SB1602 - 542R

Be it enacted by the Legislature of the State of Arizona:

Section 1. Heading change

The article heading of title 20, chapter 20, article 2, Arizona Revised Statutes, is changed from "Out‑of‑network claim dispute resolution" to "surprise out‑of‑network bills".

Sec. 2. Section 20-3111, Arizona Revised Statutes, is amended to read:

START_STATUTE20-3111. Definitions

In this article, unless the context otherwise requires:

1. "Arbitration" means a dispute resolution process in which an impartial arbitrator determines the dollar amount a health care provider is entitled to receive for payment of a surprise out‑of‑network bill.

2. "Arbitrator" means an impartial person who is appointed to conduct an arbitration.

3. "Billing company" means any affiliated or unaffiliated company that is hired by a health care provider or health care facility to coordinate the payment of bills with health insurers and to generate or bill and collect payment from enrollees on the health care provider's or health care facility's behalf.

4. "Contracted provider" means a health care provider that has entered into a contract with a health insurer to provide health care services to the health insurer's enrollees at agreed on rates.

5. 1. "Cost sharing requirements requirement" means an enrollee's applicable out‑of‑network coinsurance, copayment and deductible requirements under a health plan based on the adjudicated claim.

6. 2. "Emergency services" has the same meaning prescribed in section 20‑2801.

7. 3. "Enrollee" means an individual who is eligible to receive benefits through a health plan.

8. 4. "Health care facility" has the same meaning prescribed in section 36‑437.

9. 5. "Health care provider" means a person who is licensed, registered or certified as a health care professional under title 32 or a laboratory or durable medical equipment provider that furnishes renders services to a patient in a network facility and that separately bills the patient for the services.

10. 6. "Health care services" means treatment, services, medications, tests, equipment, devices, durable medical equipment, laboratory services or supplies rendered or provided to an enrollee for the purpose of diagnosing, preventing, alleviating, curing or healing human disease, illness or injury.

11. 7. "Health insurer" means a disability insurer, group disability insurer, blanket disability insurer, health care services organization, hospital service corporation or medical service corporation that provides health insurance in this state.

12. 8. "Health plan" means a group or individual health plan that finances or furnishes health care services and that is issued by a health insurer.

13. 9. "Network facility" means a health care facility that has entered into a contract with a health insurer to provide health care services to the health insurer's enrollees at agreed on rates.

14. 10. "Surprise out‑of‑network bill" means a bill for a health care service that was provided in a network facility by a health care provider that is not a contracted provider and that meets one of the requirements listed in section 20‑3113.

11. "Usual, customary and reasonable rate" means the eightieth percentile of all charges for a particular health care service that is performed by a health care provider in the same or similar specialty and that is provided in the same geographic area as reported in a benchmarking database maintained by a nonprofit organization that is not affiliated with any health care insurer and that is designated by the director of the department. END_STATUTE

Sec. 3. Section 20-3113, Arizona Revised Statutes, is amended to read:

START_STATUTE20-3113. Surprise out‑of‑network bill; requirements; notice; cost sharing requirements; billing; unlawful practice

A. A bill for a health care service that was provided in a network facility by a health care provider that is not a contracted provider must meet one of the following requirements to qualify as a surprise out‑of‑network bill:

1. The bill was for emergency services, including under circumstances described by section 20‑2803, subsection A and health care services directly related to the emergency services that are provided during an inpatient admission to any network facility.

2. The bill was for a health care service that was not provided in the case of an emergency and the health care provider or the provider's representative did not provide to the enrollee, or did not provide to the enrollee within a reasonable amount of time before the enrollee received the services, a written dated disclosure that contained the following information:

(a) Notice that contains the name of the billing health care provider and that states the health care provider is not a contracted provider.

(b) The estimated total cost to be billed by the health care provider or the provider's representative.

(c) Notice that the enrollee or the enrollee's authorized representative is not required to sign the disclosure to obtain medical care but if the enrollee or the enrollee's representative signs the disclosure, the enrollee may have waived any rights to dispute resolution under this article.

3. The bill was for a health care service that was not provided in the case of an emergency and the enrollee received the disclosure prescribed in paragraph 2 of this subsection, but the enrollee or the enrollee's authorized representative chose not to sign the disclosure.

B. Notwithstanding any provision of this article, a health insurer and any health plan offered by a health insurer shall comply with chapter 17, article 1 of this title.

C. Other than an applicable cost sharing requirement prescribed in this section, an enrollee is not responsible for payment of a surprise out‑of‑network bill.

D. A health insurer or any health plan offered by a health insurer may not impose for emergency services that an out‑of‑network health care provider renders to an enrollee any cost sharing requirement that is greater than the cost sharing requirement that would be imposed if the emergency services were rendered by an in‑network health care provider. The enrollee is required to pay only the applicable cost sharing requirement that would be imposed for the health care service if the service were rendered by an in‑network health care provider. The health insurer shall reimburse the out‑of‑network health care provider or enrollee, as applicable, for a health care service rendered at the in‑network rate under the enrollee's health plan as payment in full, unless the health insurer and health care provider agree otherwise.

E. If an out‑of‑network health care provider renders emergency services to an enrollee, the health care provider may bill the health insurer directly and the health insurer shall reimburse the health care provider the greatest of the following amounts:

1. The amount the enrollee's health plan would pay for the services if the services were rendered by an in‑network health care provider.

2. The usual, customary and reasonable rate for the services.

3. The amount medicare would reimburse for the services.

4. An amount that the health care insurer agrees to pay that is greater than amounts described in paragraphs 1, 2 and 3 of this subsection.

F. If an out‑of‑network health care provider renders a health care service to an enrollee and the health insurer fails to inform the enrollee that the health care service was rendered by an out‑of‑network health care provider, the health insurer may not impose any cost sharing requirement that is greater than the cost sharing requirement that would be imposed if the service were rendered by an in‑network health care provider.

G. An act or practice in violation of this section constitutes an unlawful practice under section 44‑1522. The attorney general may investigate and take appropriate action pursuant to title 44, chapter 10, article 7. END_STATUTE

Sec. 4. Repeal

Sections 20-3114, 20‑3115, 20‑3116, 20‑3117 and 20‑3118, Arizona Revised Statutes, are repealed.

Sec. 5. Section 20-3119, Arizona Revised Statutes, is amended to read:

START_STATUTE20-3119. Right of civil action

An enrollee who is aggrieved by an arbitration a decision regarding a disputed surprise out‑of‑network bill may file a civil action in superior court not later than one year after the date of the disputed decision to obtain appropriate relief with respect to the same surprise out‑of‑network bill. END_STATUTE

Sec. 6. Department of insurance and financial institutions; report; definitions

A. On or before November 1, 2021, the department of insurance and financial institutions shall review the efficacy of dispute resolution practices relating to surprise out‑of‑network bills between health care providers and health insurers and issue a report that includes any recommended legislative changes based on best practices from surprise billing laws in other states. The department shall submit the report to the governor, president of the senate and speaker of the house of representatives, provide a copy of the report to the secretary of state and post the report on the department's website.

B. For the purposes of this section, "health care provider", "health insurer" and "surprise out‑of‑network bill" have the same meanings prescribed in section 20‑3111, Arizona Revised Statutes, as amended by this act.

Sec. 7. Short title

This act may be cited as the "Stop Surprise Bills Act".