SF 2455

Senate
File
2455
-
Introduced
SENATE
FILE
2455
BY
COMMITTEE
ON
COMMERCE
(SUCCESSOR
TO
SSB
3177)
A
BILL
FOR
An
Act
relating
to
insurance
coverage
for
emergency
services,
1
reimbursements
for
out-of-network
providers,
and
2
complicating
factors.
3
BE
IT
ENACTED
BY
THE
GENERAL
ASSEMBLY
OF
THE
STATE
OF
IOWA:
4
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Section
1.
NEW
SECTION
.
514C.16A
Emergency
services
——
1
coverage.
2
1.
As
used
in
this
section,
unless
the
context
otherwise
3
requires:
4
a.
“Arbitrator
list”
means
a
list
maintained
by
the
5
commissioner
of
arbitrators
approved
in
the
state
who
are
6
listed
in
the
American
arbitration
association
roster
or
the
7
American
health
law
association
candidate
list
to
provide
8
binding
arbitration
for
purposes
of
this
section.
9
b.
“Commissioner”
means
the
commissioner
of
insurance.
10
c.
“Complicating
factor”
means
an
element
incident
to
11
the
provision
of
a
health
care
service
that
is
not
typically
12
involved
in
the
provision
of
a
health
care
service
and
is
not
13
reflected
in
the
medical
procedure
code
submitted
by
a
health
14
care
professional.
“Complicating
factor”
includes
but
is
not
15
limited
to
the
severity
of
a
covered
person’s
condition,
or
the
16
special
technical,
physical,
or
mental
effort
required
by
a
17
health
care
professional
to
provide
a
health
care
service.
18
d.
“Cost
sharing”
means
any
coverage
limit,
copayment,
19
coinsurance,
deductible,
or
other
out-of-pocket
cost
obligation
20
imposed
by
a
health
benefit
plan
on
a
covered
person.
21
e.
“Covered
person”
means
the
same
as
defined
in
section
22
514J.102.
23
f.
“Emergency
medical
condition”
means
a
medical
condition
24
that
manifests
by
symptoms
of
sufficient
severity,
including
25
but
not
limited
to
severe
pain,
that
an
ordinarily
prudent
26
person,
possessing
average
knowledge
of
medicine
and
health,
27
could
reasonably
expect
the
absence
of
immediate
medical
28
attention
to
result
in
one
of
the
following:
29
(1)
Placing
the
health
of
the
individual
in
serious
30
jeopardy.
31
(2)
Serious
impairment
to
bodily
function.
32
(3)
Serious
dysfunction
of
a
bodily
organ
or
part.
33
g.
“Emergency
services”
means
covered
inpatient
and
34
outpatient
health
care
services
that
are
furnished
by
a
health
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care
professional
who
is
qualified
to
provide
the
services
1
that
are
needed
to
evaluate
or
stabilize
an
emergency
medical
2
condition.
3
h.
“Facility”
means
the
same
as
defined
in
section
514J.102.
4
i.
“Health
benefit
plan”
means
the
same
as
defined
in
5
section
514J.102.
6
j.
“Health
care
professional”
means
the
same
as
defined
in
7
section
514J.102.
8
k.
“Health
care
services”
means
the
same
as
defined
in
9
section
514J.102.
10
l.
“Health
carrier”
means
the
same
as
defined
in
section
11
514J.102.
12
m.
“Out-of-network
provider”
means
a
health
care
13
professional
that
is
not
a
participating
provider
who
provides
14
health
care
services
to
a
covered
person.
15
n.
“Participating
facility”
means
a
facility
that
has
16
entered
into
a
contract
with
a
contracting
entity
to
provide
17
health
care
services
to
a
covered
person
with
the
expectation
18
of
receiving
payment
for
providing
the
health
care
services
19
either
directly
from
the
contracting
entity
or
from
a
health
20
carrier
affiliated
with
the
contracting
entity.
21
o.
“Participating
provider”
means
a
health
care
professional
22
who
has
entered
into
a
contract
with
a
contracting
entity
to
23
provide
health
care
services
to
a
covered
person
with
the
24
expectation
of
receiving
payment
for
providing
the
health
care
25
services
either
directly
from
the
contracting
entity
or
from
a
26
health
carrier
affiliated
with
the
contracting
entity.
27
2.
Notwithstanding
the
uniformity
of
treatment
requirements
28
of
section
514C.6,
a
policy,
contract,
or
plan
providing
for
29
third-party
payment
or
prepayment
of
medical
expenses
shall
30
provide
coverage
for
health
care
services
provided
to
a
covered
31
person
by
an
out-of-network
provider
in
any
of
the
following
32
circumstances:
33
a.
The
health
care
services
are
emergency
services.
34
b.
The
health
care
services
were
provided
at
a
participating
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facility
and
the
covered
person
did
not
have
the
ability
1
or
opportunity
to
receive
the
health
care
services
from
a
2
participating
provider.
3
3.
An
out-of-network
provider
who
provides
health
care
4
services
under
subsection
2
shall
submit
a
claim
to
the
covered
5
person’s
health
carrier
no
later
than
sixty
calendar
days
after
6
the
date
the
out-of-network
provider
provided
the
health
care
7
services.
No
more
than
sixty
calendar
days
after
receipt
of
a
8
claim,
the
health
carrier
shall
reimburse
the
out-of-network
9
provider
in
an
amount
that
is
the
greater
of
either
of
the
10
following:
11
a.
The
median
amount
that
would
have
been
paid
to
a
12
participating
provider
who
practices
in
the
same
specialty
as
13
the
out-of-network
provider
for
providing
the
same
health
care
14
services,
excluding
any
cost
sharing.
15
b.
One
hundred
fifty
percent
of
the
most
recently
published
16
federal
centers
for
Medicare
and
Medicaid
services
fee
schedule
17
for
the
health
care
service
provided
by
the
out-of-network
18
provider,
excluding
any
cost
sharing.
19
4.
An
out-of-network
provider
who
provides
health
care
20
services
under
subsection
2
shall
not
bill,
attempt
to
collect
21
from,
or
collect
from,
a
covered
person
any
amount
other
than
22
the
cost
sharing
required
by
the
covered
person’s
health
23
benefit
plan.
24
5.
a.
An
out-of-network
provider
who
provides
a
health
25
care
service
under
subsection
2
that
involves
a
complicating
26
factor
may
submit,
as
part
of
an
initial
claim
submitted
27
under
subsection
3,
a
claim
for
reimbursement
in
addition
to
28
the
amount
of
reimbursement
provided
by
subsection
3.
The
29
claim
for
additional
reimbursement
must
be
accompanied
by
30
medical
records
and
other
clinical
documentation
necessary
to
31
demonstrate
the
complicating
factor
and
justify
the
additional
32
reimbursement.
33
b.
A
health
carrier
that
receives
a
claim
for
additional
34
reimbursement
from
an
out-of-network
provider
shall,
no
more
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than
thirty
calendar
days
after
the
date
of
receipt
of
such
1
claim,
either
pay
the
out-of-network
provider
an
additional
2
reimbursement
in
an
amount
equal
to
twenty-five
percent
of
the
3
amount
paid
on
the
initial
claim
under
subsection
3,
or
issue
a
4
letter
of
denial
to
the
out-of-network
provider
that
explains
5
the
basis
for
denying
the
claim
for
additional
reimbursement.
6
c.
If
a
health
carrier
denies
a
claim
for
additional
7
reimbursement,
the
out-of-network
provider
may
file
with
the
8
commissioner
a
written
request
for
binding
arbitration
that
9
includes
all
of
the
following:
10
(1)
The
name
and
contact
information
of
the
health
carrier.
11
(2)
The
medical
records
and
clinical
documentation
12
demonstrating
the
complicating
factor
and
justifying
the
13
request
for
additional
reimbursement
that
the
out-of-network
14
provider
submitted
to
the
health
carrier.
15
(3)
The
letter
from
the
health
carrier
denying
the
claim
for
16
additional
reimbursement.
17
d.
The
commissioner
shall
notify
an
out-of-network
provider
18
that
files
a
written
request
for
binding
arbitration
under
19
paragraph
“c”
and
the
health
carrier
that
denied
the
claim
for
20
additional
reimbursement,
no
later
than
thirty
calendar
days
21
after
receipt
of
the
request,
of
the
acceptance
or
denial
of
22
the
request.
23
e.
No
more
than
thirty
calendar
days
after
the
date
of
24
receipt
of
the
notice
under
paragraph
“d”
,
the
health
carrier
25
shall
submit
written
documentation
to
the
commissioner
that
26
either
reconfirms
the
health
carrier’s
denial
of
the
claim
for
27
additional
reimbursement,
or
provides
an
alternative
payment
28
offer
for
consideration
during
arbitration.
29
f.
Prior
to
an
arbitration,
the
out-of-network
provider
30
and
health
carrier
shall
agree
upon
an
arbitrator
from
the
31
arbitrator
list,
and
submit
all
documentation
provided
under
32
paragraphs
“c”
and
“e”
to
the
selected
arbitrator.
The
33
arbitrator
shall
provide
a
written
decision
regarding
the
34
outcome
of
the
arbitration
to
the
out-of-network
provider
and
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health
carrier
no
later
than
forty-five
calendar
days
after
the
1
date
of
receipt
of
all
documentation
submitted
by
both
parties.
2
In
making
a
determination
as
to
the
outcome
of
the
arbitration,
3
the
arbitrator
shall
consider
all
of
the
following:
4
(1)
The
complicating
factor
at
issue.
5
(2)
The
medical
records
and
clinical
documentation
6
demonstrating
the
complicating
factor
and
justifying
additional
7
reimbursement
that
the
out-of-network
provider
submitted
to
the
8
health
carrier.
9
(3)
The
letter
from
the
health
carrier
to
the
out-of-network
10
provider
denying
the
claim
for
increased
reimbursement.
11
(4)
The
written
documentation
provided
by
the
health
12
carrier
that
reconfirms
the
health
carrier’s
denial
of
the
13
claim
for
increased
reimbursement,
if
any.
14
(5)
All
alternative
payment
offers
the
health
carrier
15
offered
to
the
out-of-network
provider,
if
any.
16
g.
The
costs
of
arbitration
shall
be
paid
equally
by
the
17
health
carrier
and
the
out-of-network
provider.
18
6.
This
section
does
not
prohibit
an
out-of-network
19
provider
and
a
health
carrier
from
agreeing,
through
private
20
negotiations
or
an
internal
dispute
resolution
process,
to
a
21
reimbursement
amount
that
is
greater
than
the
reimbursement
22
amount
required
by
this
section.
23
7.
a.
This
section
applies
to
the
following
classes
of
24
third-party
payment
provider
contracts,
policies,
or
plans
25
delivered,
issued
for
delivery,
continued,
or
renewed
in
this
26
state
on
or
after
January
1,
2027:
27
(1)
Individual
or
group
accident
and
sickness
insurance
28
providing
coverage
on
an
expense-incurred
basis.
29
(2)
An
individual
or
group
hospital
or
medical
service
30
contract
issued
pursuant
to
chapter
509,
514,
or
514A.
31
(3)
An
individual
or
group
health
maintenance
organization
32
contract
regulated
under
chapter
514B.
33
(4)
A
plan
established
for
public
employees
pursuant
to
34
chapter
509A.
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b.
This
section
shall
not
apply
to
accident-only,
specified
1
disease,
short-term
hospital
or
medical,
hospital
confinement
2
indemnity,
credit,
dental,
vision,
Medicare
supplement,
3
long-term
care,
basic
hospital
and
medical-surgical
expense
4
coverage
as
defined
by
the
commissioner
of
insurance;
5
disability
income
insurance
coverage;
coverage
issued
as
a
6
supplement
to
liability
insurance,
workers’
compensation
or
7
similar
insurance;
or
automobile
medical
payment
insurance.
8
8.
The
commissioner
of
insurance
may
adopt
rules
pursuant
to
9
chapter
17A
to
administer
this
section.
10
EXPLANATION
11
The
inclusion
of
this
explanation
does
not
constitute
agreement
with
12
the
explanation’s
substance
by
the
members
of
the
general
assembly.
13
This
bill
relates
to
insurance
coverage
for
emergency
14
services,
reimbursements
for
out-of-network
providers,
and
15
complicating
factors.
16
The
bill
requires
a
policy,
contract,
or
plan
providing
17
for
third-party
payment
or
prepayment
of
medical
expenses
to
18
provide
coverage
for
health
care
services
(services)
provided
19
to
a
covered
person
by
an
out-of-network
provider
if
the
20
services
are
emergency
services,
or
the
services
were
provided
21
at
a
participating
facility
and
the
covered
person
could
not
22
receive
the
services
from
a
participating
provider.
“Emergency
23
services”,
“out-of-network
provider”,
“participating
facility”,
24
and
“participating
provider”
are
defined
in
the
bill.
25
An
out-of-network
provider
that
provides
services
to
26
a
covered
person
under
the
bill
shall
submit
a
claim
to
a
27
health
carrier
(carrier)
no
later
than
60
days
after
providing
28
services.
No
more
than
60
days
after
receipt
of
a
claim,
the
29
carrier
shall
reimburse
the
out-of-network
provider
in
an
30
amount
that
is
the
greater
of
the
median
amount
that
would
have
31
been
paid
to
a
participating
provider
for
providing
the
same
32
services,
or
150
percent
of
the
fee
schedule
for
the
service,
33
excluding
any
cost
sharing.
34
An
out-of-network
provider
who
provides
services
shall
not
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bill,
attempt
to
collect
from,
or
collect
from
a
covered
person
1
any
amount
other
than
the
cost
sharing
required
by
the
covered
2
person’s
health
benefit
plan.
3
An
out-of-network
provider
who
provides
a
service
to
4
a
covered
person
that
involves
a
complicating
factor
may
5
submit,
as
part
of
an
initial
claim,
a
claim
for
an
additional
6
reimbursement.
“Complicating
factor”
is
defined
in
the
bill.
7
The
claim
for
additional
reimbursement
must
be
accompanied
8
by
medical
records
and
clinical
documentation
sufficient
to
9
demonstrate
the
complicating
factor
and
justify
the
request
for
10
additional
reimbursement.
11
A
carrier
that
receives
a
claim
for
additional
reimbursement
12
shall,
within
30
days,
either
pay
the
out-of-network
provider
13
an
additional
reimbursement
in
an
amount
equal
to
25
percent
of
14
the
initial
claim
reimbursement,
or
issue
a
letter
denying
the
15
claim
for
additional
reimbursement.
16
If
a
carrier
denies
a
claim
for
additional
reimbursement,
17
the
out-of-network
provider
may
file
a
written
request
18
for
binding
arbitration
with
the
commissioner
of
insurance
19
(commissioner)
that
includes
the
information
detailed
in
20
the
bill.
The
commissioner
shall
notify
the
out-of-network
21
provider
and
carrier
within
30
days
whether
the
request
has
22
been
accepted
or
denied.
A
carrier
that
receives
notice
23
of
arbitration
shall
submit
written
documentation
to
the
24
commissioner,
within
30
days
of
the
notice,
that
either
25
reconfirms
the
carrier’s
denial
of
additional
reimbursement,
or
26
provides
an
alternative
payment
offer
for
consideration
during
27
arbitration.
28
Prior
to
an
arbitration,
the
out-of-network
provider
and
29
carrier
shall
agree
upon
an
arbitrator
from
the
arbitrator
30
list,
and
submit
documentation
required
by
the
bill
to
the
31
arbitrator.
The
arbitrator
shall
provide
a
written
decision
32
regarding
the
outcome
of
the
arbitration
within
45
days.
The
33
arbitrator
shall
consider
the
complicating
factor
at
issue
and
34
documentation
required
by
the
bill.
The
costs
of
arbitration
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shall
be
paid
equally
by
the
carrier
and
the
out-of-network
1
provider.
2
The
bill
does
not
prohibit
an
out-of-network
provider
and
a
3
carrier
from
agreeing
to
a
reimbursement
amount
that
is
greater
4
than
the
reimbursement
amount
required
by
the
bill.
5
The
bill
applies
to
third-party
payment
provider
contracts,
6
policies,
or
plans
delivered,
issued
for
delivery,
continued,
7
or
renewed
in
this
state
on
or
after
January
1,
2027,
by
the
8
third-party
payment
providers
enumerated
in
the
bill.
The
bill
9
specifies
the
types
of
specialized
health-related
insurance
10
which
are
not
subject
to
the
bill’s
coverage
requirements.
11
The
commissioner
may
adopt
rules
to
administer
the
bill.
12
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