Fifty-third Legislature                                                   Finance

First Regular Session                                                   S.B. 1441

 

COMMITTEE ON FINANCE

SENATE AMENDMENTS TO S.B. 1441

(Reference to printed bill)

 


Strike everything after the enacting clause and insert:

"Section 1.  Section 20-3101, Arizona Revised Statutes, is amended to read:

START_STATUTE20-3101.  Definitions

In this chapter article, unless the context otherwise requires:

1.  "Adjudicate" means an insurer's decision to deny or pay a claim, in whole or in part, including the decision as to how much to pay.

2.  "Clean claim" means a written or electronic claim for health care services or benefits that may be processed without obtaining additional information, including coordination of benefits information, from the health care provider, the enrollee or a third party, except in cases of fraud.

3.  "Enrollee" means an individual who is enrolled under a health care insurer's policy, contract or evidence of coverage.

4.  "Grievance" means any written complaint that is subject to resolution through the insurer's system that is prescribed in section 20‑3102, subsection F and submitted by a health care provider and received by a health care insurer.  Grievance does not include a complaint:

(a)  By a noncontracted provider regarding an insurer's decision to deny the noncontracted provider admission to the insurer's network.

(b)  About an insurer's decision to terminate a health care provider from the insurer's network.

(c)  That is the subject of a health care appeal pursuant to chapter 15, article 2 of this title. 

5.  "Health care insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, prepaid dental plan organization, hospital service corporation, medical service corporation, dental service corporation, optometric service corporation, or hospital, medical, dental and optometric service corporation. END_STATUTE

Sec. 2.  Title 20, chapter 20, Arizona Revised Statutes, is amended by adding article 2, to read:

ARTICLE 2.  OUT-OF-NETWORK CLAIM DISPUTE RESOLUTION

START_STATUTE20-3111.  Definitions

In this article, unless the context otherwise requires:

1.  "Arbitration" means a process in which an impartial arbitrator facilities and promotes agreement between a health insurer, an enrollee and a health care provider that has issued a surprise out‑of‑network bill to the enrollee for health care services or durable medical equipment, or its billing company, to settle the bill.

2.  "Arbitrator" means an impartial person who is appointed to conduct an arbitration.

3.  "Billing company" means any affiliated or unaffiliated company that is hired by a health care provider or health care facility to coordinate the payment of bills with health insurers and to generate or bill and collect payment from enrollees on the health care provider's or health care facility's behalf.

4.  "Contracted provider" means a health care provider that has entered into a contract with a health insurer to provide health care services to the health insurer's enrollees at agreed on rates.

5.  "Cost sharing requirements" means an enrollee's coinsurance, copayment and deductible requirements under a health plan.

6.  "Enrollee" means an individual who is eligible to receive benefits through a health plan.

7.  "Health care facility" has the same meaning prescribed in section 36-437.

8.  "Health care provider" means a physician who is licensed under title 32, chapter 13 or 17, a laboratory that is licensed under title 36 or a durable medical equipment provider that provides health care services, laboratory services or durable medical equipment to an enrollee in a network facility and that separately bills the enrollee.

9.  "Health insurer" means a disability insurer, blanket disability insurer, hospital service corporation or medical service corporation that provides health insurance in this state.

10.  "Health plan" means a group or individual health plan that finances or furnishes health care services and that is issued by a health insurer.

11.  "Network facility" means a health care facility that has entered into a contract with a health insurer to provide health care services to the health insurer's enrollees at agreed on rates.

12.  "Surprise out‑of‑network bill" means a bill for a health care service or durable medical equipment that was provided in a network facility by a health care provider that is not a contracted provider if the enrollee did not know that the health care provider that performed the service or provided the equipment was not a contracted provider or if a contracted provider was not available and it was impractical to wait for a contracted provider and the patient did not knowingly elect to obtain an out‑of‑network service.END_STATUTE

START_STATUTE20-3112.  Applicability

This article does not apply to noncovered health care services, to limited benefit coverage as defined in section 20‑1137 or to charges for health care services or durable medical equipment subject to a direct payment agreement under section 32‑3216 or 36‑437.END_STATUTE

START_STATUTE20-3113.  Health care providers; notice; requirements

A.  Except in the case of an emergency and if requested by the enrollee, a health care provider, before providing health care services, shall disclose in writing to the enrollee all of the following:

1.  The health care provider does not have a contract with the enrollee's health insurer.

2.  The estimated total cost to be billed by the health care provider.

3.  The projected amounts for which the enrollee may be responsible.

4.  The circumstances under which the enrollee would be responsible for those amounts.

B.  A health care facility shall provide the enrollee with notice of the enrollee's right to the pricing information required by section 36‑437, subsections A and B and a website address where the pricing information can be found. 

START_STATUTE20-3114.  Mandatory arbitration; surprise out-of-network bills

A.  An enrollee who has received a surprise out‑of‑network bill and who disputes the amount of the bill may seek arbitration of the bill if all of the following apply:

1.  The amount of the surprise out‑of‑network bill for which the enrollee is responsible for all related health care services provided by the health care provider whether contained in one or multiple bills, after application of the enrollee's cost sharing requirements, including the amount unpaid by the health insurer, is at least one thousand dollars.

2.  The enrollee received a surprise out‑of‑network bill.

B.  If an enrollee requests arbitration of a surprise out‑of‑network bill, the health care provider and the health insurer shall participate in the arbitration.END_STATUTE

START_STATUTE20-3115.  Conduct of arbitration proceedings

A.  The department shall develop a simple, fair, efficient and cost‑effective arbitration for surprise out‑of‑network bill disputes and specify time frames, standards and other details of the arbitration proceeding.  The department may contract with one or more entities to provide arbitrators who are qualified under section 20-3116 for this process.

B.  An enrollee may request arbitration of a surprise out‑of‑network bill by submitting a request for arbitration to the department on a form prescribed by the department.

C.  On receipt of a request for arbitration, the department shall appoint an arbitrator and shall notify the health insurer and health care provider of the arbitration and the appointed arbitrator.  The health insurer and health care provider must agree on the arbitrator.  If either the health insurer or health care provider objects to the arbitrator, the department or contracted entity shall randomly assign five arbitrators.  The health insurer and the health care provider shall each strike two arbitrators, and the last arbitrator shall conduct the arbitration. 

D.  In an effort to settle the surprise out‑of‑network bill before arbitration, the parties shall participate in an informal settlement conference within thirty days after the department's notice of arbitration.  The arbitrator shall oversee the informal settlement conference.  If either the health insurer or health care provider informs the arbitrator that the other has refused to respond or participate in the informal settlement conference, the arbitrator shall require the nonresponsive party to participate in the informal settlement conference.

E.  Arbitration of any surprise out‑of‑network bill that is not settled through the informal settlement conference shall be conducted in the county in which the health care services giving rise to the bill were rendered and may be conducted telephonically on the agreement of all of the participants.

F.  Arbitration of the surprise out‑of‑network bill shall take place with or without the enrollee's participation. 

G.  The arbitrator shall determine the amount the health care provider is entitled to receive as payment for the health care services, laboratory services or durable medical equipment.  The arbitrator shall allow each party to provide information the arbitrator reasonably determines to be relevant in evaluating the surprise out‑of‑network bill, including the following information:

1.  The average contracted amount that the health insurer pays for the health care services at issue in the county where the services were performed.

2.  The average amount that the health care provider has contracted to accept for the health care services at issue in the county where the services were performed.

3.  The amount that medicare and medicaid pay for the health care services.

4.  The health care provider's direct pay rate, if any, under section 32‑3216.

5.  Any information that would be evaluated in determining whether a fee is reasonable under title 32 and not excessive, including the fee customarily charged in the locality for similar health care services and the time required, the complexity of and the skill required to perform the health care services.

6.  Any other reliable databases or sources of information on the amount paid for the health care services at issue in the county where the services were performed.

H.  Except on the agreement of the parties participating in the arbitration, the arbitration shall be conducted within one hundred eighty days after the department's notice of arbitration. 

I.  Except on the agreement of the parties participating in the arbitration, the arbitration may not last more than four hours.

J.  The arbitrator shall issue a written decision within ten business days following the arbitration hearing.  The arbitrator shall provide a copy of the decision to the enrollee, the health insurer and the health care provider.

K.  Any party to the arbitration may appeal the arbitrator's decision to the superior court in the county in which the arbitration takes place by filing, within the time limited by rule of court, a demand for trial de novo on law and fact.

L.  All pricing information provided by health insurers and health care providers in connection with the arbitration of a surprise out‑of‑network bill is confidential and may not be disclosed by the arbitrator or any other party participating in the arbitration. 

M.  A claim that is the subject of an arbitration request is not subject to article 1 of this chapter during the pendency of the arbitration.  A health insurer shall remit the payment resulting from the informal settlement conference or the amount awarded by the arbitrator within thirty days of resolution of the claim.

N.  Notwithstanding any informal settlement or the arbitrator's decision under this article, the enrollee is responsible for only the amount of the enrollee's cost sharing requirements.

O.  Unless all the parties otherwise agree, the health insurer and the health care provider shall share the costs of the arbitration equally.END_STATUTE

START_STATUTE20-3116.  Arbitrator qualifications

To qualify as an arbitrator, a person shall have at least three years' experience in health care services claims adjustment."END_STATUTE

Amend title to conform


 

 

 

1441FIN

02/15/2017

3:30 PM

S: tb

 

1441FIN

02/16/2017

9:30 AM

S: sa