§ 228 — Allowed amount; advance disclosure of allowed amount or charge for admission, procedure or service; referrals; nonparticipation in plan; penalties

Section 228. (a) As used in this section ''allowed amount'', shall mean the contractually agreed-upon maximum amount paid by a carrier to a health care provider for a health care service provided to an insured.(b) (1) Upon scheduling an admission, procedure or service for a patient or prospective patient for a condition that is not an emergency medical condition as defined in section 1 of chapter 176O or upon request by a patient or prospective patient, a health care provider shall disclose whether the health care provider is participating in the patient's health benefit plan; provided, however, that if a patient or prospective patient schedules a series of admissions, procedures or services as part of a continued course of treatment, the patient or prospective patient may waive the requirement to receive such disclosure from the health care provider for subsequent admissions, procedures or services for that course of treatment; provided further, that if the health care provider's status as participating in the patient's health benefit plan changes during a continued course of treatment, the health care provider shall inform a patient of this change in status.(2) If the health care provider is participating in the patient's or prospective patient's health benefit plan, the health care provider shall, at the time of scheduling the admission, procedure or service: (i) inform such patient or prospective patient that the patient or prospective patient may request disclosure of the allowed amount and the amount of any facility fees for the admission, procedure or service; and (ii) inform the patient or prospective patient that the patient or prospective patient may obtain additional information about any applicable out-of-pocket costs pursuant to section 23 of chapter 176O; provided, however, that if a patient or prospective patient makes a request under clause (i) of this paragraph, a health care provider shall disclose the allowed amount and the amount of any facility fees for the admission, procedure or service not later than 2 days after receipt of such request. If a health care provider is unable to quote a specific amount in advance due to the health care provider's inability to predict the specific treatment or diagnostic code, the health care provider shall disclose the estimated maximum allowed amount for the admission, procedure or service and the amount of any anticipated facility fees. A health care provider may assist a patient or prospective patient in using the patient's or prospective patient's health plan's toll-free number and website pursuant to said section 23 of said chapter 176O.(3) If the health care provider is not participating in the patient's or prospective patient's health benefit plan, the health care provider shall, at the time of scheduling the admission, procedure or service: (i) provide the charge and the amount of any facility fees for the admission, procedure or service; (ii) inform the patient or prospective patient that the patient or prospective patient will be responsible for the amount of the charge and the amount of any facility fees for the admission, procedure or service not covered through the patient's health benefit plan; and (iii) inform the patient or prospective patient that the patient or prospective patient may be able to obtain the admission, procedure or service at a lower cost from a health care provider who participates in the patient's or prospective patient's health benefit plan. A health care provider may assist a patient or prospective patient in using the patient's or prospective patient's health plan's toll-free number and website pursuant to said section 23 of said chapter 176O.(c) A health care provider referring a patient to another provider shall disclose: (i) if the provider to whom the patient is being referred is part of or represented by the same provider organization as defined in section 1 of chapter 6D; (ii) the possibility that the provider to whom the patient is being referred is not participating in the patient's health benefit plan and that if the provider is out-of-network under the terms of the patient's health benefit plan then any out-of-network applicable rates under such health benefit plan may apply and that the patient has the opportunity to verify whether the provider participates in the patient's health benefit plan prior to making an appointment or agreeing to use the services of said provider; and (iii) sufficient information about the referred provider for the patient to obtain additional information about the provider's network status under the patient's health plan and any applicable out-of-pocket costs for services sought from the referred provider pursuant to section 23 of chapter 176O.(d) A health care provider referring a patient to another provider by directly scheduling, ordering or otherwise arranging for the health care services on the patient's behalf shall, prior to scheduling, ordering or otherwise arranging for the health care services on the patient's behalf: (i) verify whether the provider to whom the patient is being referred participates in the patient's health benefit plan; and (ii) notify the patient if the provider to whom the patient is being referred is not a provider who participates in the patient's health benefit plan or if the network status of the provider to whom the patient is being referred could not be verified.(e) A health care provider shall determine if it participates in a patient's health benefit plan prior to said patient's admission, procedure or service for conditions that are not emergency medical conditions as defined in section 1 of chapter 176O. If the health care provider does not participate in the patient's health benefit plan and the admission, procedure or service was scheduled more than 7 days in advance of the admission, procedure or service, such provider shall notify the patient verbally and in writing of that fact not less than 7 days before the scheduled admission, procedure or service. If the health care provider does not participate in the patient's health benefit plan and the admission, procedure or service was scheduled less than 7 days in advance of the admission, procedure or service, such provider shall notify the patient verbally of that fact not less than 2 days before the scheduled admission, procedure or service or as soon as is practicable before the scheduled admission, procedure or service, with written notice of that fact to be provided upon the patient's arrival at the scheduled admission, procedure or service. If a health care provider that does not participate in the patient's health benefit plan fails to provide the required notifications under this subsection, the provider shall not bill the insured except for any applicable copayment, coinsurance or deductible that would be payable if the insured received the service from a participating health care provider under the terms of the insured's health benefit plan. Nothing in this subsection shall relieve a health care provider from the requirements under subsections (b) to (d), inclusive.[Text of subsection (f) added by 2020, 260, Sec. 25 effective January 1, 2025. See 2020, 260, Sec. 75, as amended by 2022, 22, Sec. 3 and 2022, 107, Sec. 2.]

(f) The commissioner shall implement this section and impose penalties for non-compliance consistent with the department's authority to regulate health care providers; provided, however, that the penalty for non-compliance shall not exceed $2,500 in each instance. A health care provider that violates any provision of this section or the rules and regulations adopted pursuant to this subsection shall be liable for penalties as provided in this subsection.