SB 518 Summary

• Establishes that HMO compensation for emergency screening and evaluation services is presumed reasonable if based at 130% of Medicare payment rates for the same or similar services in the same geographic area.

• Defines out-of-network providers as those choosing not to contract with an HMO and prohibits them from charging HMO enrollees more than applicable copayments or deductibles for emergency services.

• Requires HMOs to have 30 minutes to identify an available specialist for emergency consultations; if unsuccessful, the emergency department may arrange services and the HMO cannot deny coverage due to lack of prior authorization.

• Sets physician credentialing and recredentialing timelines including 45 calendar days for clean applications, with maximum 180-day total process, and prohibits denial based solely on lack of board certification.

• Effective date: November 1, 2017.