Bill Analysis — PCS to Senate Bill 228, Allow Employers to Offer EPO Benefit Plans (April 21, 2021)

Summary

Analysis of the proposed committee substitute (PCS) to Senate Bill 228, Allow Employers to Offer EPO Benefit Plans, for the Senate Commerce and Insurance committee, dated April 21, 2021. It states that the PCS would allow insurers to offer exclusive provider benefit plans under which care from providers outside the network would not be covered unless it was emergency services or medically necessary services when an in-network provider was not reasonably available. It would also establish continuity of care provisions, including continued payment to a provider for treatment within 90 days of the provider leaving the network. The bill would be effective July 1, 2021, and apply to contracts entered into, renewed, or amended on or after that date.

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Full text

                                                     SENATE BILL 228:
                                                     Allow Employers to Offer EPO Benefit Plans.
      2021-2022 General Assembly
     Committee:     Senate Commerce and Insurance. If favorable, Date:              April 21, 2021
                    re-refer to Health Care. If favorable, re-refer to
                    Rules and Operations of the Senate
     Introduced by: Sens. Edwards, Krawiec, Burgin                     Prepared by: Jason Moran-Bates
     Analysis of:   PCS to First Edition                                            Staff Attorney
                    S228-CSBC-20

     OVERVIEW: The proposed committee substitute to Senate Bill 228 would allow insurers to offer
     exclusive provider benefit health plans and establish continuity of care provisions for those plans.
     BILL ANALYSIS:
     The PCS to Senate Bill 228 would allow insurers to offer exclusive provider benefit plans where out-of-
     network services would not be covered unless they were emergency services or medically necessary
     services provided when an in-network provider was not reasonably available.
     The PCS would create definitions for "exclusive provider benefit plan," "exclusive provider organization,"
     "insurer," and "participating provider."
     Providers who were members of one insurer's exclusive network would be permitted to participate in
     networks with other insurers. Insurers offering exclusive provider benefit plans would have to make
     annual reports to the Department of Insurance on the terms of their agreements with providers in the
     exclusive network. The existing insurance rules for preferred provider organizations would also apply to
     exclusive provider organizations.
     The PCS would also establish continuity of care provisions for exclusive provider organizations (EPO).
     This transitional coverage would be available to individuals who are newly insured by the EPO and to
     individuals whose healthcare providers left the EPO's network.
            •     In general, the insurer would have to continue paying the provider for treatment received within
                  90 days of the provider leaving the network.
            •     If the care is related to surgery, organ transplantation, or inpatient care, coverage must be continued
                  for 90 days after discharge.
            •     If the care is related to pregnancy, and the insured was in her second trimester when the provider
                  left the network, coverage must continue through 60 days of postpartum care.
            •     Coverage for terminal illness must be extended for the duration of the insured's life.
     Insurers may condition coverage for continuing care on the following:
            •     The provider agreeing to accept reimbursement from the insurer and not charge the patient a
                  greater cost-share.
            •     The provider agreeing to comply with the insurer's quality assurance programs and policies for in-
                  network providers.
                                                                                                                                                             Legislative Analysis
     Jeffrey Hudson
                                                                                                                                                                   Division
         Director                                  S228-SMBC-37(CSBC-20)-v-1                                                                                   919-733-2578
This bill analysis was prepared by the nonpartisan legislative staff for the use of legislators in their deliberations and does not constitute an official statement of legislative intent.
Senate PCS 228
Page 2

   •     The provider agreeing to discontinue providing services to the insured at the end of the transition
         period and assist the insured in finding an in-network provider.
Insurers would not be required to:
   •     Cover benefits during the transition period that would not have been covered previously.
   •     Provide continuing coverage when the provider is removed from the network for reasons of fraud.
   •     Provide transition coverage when the insurer determines the provider's continuing services would
         result in serious danger to the health or safety of the insured.


EFFECTIVE DATE: This bill would be effective July 1, 2021, and apply to contracts entered into,
renewed, or amended on or after that date.


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