadvertent out-of-network services includes laboratory testing
8 ordered by an in-network health care provider and performed by an out-of-
9 network bio-analytical laboratory.
10 Sec. 10. Knowingly, voluntarily, and specifically selected an out-
11 of-network health care provider means that a covered person chose the
12 services of a specific health care provider, with full knowledge that the
13 health care provider is out-of-network with respect to the covered
14 person’s health benefits plan, under circumstances that indicate that the
15 covered person had the opportunity to obtain covered services by an in-
16 network health care provider, but instead selected the out-of-network
17 health care provider.
18 Sec. 11. Medical assistance program means the medical assistance
19 program established pursuant to the Medical Assistance Act.
20 Sec. 12. Medically necessary means a health care service that a
21 health care provider, exercising his or her prudent clinical judgment,
22 would provide to a covered person for the purpose of evaluating,
23 diagnosing, or treating an illness, an injury, or a disease, or its
24 symptoms, and that is in accordance with the generally accepted standards
25 of medical practice; that is clinically appropriate, in terms of type,
26 frequency, extent, site, and duration, and considered effective for the
27 covered person's illness, injury, or disease; that is not primarily for
28 the convenience of the covered person or the health care provider; and
29 that is not more costly than an alternative service or sequence of
30 services at least as likely to produce equivalent therapeutic or
31 diagnostic results as to the diagnosis or treatment of that covered
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1 person's illness, injury, or disease.
2 Sec. 13. TRICARE means a health care program of the United States
3 Department of Defense Military Health System.
4 Sec. 14. Prior to scheduling an appointment with a covered person
5 for a nonemergency procedure, a health care facility shall:
6 (1) Disclose to the covered person whether the health care facility
7 is in-network or out-of-network with respect to the covered person’s
8 health benefits plan;
9 (2) Advise the covered person to check with the health care provider
10 arranging the facility services to determine whether or not that health
11 care provider and any health care provider reasonably anticipated to
12 provide services to the covered person is in-network or out-of-network
13 with respect to the covered person's health benefits plan;
14 (3) Advise the covered person that, at an in-network health care
15 facility with respect to the person's health benefits plan:
16 (a) The covered person will have a financial responsibility
17 applicable to an in-network procedure and not in excess of the covered
18 person's copayment, deductible, or coinsurance as provided in the covered
19 person's health benefits plan;
20 (b) Unless the covered person, at the time of the disclosure
21 required pursuant to this subdivision, has knowingly, voluntarily, and
22 specifically selected an out-of-network health care provider to provide
23 services, the covered person will not incur any out-of-pocket costs in
24 excess of the charges applicable to an in-network procedure; and
25 (c) Any bills, charges, or attempts to collect by the health care
26 facility or any health care provider involved in the procedure, in excess
27 of the covered person's copayment, deductible, or coinsurance as provided
28 in the covered person's health benefits plan in violation of subdivision
29 (b) of this subdivision, should be reported to the covered person's
30 carrier; and
31 (4) Advise the covered person that, at an out-of-network health care
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1 facility with respect to the covered person's health benefits plan:
2 (a) The covered person may have a financial responsibility
3 applicable to health care services provided at an out-of-network
4 facility, in excess of the covered person’s copayment, deductible, or
5 coinsurance, and the covered person may be responsible for any costs in
6 excess of those allowed by the health benefits plan; and
7 (b) The covered person should contact the covered person's carrier
8 for further consultation on those costs.
9 Sec. 15. A health care facility shall post on the facility's web
10 site:
11 (1) The health benefits plans in which the health care facility is a
12 participating health care provider;
13 (2) A statement that physician services provided in the health care
14 facility are not included in the facility's charges; and
15 (3) A statement that health care providers who provide services in
16 the health care facility may or may not participate with the same health
17 benefits plans as the health care facility.
18 Sec. 16. (1) Prior to scheduling a nonemergency procedure, a health
19 care provider shall disclose to a covered person the following:
20 (a) The health benefits plans in which the provider is a
21 participating provider and facilities with which the provider is
22 affiliated; and
23 (b) If the provider is out-of-network for the covered person, that
24 the covered person will have a financial responsibility applicable to
25 health care services provided by an out-of-network provider, in excess of
26 the covered person's copayment, deductible, or coinsurance, and the
27 covered person may be responsible for any costs in excess of those
28 allowed by the health benefits plan.
29 (2) A health care provider who is a physician shall provide, to the
30 extent the information is available:
31 (a) The name, practice name, and telephone number of any provider
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1 scheduled to perform anesthesiology, laboratory, pathology, radiology, or
2 assistant surgeon services in connection with care to be provided in the
3 physician's office for the covered person or coordinated or referred by
4 the physician for the covered person at the time of referral to, or
5 coordination of, services with that provider to the covered person; and
6 (b) For a covered person's scheduled facility admission or scheduled
7 outpatient facility services, the name, practice name, and telephone
8 number of any other physician whose services will be arranged by the
9 physician and are scheduled at the time of the preadmission, testing,
10 registration, or admission at the time the nonemergency services are
11 scheduled to the covered person and the facility.
12 Sec. 17. If a covered person receives medically necessary services
13 at any health care facility on an emergency or urgent basis as defined by
14 the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. 1395dd et
15 seq., the facility shall not bill the covered person in excess of any
16 deductible, copayment, or coinsurance amount applicable to in-network
17 services pursuant to the covered person's health benefits plan.
18 Sec. 18. If a covered person receives inadvertent out-of-network
19 services or medically necessary services at an in-network or out-of-
20 network health care facility on an emergency or urgent basis as defined
21 by the Emergency Medical Treatment and Active Labor Act, 42 U.S.C. 1395dd
22 et seq., the health care provider performing those services shall:
23 (1) In the case of inadvertent out-of-network services, not bill the
24 covered person in excess of any deductible, copayment, or coinsurance
25 amount; and
26 (2) In the case of emergency and urgent services, not bill the
27 covered person in excess of any deductible, copayment, or coinsurance
28 amount applicable to in-network services pursuant to the covered person's
29 health benefits plan.
30 Sec. 19. (1) If a covered person receives inadvertent out-of-
31 network services or receives services at an in-network or out-of-network
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1 health care facility on an emergency or urgent basis, the carrier shall
2 ensure that the covered person incurs no greater out-of-pocket costs than
3 the covered person would have incurred with an in-network health care
4 provider for covered services.
5 (2) With respect to inadvertent out-of-network services or services
6 at an in-network or out-of-network health care facility on an emergency
7 or urgent basis, benefits provided by a carrier that the covered person
8 receives for health care services shall be assigned to the out-of-network
9 health care provider, which shall require no action on the part of the
10 covered person.
11 (3) Once the benefit is assigned, any reimbursement paid by the
12 carrier shall be paid directly to the out-of-network health care
13 provider. The carrier shall provide the out-of-network health care
14 provider with a written remittance of payment that specifies the proposed
15 reimbursement and the applicable deductible, copayment, or coinsurance
16 amounts owed by the covered person.
17 (4) If inadvertent out-of-network services or services provided at
18 an in-network or out-of-network health care facility on an emergency or
19 urgent basis are performed, the out-of-network health care provider may
20 bill the carrier for the services rendered. The carrier may pay the
21 billed amount or notify the health care provider within twenty days after
22 the date of the receipt of the claim that the carrier considers the claim
23 to be excessive.
24 (5) If the carrier provides this notification, the carrier and the
25 health care provider shall have thirty days after the date of this
26 notification to negotiate a settlement. The carrier may attempt to
27 negotiate a final reimbursement amount with the out-of-network health
28 care provider which differs from the amount paid by the carrier pursuant
29 to this section.
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