SENATE DOCKET, NO. 1194        FILED ON: 1/19/2017

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 522

The Commonwealth of Massachusetts

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PRESENTED BY:

Eileen M. Donoghue

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To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
Court assembled:

The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:

An Act reducing the financial burden of surprise medical bills for patients.

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PETITION OF:

SENATE DOCKET, NO. 1194        FILED ON: 1/19/2017

SENATE  .  .  .  .  .  .  .  .  .  .  .  .  .  .  No. 522

The Commonwealth of Massachusetts

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In the One Hundred and Ninetieth General Court
(2017-2018)

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An Act reducing the financial burden of surprise medical bills for patients.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:
 

Chapter 176O of the General Laws, as so appearing, is hereby amended by inserting after Section 27 the following new section:-

Section 28. (a) Definitions. For the purposes of this section:

(1) “Emergency services” means, with respect to an emergency medical condition:  (1) a medical screening examination as required under section 1867 of the social security act, 42 U.S.C. § 1395dd, which is within the capability of the emergency division of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition; and (2) within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under section 1867 of the social security act, 42 U.S.C. § 1395dd, to stabilize the patient.

(2) “Non-participating” means not having a contract with a carrier to provide health care services to an insured.

(3) “Non-participating provider rate” means with respect to payment to a non-participating provider under this section, 100 percent of the Medicare reimbursement rate or reasonable approximation thereof for those services as if they were rendered to a Medicare beneficiary not taking into consideration any beneficiary cost sharing. For services or supplies for which there is no Medicare reimbursement amount, the amount as determined by the commissioner of the center for health information and analysis is to be consistent with Medicare payment policies at a 100 percent level and set in consultation with the commissioner of insurance.

(b) Services that must be covered by law.

(1) Emergency services for an insured.

(A) When a carrier receives a bill for emergency services from a non-participating provider, the carrier shall pay a reasonable amount not less than the non-participating provider rate for the emergency services rendered by the non-participating physician, except for the insured's co-payment, coinsurance or deductible, if any, and shall ensure that the insured shall incur no greater out-of-pocket costs for the emergency services than the insured would have incurred with a participating provider.

(B) Any provider that is reimbursed for services pursuant to this section is prohibited from billing, charging, seeking payment or reimbursement from, or having any recourse against a insured or a person acting on behalf of insured.  This prohibition does not prohibit the provider from collecting any applicable co-payment, coinsurance or deductible from the insured.

(2) Non-participating providers at participating facilities.

(A) When a carrier receives a bill for services provided by a non-participating provider at a participating facility that the carrier is required to pay pursuant to Section 6 of this Chapter, the carrier shall pay a reasonable rate not less than the non-participating provider rate for the services rendered by the non-participating provider, except for the insured’s co-payment, coinsurance or deductible, if any, and shall ensure that the insured shall incur no greater out-of-pocket costs for the implicated services than the insured would have incurred with a participating provider.

(B) Any provider that is reimbursed for services pursuant to this section is prohibited from billing, charging, seeking payment or reimbursement from, or having any recourse against an insured or a person acting on behalf of insured.  This prohibition does not prohibit the provider from collecting any applicable co-payment, coinsurance or deductible from the insured.

(c) Non-participating provider charges that are not reimbursable by the carrier.

(1) Any provider not receiving a non-participating provider rate pursuant this section that chooses to treat an insured must perform an eligibility check to determine whether such provider is a participating provider in the insured’s carrier network.  In the event that the provider is not a participating provider in the insured’s carrier network, the provider must disclose to the insured, and obtain a written consent confirming the insured’s understanding that: (a) the provider is not a participating provider in the insured’s network, (b) the insured will be responsible for the cost of services,  (c) the dollar amount or reasonable estimate for cost of services to be provided, and (d) the insured could seek care from a provider in the insured’s carrier network.  The provider will be deemed to have made appropriate disclosures if the provider utilizes the below template.

(2) Any non-participating provider that fails either to do an eligibility check or to obtain the appropriate consent as described in the previous section is prohibited from billing or charging the insured for services rendered.  Nothing in this section shall prohibit a provider from offering and performing services once the provider has clearly informed the insured of his or her rights and obligations and obtained a written consent from the insured as set forth above.