BILL REQ. #:  H-0485.2 

Read first time 01/25/11.   Referred to Committee on Health Care & Wellness.

     AN ACT Relating to payment for critical services rendered by out-of-network providers in in-network hospitals; adding a new section to chapter 48.43 RCW; and adding a new section to chapter 41.05 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   A new section is added to chapter 48.43 RCW to read as follows:
     (1)(a) For covered critical services rendered to a covered person by an out-of-network health care provider in an in-network hospital on or after the effective date of this section, a health carrier shall pay the claim submitted by the health care provider at the rate that must be paid to an out-of-network provider for emergency services under 45 C.F.R. 147.138(b)(3) (2010).
     (b) The insurance commissioner may, by rule, change the amount that must be paid under (a) of this subsection based on changes made to 45 C.F.R. 147.138(b)(3) (2010).
     (c) The legislature encourages employer-sponsored self-funded health plans and third-party administrators of employer-sponsored self-funded health plans to voluntarily comply with subsection (1) of this section under circumstances where they are not required to do so by federal law.
     (2)(a) A health carrier, an employer-sponsored self-funded health plan, or a third-party administrator of an employer-sponsored self-funded health plan, shall pay an out-of-network health care provider directly for critical services, regardless of whether the amount to be paid is determined under subsection (1) of this section or, in the case of an employer-sponsored self-funded health plan, by the terms and conditions of the plan or applicable federal law.
     (b) The amount paid to the out-of-network health care provider under this section, plus any applicable copayment, coinsurance, or deductible payable by the person who received the critical services, constitute payment in full for the critical services rendered by the out-of-network health care provider. The person who received the critical services is not responsible for any amount in excess of applicable copayments, coinsurance, or deductibles. Any attempt on the part of a provider to recover excess funds from the person constitutes a violation of RCW 18.130.180(7).
     (3) For purposes of this section:
     (a) "Critical services" means:
     (i) Emergency services as defined in RCW 48.43.005; and
     (ii) Services provided outside a hospital's emergency department that are necessary to stabilize a person who received emergency services in the hospital's emergency department.
     (b) "Stabilize" means that no material deterioration of the emergency medical condition is likely, within reasonable medical probability, to result from or occur during the transfer of the person from a facility.
     (4) This section does not apply to payments made by carriers for critical services under state purchased health care programs designed to serve low-income populations.

NEW SECTION.  Sec. 2   A new section is added to chapter 41.05 RCW to read as follows:
     (1)(a) For covered critical services rendered to a covered person by an out-of-network health care provider in an in-network hospital on or after the effective date of this section, a health benefit plan offered to public employees and their covered dependents shall pay the claim submitted by the health care provider at the rate that must be paid to an out-of-network provider for emergency services under 45 C.F.R. Sec. 147.138(b)(3) (2010).
     (b) The insurance commissioner may, by rule, change the amount that must be paid under (a) of this subsection based on changes made to 45 C.F.R. Sec. 147.138(b)(3) (2010).
     (2)(a) A health benefit plan offered to public employees and their covered dependents shall pay an out-of-network health care provider directly for critical services.
     (b) The amount paid to the out-of-network health care provider under this subsection, plus any applicable copayment, coinsurance, or deductible payable by the person who received the critical services, constitutes payment in full for the critical services rendered by the out-of-network health care provider. The person who received the critical services is not responsible for any amount in excess of applicable copayments, coinsurance, or deductibles. Any attempt on the part of a provider to recover excess funds from the person constitutes a violation of RCW 18.130.180(7).
     (3) For purposes of this section:
     (a) "Critical services" means:
     (i) Emergency services as defined in RCW 48.43.005; and
     (ii) Services provided outside a hospital's emergency department that are necessary to stabilize a person who received emergency services in the hospital's emergency department.
     (b) "Stabilize" means that no material deterioration of the emergency medical condition is likely, within reasonable medical probability, to result from or occur during the transfer of the person from a facility.

NEW SECTION.  Sec. 3   If any provision of this act or its application to any person or circumstance is held invalid, the remainder of the act or the application of the provision to other persons or circumstances is not affected.