SB 260 Establishes a negotiation and arbitration procedure to determine the reimbursement level for health care services provided by nonparticipating providers at participating facilities and prohibits balance billing under certain circumstances
Sponsor: Brown
LR Number: 1396S.01I Fiscal Note available
Committee: Small Business, Insurance and Industry
Last Action: 3/5/2013 - Hearing Conducted S Small Business, Insurance and Industry Committee Journal Page:
Title: Calendar Position:
Effective Date: August 28, 2013

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Current Bill Summary


SB 260 - This act protects patients from paying out-of-network rates at participating facilities (in-network), prohibits balance billing and establishes a negotiation and arbitration procedure to determine the reimbursement level for out-of-network health care services that are performed at participating facilities.

Under the terms of this act, when an enrollee utilizes a participating facility and in network health care services are provided by a nonparticipating facility-based provider, the health carrier shall ensure that the enrollee shall incur no greater out-of-pocket costs than the enrollee would have incurred with a participating facility-based provider for covered services.

Under the act, if an enrollee agrees in writing to assign benefits, then the nonparticipating facility-based provider may bill the health carrier, and the health carrier may either pay the billed amount or negotiate the reimbursement amount with the nonparticipating facility-based provider. If an enrollee makes an assignment of his or her benefits, then the act prohibits the nonparticipating facility-based provider from billing the patient more than the deductible, copayment or coinsurance amounts that would apply if the enrollee had utilized a participating facility-based provider for the health care services. Furthermore, if the enrollee specifically rejects (in writing) assignment of benefits then the facility-based provider would be allowed to bill the enrollee for the services rendered, without being subject to the balance billing prohibition.

If an assignment is made, and the health carrier and the nonparticipating facility-based provider are unable to agree on reimbursement within 30 days after receipt of a written explanation of benefits, then either party may initiate binding arbitration to determine payment, in which case each party would be required to submit its final offer and an arbitrator would be selected from a list published by the Missouri Department of Insurance. Binding arbitration shall provide for a written decision within 45 days after the request is filed with the department. Both parties shall be bound by the arbitrator's decision. The arbitrator's expenses and fees, incurred in the conduct of the arbitration, shall be paid as provided in the decision.

The provisions of this act shall not apply to an enrollee who willfully chooses to access a nonparticipating facility-based provider for health care services available through the health carrier's network of participating providers. In these circumstances, the contractual requirements for nonparticipating facility-based provider reimbursements shall apply.

Under the act, the provisions of the prompt pay law (Section 376.383) shall not apply during the pendency of a decision to pay the bill or choose binding arbitration (reimbursement negotiations). Any interest required to be paid a nonparticipating facility-based provider under the prompt pay law shall not accrue until after 30 days of an arbitrator's decision.

STEPHEN WITTE