SB3188 Summary

• Requires insurers to ensure beneficiaries using participating network hospitals or ambulatory surgery centers incur no greater out-of-pocket liability when treated by nonparticipating facility-based physicians or providers than they would with participating providers.

• Allows insurers to initiate binding arbitration to challenge charges from nonparticipating physicians or providers when charges exceed either the amount paid to participating providers in the same specialty and area or 125% of Medicare coverage for the same services.

• Establishes Department of Insurance oversight of binding arbitration with 30-day resolution timeline, requiring the nonprevailing party to pay arbitrator fees.

• Prohibits nonparticipating facility-based physicians and providers from billing beneficiaries beyond applicable deductibles, copayments, and coinsurance amounts, with violations referred to the Attorney General for civil action.

• Effective January 1, 2011; applies to state employees, counties, municipalities, school districts, health maintenance organizations, and voluntary health service plans.