AB 533 Summary

• Requires health care service plans and health insurers to cap patient cost-sharing when receiving nonemergency services from out-of-network providers at contracting health facilities at the in-network cost-sharing amount, effective July 1, 2016.

• Establishes independent dispute resolution processes administered by the Department of Managed Health Care and Insurance Commissioner to resolve payment disputes between insurers/plans and noncontracting individual health professionals.

• Requires plans and insurers to base reimbursement to noncontracting providers on Medicare reimbursement rates for the same or similar services in the geographic area where services were rendered.

• Prohibits noncontracting providers from billing patients more than in-network cost-sharing amounts unless the patient provides written consent at least three business days in advance that meets specified criteria, including a cost estimate and disclosure of lower-cost contracting provider options.

• Requires noncontracting providers to refund any overpayments within 30 business days, with interest accruing at 15% per annum for amounts not refunded, and exempts emergency services and Medi-Cal plans from these requirements.