ARIZONA HOUSE OF REPRESENTATIVES

Fifty-seventh Legislature

First Regular Session

Senate: HHS DP 7-0-0-0 | 3rd Read 29-0-1-0

SB 1626: health insurance; surprise billing; disputes

Sponsor: Senator Werner, LD 4

Committee on Health & Human Services

Overview

Clarifies that the requirements and procedures related to providing notice to an enrollee of their statutory right to dispute surprise out-of-network bills applies only to claims that are not subject to an independent dispute resolution (IDR) under the No Surprises Act (NSA).

History

Laws 2017, Chapter 190, establishes a process for an enrollee who has received a surprise out-of-network bill to seek a dispute resolution for the disputed amount. A surprise out-of-network bill is a bill for a health care service, a laboratory service or durable medical equipment that was provided in a network facility by a health care provider that is not a contracted provider. A bill must meet certain criteria to qualify as a surprise out-of-network bill. The dispute resolution process consists of an informal settlement teleconference and arbitration. The Department of Insurance and Financial Institutions (DIFI) is required to develop a simple, fair, efficient and cost-effective arbitration procedure for surprise out-of-network bill disputes, as well as specify time frames, standards and other details for the arbitration proceeding (A.R.S. §§ 20-3111, 20-3113 and 20-3114).

An enrollee may seek dispute resolution for a surprise out-of-network bill by filing a request with DIFI within one year of the date of service noted in the surprise out-of-network bill. DIFI, in conjunction with appropriate health care boards, must prescribe a notice that outlines an enrollee's rights to dispute surprise out-of-network bills. Health insurers are required to include the prescribed notice in each explanation of benefits or other similar claim adjudication notices issued to enrollees that involves covered services provided by a noncontracted health care provider. If an enrollee contacts a health care provider, a provider's representative or a billing company regarding a dispute involving a surprise out-of-network bill, the health care provider, the provider's representative or the billing company must provide written notice to the enrollee of the dispute resolution process (A.R.S. § 20-3117).

The NSA is a federal law aimed towards protecting consumers from receiving surprise medical bills resulting from out-of-network care. The federal law also requires health care insurers to give patients a notice about their surprise billing protections (26 U.S.C. § 9816).

The NSA applies to the uninsured and individuals insured by: 1) individual and group health insurance plans; 2) student health insurance plans; 3) employer self-funded plans; 4) non-federal government plans, such as state, county and city plans; 5) church plans; and 6) federal employees health benefit plans. The NSA does not apply to individuals covered under short term limited duration plans, critical illness policies, other limited benefit plans, Medicare, the Arizona Health Care Cost Containment System, Indian Health Services, Veterans Affairs Health Care or TRICARE (DIFI).

Provisions

1. Clarifies that the requirements for health insurers to provide surprise out-of-network billing notices to enrollees, only applies to claims that are not subject to an IDR under the NSA. (Sec. 1)

2. Specifies that if an enrollee contacts a health care provider, a provider's representative or a billing company regarding a dispute involving a surprise out-of-network bill that is not subject to an IDR under the NSA, then the health care provider, a provider's representative or a billing company must provide the surprise out-of-network billing notice to the enrollee. (Sec. 1)

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6. SB 1626

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