§4303-C. Protection from surprise bills

1.  Surprise bill defined.  As used in this section, unless the context otherwise indicates, "surprise bill" means a bill for health care services, other than emergency services, received by an enrollee for covered services rendered by an out-of-network provider, when such services were rendered by that out-of-network provider at a network provider, during a service or procedure performed by a network provider or during a service or procedure previously approved or authorized by the carrier and the enrollee did not knowingly elect to obtain such services from that out-of-network provider. "Surprise bill" does not include a bill for health care services received by an enrollee when a network provider was available to render the services and the enrollee knowingly elected to obtain the services from another provider who was an out-of-network provider.

[PL 2017, c. 218, §2 (NEW); PL 2017, c. 218, §3 (AFF).]

2.  Requirements.  With respect to a surprise bill:

A. A carrier shall require an enrollee to pay only the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for health care services if the services were rendered by a network provider;   [PL 2017, c. 218, §2 (NEW); PL 2017, c. 218, §3 (AFF).]

B. A carrier shall reimburse the out-of-network provider or enrollee, as applicable, for health care services rendered at the average network rate under the enrollee's health care plan as payment in full, unless the carrier and out-of-network provider agree otherwise; and   [PL 2017, c. 218, §2 (NEW); PL 2017, c. 218, §3 (AFF).]

C. Notwithstanding paragraph B, if a carrier has an inadequate network, as determined by the superintendent, the carrier shall ensure that the enrollee obtains the covered service at no greater cost to the enrollee than if the service were obtained from a network provider or shall make other arrangements acceptable to the superintendent.   [PL 2017, c. 218, §2 (NEW); PL 2017, c. 218, §3 (AFF).]

[PL 2017, c. 218, §2 (NEW); PL 2017, c. 218, §3 (AFF).]

SECTION HISTORY

PL 2017, c. 218, §2 (NEW). PL 2017, c. 218, §3 (AFF).