Substitute House Bill 388 Summary

• Health plan issuers must reimburse out-of-network providers for unanticipated out-of-network care provided at in-network facilities and for emergency services at out-of-network facilities, emergency facilities, or ambulances.

• Reimbursement shall be the greatest of: (1) the median in-network rate for that service in the geographic region, (2) the plan's standard out-of-network calculation method, or (3) the Medicare Part A or B rate for that service.

• Providers and facilities cannot bill covered persons for the difference between health plan reimbursement and their charges for unanticipated or emergency out-of-network care.

• If negotiation over reimbursement fails within 30 days or parties reach impasse, either party may request binding arbitration through the superintendent of insurance for claims exceeding $750 (or bundled claims totaling more than $750).

• Arbitrators must consider in-network rates, Medicare rates, geographic availability of providers, and prior contractual relationships when determining fair reimbursement; the nonprevailing party pays 70% of arbitration fees.