SECTION 1. The General Laws are hereby amended by inserting after chapter 176O the following chapter:-
OUT-OF-NETWORK SERVICES PROVIDED BY EMERGENCY MEDICINE CLINICIANS.
Section 1. As used in this chapter, the following words shall have the following meanings unless the context clearly requires otherwise:
“Emergency department visit”, the period of time beginning when an insured enters into an emergency department of a hospital until the time the insured is discharged from the emergency department of the hospital, admitted into the hospital or transferred to another facility.
“Emergency medicine clinician”, a physician or other mid-level provider, licensed under sections 2, 9F or 80B of chapter 112 or other applicable state law.
“Emergency medical services”, all services rendered by an emergency medicine clinician to an insured during an emergency department visit.
“Insured”, a person who is covered by a health benefit plan or group health plan insured or administered by an insurance carrier.
“Insurance carrier”, an insurer licensed or otherwise authorized to transact insurance under chapter 175, a nonprofit hospital service corporation organized under chapter 176A, a nonprofit medical service corporation organized under chapter 176B, a health maintenance organization organized under chapter 176G, an organization entering into a preferred provider arrangement under chapter 176I or a third-party administrator authorized pursuant to chapter 176O.
“Minimum emergency medicine services benefit”, the amount the insured's insurance carrier shall pay for emergency medicine services if rendered by an in-network emergency medicine clinician, the usual and customary rate for such services or the amount Medicare would reimburse for such services, whichever is greater; provided, however, that in no event shall the minimum emergency medicine services benefit exceed $1,500 per emergency department visit; provided further, that the $1,500 cap shall be increased each year by an amount equal to the annual average inflation rates for the medical care commodities and the medical care services component of the United States Consumer Price Index; provided further, that as used in this section, the term “usual and customary rate” shall mean the eightieth percentile of all charges for the particular health care service performed by an emergency medicine clinician provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization specified by the commissioner of insurance; provided, however, that such nonprofit organization shall not be affiliated with any insurance carrier.
“Out-of-network services”, services rendered by an emergency medicine clinician to an insured during an emergency department visit when the emergency medicine clinician has not entered into a contract with the insured’s insurance carrier.
Section 2. (a) When out-of-network services are provided to an insured, the emergency medicine clinician shall bill the insured’s insurance carrier directly and the insurance carrier shall pay the emergency medicine clinician at the minimum emergency medicine services benefit for the professional services rendered, as coded and billed by the emergency medicine clinician.
(b) Insurance carriers shall pay the minimum emergency services benefit directly to the emergency medicine clinician not more than 30 calendar days after the submission of the claim by the emergency medicine clinician.
(c) An emergency medicine clinician shall not bill an insured separately or otherwise hold an insured financially responsible for out-of-network services.
(d) Insurance carriers shall not state, communicate or include false or misleading information in the insurance carrier’s written explanation of benefits to an insured.
Section 3. A person aggrieved by a violation of this chapter may file a civil action in a court of competent jurisdiction in the commonwealth.
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