March 24, 2020 - Introduced by Representatives Kolste, Hebl, Zamarripa, Stubbs,
Billings, Cabrera, Anderson, Sargent, Subeck, Brostoff, Bowen,
Shankland, Neubauer, Sinicki, Considine, Ohnstad, Hintz and Vruwink,
cosponsored by Senators Smith and Larson. Referred to Committee on
Health.

This bill creates disclosure, notice, billing, and arbitration requirements for the
situation in which an enrollee in a defined network or preferred provider plan
(“plan”) may receive services from a health care provider that is not in the plan's
network.

Under the bill, a plan must annually provide to enrollees a directory of
providers and a list of health care facilities that are in its network. The bill also
requires that a provider who is not in the network of the enrollee's plan but is
providing a service at an in-network health care facility must disclose that
information to the enrollee, provide the enrollee a good faith estimate of the cost of
services the enrollee may be responsible for, and inform the enrollee of the
availability of arbitration to settle disputes over the cost of services. The health care
facility may opt to provide the notice for the provider.

Under the bill, if an enrollee of a plan requires medically necessary services that
are not available from an in-network provider within a reasonable time, then the
plan must provide an opportunity for referral to an out-of-network provider. The
plan must reimburse the out-of-network provider at the usual and customary rate
or at a rate agreed to between the provider and the plan and may not require the
enrollee to pay more than the enrollee would have paid had the provider been in the

plan's network. If there a dispute over the reimbursement, the plan or provider may
submit the dispute using the arbitration process described below. The bill requires
the enrollee to provide the out-of-network provider an assignment of benefits for
any service, item, or supply provided by that provider.

Similarly, under the bill, if an enrollee of a plan receives emergency services
from an out-of-network provider, then the plan must reimburse the provider at the
usual and customary rate or at a rate agreed to between the provider and the plan
and may not require the enrollee to pay more than the enrollee would have paid if
the provider was in the plan's network. If there a dispute over the reimbursement,
the plan or provider may submit the dispute using the arbitration process described
below.

The bill requires the commissioner of insurance to promulgate rules to
establish the arbitration process under which enrollees, plans, and out-of-network
providers may submit billing disputes to an independent dispute resolution entity.
Under the bill, an enrollee may request arbitration for a claim if the amount that the
enrollee is financially responsible for, after copayments, deductibles, and
coinsurance, is more than $500, unless that amount is less than the good faith
estimate provided by the provider. The plan or provider may not use the arbitration
process to dispute bills for certain emergency services that do not exceed a specified
amount or services for which provider fees are subject by law to monetary
limitations.

Once a dispute is filed, the independent dispute resolution entity has 30 days
to determine a reasonable fee for the services provided to the enrollee by the
out-of-network provider. If the dispute is between the plan and provider, each party
submits what it thinks is a reasonable fee for the services, and the independent
dispute resolution entity must choose one of those amounts. However, if the entity
finds that both sides' amounts are unreasonable or that a settlement between the
parties is likely, it may direct the plan and provider to attempt a good faith
negotiation for settlement and, if they reach an agreement, the entity will select that
amount as its final determination. If the dispute is between the enrollee and
provider, the independent dispute resolution entity determines a reasonable fee
based upon factors that include whether there is a gross disparity between the fee
billed by the provider and other fees charged by that provider; the provider's training
and experience; and the circumstances and complexity of the particular case. The
entity's determination is binding on the parties.

The bill provides that the losing party must pay the costs of the arbitration with
two exceptions. First, if a settlement is reached between a plan and provider at the
direction of the independent dispute resolution entity, the costs are evenly divided
between the parties. Second, if the enrollee is the losing party, the maximum amount
the enrollee may be charged is $100 and the commissioner may waive or reduce the
charge if requiring full payment would impose a hardship on the enrollee. The bill
requires the commissioner to determine and establish a mechanism to cover the
arbitration costs that are otherwise unpaid by enrollees.