H.F. 2630 Section 1. NEW SECTION . 514M.1 Definitions. 1 As used in this chapter unless the context otherwise 2 requires: 3 1. “Authorized representative” means the same as defined in 4 section 514J.102. 5 2. “Balance billing” means the practice of a provider 6 billing for the difference between the provider’s charge for 7 the provision of a health care service and a health carrier’s 8 allowed amount for the health care service. 9 3. “Centers of excellence” means a specialized program 10 within a facility that has an exceptionally high concentration 11 of health care professionals with expertise and related 12 resources centered on a particular medical area and delivered 13 in a comprehensive, interdisciplinary fashion. 14 4. “Commissioner” means the commissioner of insurance. 15 5. “Cost-sharing” means any coverage limit, copayment, 16 coinsurance, deductible, or other out-of-pocket expense 17 obligation imposed on a covered person by a health benefit plan 18 providing for third-party payment or prepayment of health or 19 medical expenses. 20 6. “Covered benefit” or “benefit” means the same as defined 21 in section 514J.102. 22 7. “Covered person” means the same as defined in section 23 514J.102. 24 8. “Emergency medical condition” means the same as defined 25 in section 514C.16. 26 9. “Emergency services” means the same as defined in section 27 514C.16. 28 10. “Essential community provider” means a provider 29 that serves predominantly low-income, medically underserved 30 individuals. 31 11. “Facility” means the same as defined in section 32 514J.102. 33 12. “Health benefit plan” means the same as defined in 34 section 514J.102. 35 -1- LSB 5664YH (4) 88 ko/rn 1/ 30

H.F. 2630 13. “Health care professional” means the same as defined in 1 section 514J.102. 2 14. “Health care provider” or “provider” means the same as 3 defined in section 514J.102. 4 15. “Health care services” means services for the diagnosis, 5 prevention, treatment, cure or relief of a physical, mental 6 or behavioral health condition, illness, injury, or disease, 7 including mental health and substance use disorders. 8 16. “Health carrier” or “carrier” means an entity subject to 9 the insurance laws and regulations of this state, or subject 10 to the jurisdiction of the commissioner, that contracts or 11 offers to contract, or enters into an agreement to provide, 12 deliver, arrange for, pay for, or reimburse any of the costs of 13 health care services, including a health insurance company, a 14 health maintenance organization, a hospital and health service 15 corporation, or any other entity providing a plan of health 16 insurance, health benefits, or health care services. 17 17. “In-network” means a health care service that is 18 provided to a covered person by a health care provider that is 19 a participating provider in the covered person’s network plan. 20 18. “Intermediary” means a person authorized to negotiate 21 and execute a provider contract with a health carrier on behalf 22 of a health care provider or on behalf of a network. 23 19. “Network” means a group or groups of participating 24 providers providing health care services under a network plan. 25 20. “Network plan” means a health benefit plan that either 26 requires a covered person to use, or offers incentives for a 27 covered person to use, health care providers managed, owned, 28 under contract with, or employed by a specific health carrier. 29 21. “Out-of-network” means a health care service that is 30 provided to a covered person by a health care provider that is 31 not a participating provider in the covered person’s network 32 plan. 33 22. “Participating provider” means a provider that, under 34 a contract with a health carrier, or with a health carrier’s 35 -2- LSB 5664YH (4) 88 ko/rn 2/ 30

H.F. 2630 contractor or subcontractor, has agreed to provide health care 1 services to covered persons with an expectation of receiving 2 payment directly or indirectly from the health carrier, in 3 addition to a covered person’s cost-sharing. 4 23. “Person” means the same as defined in section 514J.102. 5 24. “Primary care” means general health care services of the 6 type provided at the time a patient seeks preventive care or 7 first seeks health care services for a specific health concern. 8 “Primary care” includes all of the following: 9 a. Care that promotes and maintains mental and physical 10 health and wellness. 11 b. Care that prevents disease. 12 c. Screening, diagnosing, and treatment of acute or chronic 13 conditions caused by disease, injury, or illness. 14 d. Patient counseling and education. 15 e. Provision of a broad spectrum of preventive and curative 16 health care over a period of time. 17 f. Coordination of care. 18 25. “Primary care professional” means a participating 19 provider designated by a health carrier to supervise, 20 coordinate, or to provide initial care or continuing care to a 21 covered person, and who may be required by the health carrier 22 to initiate a referral for specialty care and to maintain 23 supervision of health care services rendered to the covered 24 person. 25 26. “Specialist” means a health care professional who meets 26 all of the following requirements: 27 a. Focuses on a specific area of physical, mental, or 28 behavioral health, or focuses on a specific group of patients. 29 b. Has successfully completed required training and is 30 recognized by the state to provide specific specialty care. 31 27. “Specialty care” means advanced medically necessary care 32 and treatment of a specific physical, mental, or behavioral 33 health condition, or a health condition which may manifest 34 in particular ages or subpopulations, that is provided by a 35 -3- LSB 5664YH (4) 88 ko/rn 3/ 30

H.F. 2630 specialist, preferably in coordination with a primary care 1 professional or other health care professional. 2 28. “Telehealth” means the same as defined in section 3 514C.34. 4 29. “Tiered network” means a network that identifies and 5 groups some or all types of participating providers into 6 specific groups to which different provider reimbursement, 7 covered person cost-sharing, provider access requirements, 8 or any combination thereof, apply for the same health care 9 services. 10 30. “To stabilize” means to provide medical treatment for an 11 individual’s emergency medical condition as may be necessary 12 to assure within a reasonable medical probability that no 13 material deterioration of the individual’s emergency medical 14 condition is likely to result from, or occur during, the 15 transfer of the individual to or from a facility. “Transfer” 16 means, for purposes of this subsection, the movement, including 17 the discharge, of an individual outside of a facility at the 18 direction of any person employed by, affiliated with, or 19 associated with the facility directly or indirectly, but does 20 not include the movement of an individual who meets any of the 21 following criteria: 22 a. The individual has been declared legally dead by a health 23 care professional. 24 b. The individual leaves the facility against medical 25 advice. 26 Sec. 2. NEW SECTION . 514M.2 Network adequacy —— 27 commissioner approval. 28 1. A health carrier providing a network plan shall maintain 29 a network that is adequate in the number of participating 30 providers and in the appropriate types of participating 31 providers, including participating essential community 32 providers, to assure that all covered health care services 33 provided to covered persons will be accessible without 34 unreasonable travel or delay. Covered persons shall have 35 -4- LSB 5664YH (4) 88 ko/rn 4/ 30

H.F. 2630 access to emergency services twenty-four hours per day, seven 1 days per week. 2 2. The commissioner shall determine, by rules promulgated 3 pursuant to chapter 17A, network adequacy that meets the 4 requirements of this section and may establish network adequacy 5 requirements by reference to any reasonable criteria which 6 shall include but not be limited to all of the following: 7 a. The ratio of participating provider to covered persons 8 by specialty care areas. 9 b. The ratio of participating primary care providers to 10 covered persons. 11 c. The geographic accessibility of participating providers. 12 d. The geographic variation and population dispersion of 13 participating providers. 14 e. The average wait time for a covered person to obtain an 15 appointment with a participating provider. 16 f. Participating provider hours of operation. 17 g. The ability of the network to meet the needs of covered 18 persons, including low-income individuals, children, and 19 adults with serious, chronic, or complex health conditions, 20 or physical or mental disabilities, or limited English 21 proficiency. 22 h. Other health care service delivery options made available 23 to covered persons, such as telehealth, mobile clinics, and 24 centers of excellence. 25 i. The technological and specialty care services available 26 to serve the medical needs of covered persons requiring 27 technologically advanced or specialty care services. 28 3. a. A health carrier shall establish and maintain a 29 process, to be approved by the commissioner, to assure that a 30 covered person obtains a covered benefit at an in-network level 31 of benefits, including an in-network level of cost-sharing, 32 from an out-of-network provider, or shall establish another 33 protocol approved by the commissioner to address each of the 34 following circumstances: 35 -5- LSB 5664YH (4) 88 ko/rn 5/ 30

H.F. 2630 (1) The health carrier has a sufficient network pursuant 1 to subsections 1 and 2, but does not have a specific type of 2 participating provider available to provide a covered benefit 3 to a covered person, or the health carrier does not have a 4 specific type of participating provider available to provide a 5 covered benefit to a covered person without unreasonable travel 6 or delay. 7 (2) The health carrier has an insufficient number or type 8 of participating providers pursuant to subsections 1 and 2 9 available to provide a covered benefit to a covered person 10 without unreasonable travel or delay. 11 b. A health carrier shall inform covered persons of the 12 process, pursuant to paragraph “a” , that a covered person may 13 use to request access to a covered benefit provided by an 14 out-of-network provider in each of the following circumstances: 15 (1) The covered person is diagnosed with a condition or 16 disease that requires specialized health care services and the 17 health carrier does not have a participating provider with 18 the required specialty, or with the professional training and 19 expertise, to provide health care services for the covered 20 person’s condition or disease. 21 (2) The covered person is diagnosed with a condition or 22 disease that requires specialized health care services and 23 the health carrier cannot provide reasonable access to a 24 participating provider with the required specialty, or with 25 the professional training and expertise to provide health care 26 services to the covered person for the condition or disease, 27 without requiring unreasonable travel or delay. 28 c. A health carrier shall treat health care services 29 a covered person receives from an out-of-network provider 30 pursuant to paragraph “b” as if the health care services are 31 provided by a participating provider, including counting the 32 covered person’s cost-sharing for the health care services 33 toward the covered person’s maximum out-of-pocket limit 34 applicable to the same health care services if obtained from 35 -6- LSB 5664YH (4) 88 ko/rn 6/ 30

H.F. 2630 a participating provider under the covered person’s health 1 benefit plan. 2 d. A health carrier’s process pursuant to this subsection 3 shall ensure that a covered person’s request to obtain a 4 covered benefit from an out-of-network provider is addressed 5 by the health carrier in a time period that is medically 6 appropriate for the covered person’s medical condition. 7 e. A health carrier shall establish and maintain a system 8 that documents all requests made by covered persons to obtain 9 a covered benefit from an out-of-network provider pursuant 10 to this subsection and shall provide complete copies of the 11 documentation to the commissioner within five business days of 12 the commissioner’s request for the documentation. 13 f. The process established in this subsection shall not be 14 construed by a health carrier as a substitute for establishing 15 and maintaining a sufficient provider network pursuant to 16 this section, nor shall the process be construed by a covered 17 person as a process to circumvent the use of a participating 18 provider to provide covered benefits available through a health 19 carrier’s network. 20 4. Nothing in this section shall be construed to prevent a 21 covered person from exercising the covered person’s rights and 22 remedies relating to internal and external claims grievance and 23 appeals processes pursuant to applicable state or federal law. 24 5. A health carrier shall monitor, on an ongoing basis, the 25 ability, clinical capacity, and legal authority of the health 26 carrier’s participating providers to furnish all contracted 27 covered benefits to covered persons. 28 6. a. Prior to or at the time a health carrier files a 29 newly offered network in this state, the health carrier shall 30 file with the commissioner for approval in the form and manner 31 pursuant to rules adopted by the commissioner, an access plan 32 that meets the requirements of this chapter. 33 b. A health carrier may request that the commissioner 34 deem portions of the submitted access plan as proprietary 35 -7- LSB 5664YH (4) 88 ko/rn 7/ 30

H.F. 2630 or trade secret. The health carrier shall make the access 1 plan, absent information deemed proprietary or trade secret by 2 the commissioner, readily accessible on the health carrier’s 3 main internet site, at all of the health carrier’s business 4 premises, and to any individual upon request. For purposes of 5 this paragraph, information is only proprietary or trade secret 6 if revealing the information will allow the health carrier’s 7 direct competitors to obtain competitive information. 8 c. A health carrier shall notify the commissioner of any 9 material change to an existing network plan within ten business 10 days after the date that the material change occurs. The 11 carrier shall include in the notice a reasonable time frame, 12 not to exceed fifteen business days, within which the carrier 13 will submit an updated access plan to the commissioner for 14 approval. 15 7. A health carrier’s access plan pursuant to subsection 6 16 shall at a minimum describe or contain all of the following: 17 a. The health carrier’s network, including how the use of 18 telehealth or other technology will be used to meet network 19 access standards, if applicable. 20 b. The health carrier’s procedures for making referrals 21 and authorizing referrals within and outside of the health 22 carrier’s network. 23 c. The health carrier’s ongoing process for monitoring 24 and assuring the sufficiency of the health carrier’s network 25 to meet the health care needs of all covered persons in the 26 network plan. 27 d. The factors used by the health carrier to establish 28 the health carrier’s network, including a description of the 29 proposed network and the criteria used by the health carrier to 30 select providers or to tier providers, if applicable. 31 e. The health carrier’s efforts to address the needs of all 32 covered persons in the network plan, including individuals with 33 limited English proficiency or illiteracy, diverse cultural 34 or ethnic backgrounds, physical or mental disabilities, and 35 -8- LSB 5664YH (4) 88 ko/rn 8/ 30

H.F. 2630 serious, chronic, or complex medical conditions. This shall 1 include the health carrier’s efforts, if applicable, to include 2 various types of essential community providers in the health 3 carrier’s network. 4 f. The health carrier’s methods for assessing the health 5 care needs of all covered persons and the covered persons’ 6 satisfaction with the health care services offered by the 7 participating providers. 8 g. The health carrier’s methods of informing covered 9 persons of covered health care services and the features of the 10 specific health benefit plans offered by the health carrier, 11 including but not limited to: 12 (1) The grievance and appeal procedures. 13 (2) The process for a covered person to select and to change 14 network providers. 15 (3) The health carrier’s process for updating the health 16 benefit plan’s provider directories for each of the health 17 benefit plan’s networks. 18 (4) All health care services offered, including those 19 health care services offered through a preventive care benefit, 20 if applicable. 21 (5) The procedures for a covered person to access covered 22 emergency, urgent, and specialty health care services. 23 h. The health carrier’s system for ensuring coordination and 24 continuity of care in each of the following circumstances: 25 (1) For a covered person referred to a specialty provider. 26 (2) For a covered person using ancillary services, 27 including social services and other community resources, and 28 for ensuring appropriate discharge planning from such services. 29 i. The health carrier’s process for enabling a covered 30 person to change primary care providers. 31 j. The health carrier’s proposed plan for providing 32 continuity of care in the event of a contract termination 33 between the health carrier and any of the health carrier’s 34 participating providers, or in the event of the health 35 -9- LSB 5664YH (4) 88 ko/rn 9/ 30

H.F. 2630 carrier’s insolvency or other inability to continue operations. 1 The proposed plan shall detail the process by which the 2 health carrier will notify covered persons of the contract 3 termination, the health carrier’s insolvency, or other 4 cessation of operations; and the process by which the health 5 carrier will transition covered persons to other health care 6 providers in a medically appropriate manner. 7 k. The health carrier’s process for monitoring a covered 8 person’s access to participating provider specialist services 9 including emergency room care, anesthesiology, radiology, 10 hospitalist care, pathology services, and laboratory services. 11 l. Any other information required by the commissioner to 12 determine the health carrier’s compliance with this chapter. 13 Sec. 3. NEW SECTION . 514M.3 Prohibition on balance billing. 14 1. A health carrier shall establish a mechanism by which 15 a participating provider will be notified on an ongoing 16 basis of the specific covered health care services for which 17 the participating provider is responsible, including any 18 limitations or conditions on the participating provider’s 19 provisions of the health care services. 20 2. Each contract executed between a health carrier and a 21 participating provider shall contain a hold harmless provision 22 that provides protection for covered persons. This requirement 23 shall be met by including a provision that contains language 24 substantially similar to the following: 25 Provider agrees that in no event, including but not limited 26 to nonpayment by a health carrier or an intermediary, the 27 insolvency of a health carrier or an intermediary, or breach 28 of this agreement, shall the provider bill, charge, collect a 29 deposit from, seek compensation, remuneration, or reimbursement 30 from, or have any legal recourse against a covered person 31 or another individual, other than the health carrier or 32 intermediary, for health care services provided pursuant to 33 this agreement. This agreement shall not be construed as 34 prohibiting a provider from collecting a covered person’s 35 -10- LSB 5664YH (4) 88 ko/rn 10/ 30

H.F. 2630 cost-sharing as specifically provided in the covered person’s 1 evidence of coverage, or from collecting fees for health care 2 services delivered on a fee-for-service basis to a covered 3 person. This agreement does not prohibit a provider, except 4 for a health care professional who is employed full-time on the 5 staff of a health carrier and has agreed to provide health care 6 services exclusively to that health carrier’s covered persons, 7 and a covered person from agreeing to the provider continuing 8 to provide health care services solely at the expense of the 9 covered person, as long as the provider has clearly informed 10 the covered person that the health carrier may not cover or 11 continue to cover a specific health care service or services. 12 Except as provided herein, this agreement shall not prohibit 13 the provider from pursuing any legal remedy available to the 14 provider. 15 3. Each contract executed between a health carrier and a 16 participating provider shall set forth that in the event of 17 the health carrier’s or the intermediary’s insolvency or other 18 cessation of operations, the provider’s obligation to deliver 19 covered health care services to a covered person without 20 balance billing the covered person shall continue until the 21 earlier of either of the following: 22 a. The termination of the covered person’s coverage under 23 the applicable health benefit plan including any extension of 24 the covered person’s coverage provided under the contract terms 25 or pursuant to applicable state or federal laws, for a covered 26 person who is undergoing an active course of medical treatment. 27 b. The date the contract between the health carrier and 28 the provider, including any required extension for covered 29 persons undergoing an active course of medical treatment, would 30 have terminated if the health carrier or an intermediary had 31 remained in operation. 32 4. The contract provisions pursuant to subsections 2 and 33 3 shall be construed in favor of the covered person, shall 34 survive the termination of the contract regardless of the 35 -11- LSB 5664YH (4) 88 ko/rn 11/ 30

H.F. 2630 reason for the termination, including the insolvency of the 1 health carrier or intermediary, and shall supersede any oral 2 or written contrary agreement between a provider and a covered 3 person or the representative of a covered person. 4 5. In no event shall a participating provider collect or 5 attempt to collect any money from a covered person owed to the 6 provider by a health carrier. 7 Sec. 4. NEW SECTION . 514M.4 Participating providers. 8 1. A health carrier’s selection standards for selecting 9 and tiering participating providers shall be developed 10 for providers and each type of specialty care. The health 11 carrier’s selection standards shall be used in determining 12 the selection and tiering, as applicable, of participating 13 providers by the health carrier and the health carrier’s 14 intermediaries. 15 2. A health carrier’s selection and tiering criteria shall 16 not be established in a manner that results in any of the 17 following: 18 a. Allows a health carrier to discriminate against 19 high-risk populations by excluding a provider or tiering a 20 provider because the provider is located in a geographic area 21 that contains populations or providers presenting a risk of 22 higher than average claims, losses, or health care services 23 utilization. 24 b. Excludes a provider because the provider treats or 25 specializes in treating populations presenting a risk of 26 higher than average claims, losses, or health care services 27 utilization. 28 c. This subsection shall not be construed to prohibit a 29 health carrier from declining to select a provider who fails to 30 meet other legitimate selection criteria utilized by the health 31 carrier developed in compliance with this chapter. 32 3. This chapter shall not be construed to require a health 33 carrier or its intermediaries to contract with or retain more 34 providers acting within the scope of the provider’s licenses or 35 -12- LSB 5664YH (4) 88 ko/rn 12/ 30

H.F. 2630 certifications under state law than are necessary to maintain a 1 sufficient provider network pursuant to section 514M.2. 2 4. A health carrier shall make the health carrier’s 3 standards for selecting and tiering participating providers 4 available for review and approval by the commissioner pursuant 5 to rules adopted by the commissioner. A description of the 6 standards the health carrier uses for selecting and tiering 7 participating providers shall be available, in plain language, 8 on the health carrier’s publicly accessible internet site. 9 5. A health carrier shall notify participating providers 10 of each participating provider’s responsibilities with 11 respect to the health carrier’s applicable administrative 12 policies and programs, including but not limited to payment 13 terms; utilization review; quality assessment and improvement 14 programs; credentialing; grievance and appeals procedures; 15 data reporting requirements; reporting requirements for timely 16 notice of changes in the participating provider’s practice; 17 confidentiality requirements; and any applicable federal and 18 state requirements. 19 6. A health carrier shall not offer an inducement to a 20 participating provider to encourage or otherwise incent the 21 participating provider to deliver less than medically necessary 22 services to a covered person. 23 7. A health carrier shall not prohibit a participating 24 provider from any of the following: 25 a. Discussing any specific treatment options with a covered 26 person irrespective of the health carrier’s position on the 27 treatment options. 28 b. From advocating on behalf of a covered person within 29 the utilization review process, grievance process, or appeals 30 process established by the health carrier, a person contracting 31 with the health carrier, or in accordance with any rights or 32 remedies available under state or federal law. 33 8. Each contract executed by a health carrier and a 34 participating provider shall require that the participating 35 -13- LSB 5664YH (4) 88 ko/rn 13/ 30

H.F. 2630 provider comply with the federal Health Insurance Portability 1 and Accountability Act of 1996, Pub. L. No. 104-191. 2 Sec. 5. NEW SECTION . 514M.5 Participating providers —— 3 removal or voluntary exit from a network. 4 1. As used in this section, unless the context otherwise 5 requires: 6 a. “Active course of treatment” means, in reference to a 7 covered person that has been treated on a regular basis by 8 a participating provider that is either being removed from a 9 network or that is voluntarily leaving a network, any of the 10 following: 11 (1) An ongoing course of treatment for a life-threatening 12 health condition. 13 (2) An ongoing course of treatment for a serious acute 14 condition. 15 (3) The second or third trimester of pregnancy. 16 (4) An ongoing course of treatment for a health condition 17 for which the treating health care professional attests that 18 discontinuing care by that health care professional will allow 19 the covered person’s condition to deteriorate or interfere with 20 anticipated outcomes. 21 b. “Life-threatening health condition” means a disease or 22 condition for which the likelihood of death is probable unless 23 the course of the disease or condition is interrupted. 24 c. “Serious acute condition” means a disease or condition 25 requiring complex ongoing care that a covered person is 26 currently receiving, such as chemotherapy or radiation therapy. 27 2. A health carrier and a participating provider shall 28 provide at least sixty calendar days advance written notice 29 to the other party before the participating provider is 30 either removed from the network by the health carrier or the 31 participating provider voluntarily exits the network without 32 cause. 33 3. a. A health carrier shall provide written notice to 34 all covered persons who have received health care services 35 -14- LSB 5664YH (4) 88 ko/rn 14/ 30

H.F. 2630 on a regular basis from a participating provider of the 1 participating provider’s removal from the network, or of the 2 participating provider’s voluntary exit from the network, 3 within thirty calendar days of the date of the receipt or the 4 issuance of a notice provided in accordance with subsection 1. 5 b. If a participating provider that is a primary care 6 provider either gives or receives a notice pursuant to 7 subsection 1, the participating provider shall provide the 8 health carrier with a list of the participating provider’s 9 patients that are covered by a health benefit plan offered by 10 the health carrier. The health carrier shall also notify all 11 covered persons who have received health care services provided 12 by the primary care provider within thirty calendar days of 13 receipt of the list from the primary care provider. 14 4. a. If a covered person’s participating provider 15 voluntarily leaves a network or is removed from the network, 16 the health carrier shall establish and maintain procedures to 17 transition the covered person, if the covered person is in an 18 active course of treatment, to a participating provider in a 19 manner that ensures continuity of care. 20 b. A health carrier shall provide notice pursuant to 21 subsection 2 and shall make available to the covered person 22 a list of available participating providers of the same 23 provider type in the same geographic area. In addition, the 24 health carrier shall make available to the covered person the 25 procedure to request continuity of care. The procedure shall 26 provide for all of the following: 27 (1) A request for continuity of care shall be made to the 28 health carrier by the covered person or by the covered person’s 29 authorized representative. 30 (2) A request for continuity of care shall be reviewed by 31 the health carrier’s medical director after consultation with 32 the treating health care professional for a covered person who 33 meets the criteria pursuant to subsection 4, paragraph “a” , 34 and who is under the care of a health care professional who 35 -15- LSB 5664YH (4) 88 ko/rn 15/ 30

H.F. 2630 has not been removed from the network or who is not leaving 1 the network for cause. Any decisions made with respect to a 2 request for continuity of care shall be subject to the health 3 benefit plan’s internal and external grievance and appeal 4 processes in accordance with applicable state and federal laws 5 and regulations. 6 5. The continuity of care period for a covered person who 7 is in the second or third trimester of pregnancy shall extend 8 through the postpartum period. The continuity of care period 9 for a covered person who is undergoing an active course of 10 treatment shall extend to the earliest of all of the following: 11 a. The termination of the course of treatment by the covered 12 person or by the treating health care professional. 13 b. Ninety days unless the medical director of the treating 14 facility determines that a longer period is necessary. 15 c. The date that the covered person’s care is successfully 16 transitioned to a participating provider. 17 d. The covered person’s benefit limitations under the health 18 benefit plan are met or exceeded. 19 e. The covered person’s care is no longer medically 20 necessary as determined by the covered person’s treating health 21 care professional. 22 6. In addition to the requirements pursuant to subsection 23 5, a covered person’s continuity of care request shall only be 24 granted by a health carrier if the following requirements are 25 satisfied: 26 a. A new health care professional agrees in writing to 27 accept the same payment from, and abide by the same terms and 28 conditions with respect to, the health carrier for that covered 29 person as provided in the covered person’s original provider’s 30 contract with the health carrier. 31 b. A new health care professional agrees in writing not 32 to seek any payment from the covered person for any amount 33 for which the covered person would not be responsible if the 34 covered person’s previous provider was still a participating 35 -16- LSB 5664YH (4) 88 ko/rn 16/ 30

H.F. 2630 provider. 1 Sec. 6. NEW SECTION . 514M.6 Health carriers and 2 participating providers —— rights and responsibilities. 3 1. The rights and responsibilities pursuant to a contract 4 between a health carrier and a participating provider shall 5 not be assigned or delegated by either party without the prior 6 written consent of the other party. 7 2. A health carrier shall be responsible for ensuring 8 that a participating provider furnishes covered benefits to 9 all covered persons without regard to the covered person’s 10 enrollment in one of the health carrier’s health benefit plans 11 as a private purchaser of the plan or as a participant in 12 a publicly financed program of health care services. This 13 requirement shall not apply if a participating provider should 14 not render services to a covered person due to limitations 15 arising from the participating provider’s lack of training, 16 experience, skill, or licensing restrictions. 17 3. A health carrier shall notify each participating 18 provider of the participating provider’s obligations, if any, 19 to collect cost-sharing from a covered person pursuant to the 20 covered person’s evidence of coverage, or of the participating 21 provider’s obligations to notify a covered person of the 22 covered person’s personal financial obligations for a health 23 care service that is not a covered benefit. 24 4. A health carrier shall not penalize a participating 25 provider because the participating provider, in good faith, 26 reports to state or federal authorities any act or practice by 27 the health carrier that may jeopardize a patient’s health or 28 welfare. 29 5. A health carrier shall establish a mechanism by which a 30 participating provider can, at the time health care services 31 are provided, determine whether an individual is a covered 32 person or is within a grace period for payment of a premium 33 during which the health carrier may hold a participating 34 provider’s claim for payment for health care services pending 35 -17- LSB 5664YH (4) 88 ko/rn 17/ 30

H.F. 2630 receipt of the covered person’s payment of the premium. 1 6. A health carrier shall establish procedures for 2 efficient resolution of administrative, payment, or other 3 disputes between a participating provider and the health 4 carrier. 5 7. A contract between a health carrier and a participating 6 provider shall not contain any provision that conflicts with 7 the network health benefit plan or with the requirements of 8 this chapter. 9 8. At the time a contract is executed, a health carrier 10 and, if applicable, an intermediary shall timely notify a 11 participating provider of all provisions and other documents 12 incorporated by reference in the contract. During the term 13 of the contract, the health carrier shall timely notify the 14 participating provider of any material changes in the contract. 15 For purposes of this subsection, “timely notice” and “material 16 change” shall be defined in the contract. 17 9. A health carrier shall timely inform a health care 18 provider of the provider’s network participation status for any 19 health benefit plan in which the health carrier has included 20 the provider as a participating provider. 21 Sec. 7. NEW SECTION . 514M.7 Participating facilities —— 22 out-of-network facility-based providers. 23 1. For purposes of this section, “facility-based provider” 24 means a provider who provides health care services to patients 25 at an inpatient or ambulatory facility, including services 26 such as pathology, anesthesiology, emergency room care, and 27 radiology. The health care services are typically arranged 28 with the facility-based provider by the facility by contract 29 as part of the facility’s general business operations, and a 30 covered person or the covered person’s health benefit plan do 31 not have the option to select a specific provider to provide 32 specific health care services. 33 2. At the time a participating facility schedules a 34 procedure or seeks prior authorization from a health carrier 35 -18- LSB 5664YH (4) 88 ko/rn 18/ 30

H.F. 2630 for the provision of nonemergency services to a covered person, 1 the participating facility shall provide the covered person 2 with a written out-of-network services disclosure that contains 3 all of the following information: 4 a. That certain facility-based providers may provide health 5 care services to the covered person during the course of 6 treatment. 7 b. That certain facility-based providers may not be 8 participating providers and that a health care service provided 9 by an out-of-network provider is provided on an out-of-network 10 basis. 11 c. A detailed description of the charges for the 12 out-of-network services for which the covered person may be 13 responsible. 14 d. A notification that the covered person may either agree 15 to pay any charges for health care services provided on an 16 out-of-network basis, contact the covered person’s health 17 carrier for additional assistance, or rely on other rights and 18 remedies that may be available under state or federal law. 19 e. A statement indicating that the covered person may obtain 20 a list of facility-based providers from the covered person’s 21 health benefit plan that are participating providers and that 22 the covered person may request a participating facility-based 23 provider. 24 3. Upon admission at a participating facility where 25 a covered person will obtain nonemergency services, the 26 participating facility shall provide the covered person 27 with the written out-of-network services disclosure pursuant 28 to subsection 2, and obtain the covered person’s or the 29 covered person’s authorized representative’s signature on the 30 disclosure acknowledging that the covered person received the 31 disclosure prior to receipt of health care services. 32 4. a. If an out-of-network facility-based provider sends a 33 billing notice directly to a covered person for a health care 34 service provided by the out-of-network facility-based provider, 35 -19- LSB 5664YH (4) 88 ko/rn 19/ 30

H.F. 2630 the billing notice shall include the payment responsibility 1 notice pursuant to paragraph “b” . 2 b. The payment responsibility notice shall state the 3 following or contain substantially similar language: 4 Payment responsibility notice —— The health care service[s] 5 outlined below was [were] performed by a facility-based 6 provider who is an out-of-network provider with your health 7 benefit plan. You are responsible for paying your applicable 8 cost-sharing just as you would be if the provider is within 9 your health benefit plan’s network. With regard to the 10 remaining charges for the health care services, you have three 11 choices: 12 [1] You may choose to pay the balance of the bill. 13 [2] If the difference in the billed charge and your health 14 benefit plan’s allowable amount is more than five hundred 15 dollars, you must send the bill to your health benefit plan 16 for processing pursuant to the health carrier’s out-of-network 17 facility-based provider billing process. 18 [3] You may rely on other rights and remedies that may be 19 available in Iowa. 20 c. Nothing in this section shall preclude a covered person 21 from agreeing to pay a bill received from an out-of-network 22 facility-based provider. 23 5. a. A health carrier shall develop a program for payment 24 of out-of-network facility-based provider’s bills that provides 25 for all of the following: 26 (1) A health carrier may elect to pay an out-of-network 27 facility-based provider bill as submitted by the provider, or 28 the health carrier may elect to pay in accordance with the 29 benchmark established in subparagraph (2). 30 (2) A payment to an out-of-network facility-based provider 31 shall be presumed to be reasonable if the payment is based on 32 either the higher of the health carrier’s contracted rate with 33 the facility at which the out-of-network provider rendered the 34 health care service, or on two hundred percent of the Medicare 35 -20- LSB 5664YH (4) 88 ko/rn 20/ 30

H.F. 2630 rate for the same or similar health care service provided in 1 the same geographic area. 2 b. This section does not preclude a health carrier and 3 an out-of-network facility-based provider from agreeing to a 4 separate payment arrangement. 5 c. An out-of-network facility-based provider who objects to 6 a payment made pursuant to paragraph “a” may elect the provider 7 mediation process pursuant to subsection 6. 8 6. a. A health carrier shall establish a health care 9 provider mediation process for disputes concerning payments of 10 an out-of-network facility-based provider bills for providers 11 objecting to the payment pursuant to subsection 5. 12 b. The mediation process shall be established in accordance 13 with a mediation standard established by the American 14 arbitration association or other nationally recognized 15 mediation organization. 16 c. The cost of mediation and the cost of the mediators 17 shall be divided evenly and paid by the health carrier and the 18 nonparticipating facility-based provider. 19 d. A health carrier shall maintain documentation of each 20 request for mediation and of each mediation completed pursuant 21 to this subsection. Upon request of the commissioner, the 22 health carrier shall submit a report regarding all requested 23 and completed mediations to the commissioner in the form and 24 manner prescribed by the commissioner. 25 7. The rights and remedies pursuant to this section shall 26 be in addition to and shall not preempt any other rights and 27 remedies available to a covered person under state or federal 28 law. 29 8. This section shall not apply to any of the following: 30 a. Providers or covered persons using the process 31 established in section 514M.2, subsection 3. 32 b. Facilities that have made arrangements with 33 facility-based providers employed by the facility that prohibit 34 the facility-based providers from balance billing covered 35 -21- LSB 5664YH (4) 88 ko/rn 21/ 30

H.F. 2630 persons. 1 c. Providers with whom the facility contracts and prohibits 2 from balance billing covered persons covered by a health 3 benefit plan with which the facility contracts. 4 Sec. 8. NEW SECTION . 514M.8 Disclosure requirements —— 5 health carriers and facilities. 6 1. A health carrier shall develop a written disclosure to be 7 provided to a covered person or the covered person’s authorized 8 representative at the time of precertification, if applicable, 9 for a covered health care service to be provided at a facility 10 that is in the covered person’s health benefit plan’s network 11 if there is a possibility that the covered health care service 12 or an ancillary health care service may be rendered by a health 13 care professional that is out-of-network. The disclosure shall 14 include all of the following: 15 a. That the covered person may be subject to higher 16 cost-sharing as described in the covered person’s plan summary 17 of coverage and benefits documents, or balance billing, if the 18 covered health care services are performed by a health care 19 professional who is not in the covered person’s health plan’s 20 network. 21 b. The amount the covered person’s health plan will pay for 22 the health care service if the health care service is provided 23 by an out-of-network provider. 24 c. Options for accessing health care services from a 25 participating provider. 26 2. For nonemergency health care services, a facility 27 contracted with a health carrier shall develop a written 28 disclosure to be provided to a covered person of the health 29 carrier within ten business days of the date the covered person 30 schedules an appointment for health care services at the 31 facility, or at the time of a covered person’s nonemergency 32 admission to the facility, that confirms that the facility is a 33 participating provider of the covered person’s health benefit 34 plan. The disclosure shall inform the covered person that a 35 -22- LSB 5664YH (4) 88 ko/rn 22/ 30

H.F. 2630 health care professional may provide services to the covered 1 person while at the facility and may not participate in the 2 covered person’s health benefit plan. 3 Sec. 9. NEW SECTION . 514M.9 Provider directories —— health 4 carriers. 5 1. A health carrier shall post a current and accurate 6 provider directory, updated at least monthly, for each of the 7 health carrier’s network plans on the health carrier’s internet 8 site. The health carrier shall ensure that the general public 9 is able to view all of the current participating providers for 10 a specific health benefit plan via a clearly identified link or 11 tab without requiring an individual to create or to access an 12 account, or without requiring an individual to enter a policy 13 or a contract number. The provider directory shall contain all 14 of the information pursuant to subsection 2. 15 2. The health carrier shall audit a statistically 16 significant sample size of each provider directory quarterly to 17 ensure accuracy. The health carrier shall retain documentation 18 of each audit and make the documentation available for 19 review by the commissioner within ten business days of the 20 commissioner’s request for the documentation. 21 3. A health carrier shall provide a print copy of the 22 current provider directory upon request of a covered person or 23 a prospective covered person. 24 4. Each provider directory shall contain all of the 25 following: 26 a. A description of the criteria the health carrier used to 27 establish the health carrier’s network. 28 b. A description of the criteria the health carrier used to 29 establish the health carrier’s tiered network, if applicable. 30 c. The process used by the health carrier to designate the 31 different provider tiers in a tiered network. 32 d. For each provider and each facility in the network, 33 identify the tier in which the provider or the facility is 34 placed, to enable a covered person or a prospective covered 35 -23- LSB 5664YH (4) 88 ko/rn 23/ 30

H.F. 2630 person to easily identify the provider’s tier or the facility’s 1 tier. 2 e. Designate each participating provider for which an 3 authorization or a referral may be required for a covered 4 person to access certain health care services. 5 f. For each health care professional: 6 (1) Name. 7 (2) Gender. 8 (3) Participating office locations. 9 (4) Specialty, if applicable. 10 (5) Medical group affiliations, if applicable. 11 (6) Facility affiliations, if applicable. 12 (7) Participating facility affiliations, if applicable. 13 (8) Languages spoken other than English, if applicable. 14 (9) Languages other than English spoken by the health 15 professional’s clinical staff, if applicable. 16 (10) Whether the health care professional is accepting new 17 patients. 18 (11) Contact information, including telephone number and 19 email. 20 (12) Board certifications. 21 g. For each facility: 22 (1) Facility name. 23 (2) Facility type, including but not limited to acute, 24 rehabilitation, children’s center, or cancer center. 25 (3) Participating facility locations. 26 (4) Facility accreditation status. 27 (5) Available health care services. 28 (6) Contact information, including telephone number and 29 email for each location of the facility. 30 (7) Physical address for each location of the facility. 31 5. A health carrier shall include the specific name of each 32 network plan, as marketed and issued in this state, on the 33 corresponding provider directory. 34 6. A health carrier shall include in the carrier’s 35 -24- LSB 5664YH (4) 88 ko/rn 24/ 30

H.F. 2630 electronic and print versions of each provider directory 1 a customer service email address, telephone number, and 2 electronic link that covered persons and the general public 3 may use to notify the health carrier of inaccurate provider 4 directory information. 5 7. A provider directory, whether in electronic or print 6 form, shall accommodate the communication needs of individuals 7 with disabilities and include a link to, or information 8 regarding, assistance available for individuals with limited 9 English proficiency. 10 8. A health carrier shall include a disclosure in each print 11 copy of a provider directory that the information included 12 in the provider directory is accurate as of the print date 13 and shall advise a covered person or a prospective covered 14 person that for more recent information the covered person or 15 prospective covered person should consult the health carrier’s 16 internet site, or contact customer service at the telephone 17 number provided in the print copy to obtain up-to-date provider 18 directory information. 19 Sec. 10. NEW SECTION . 514M.10 Intermediaries. 20 1. An intermediary and a participating provider with whom 21 the intermediary contracts shall comply with all applicable 22 requirements of section 514M.6. 23 2. A health carrier’s responsibility to monitor the 24 offering of covered benefits to covered persons pursuant 25 to section 514M.6 shall not be delegated or assigned to an 26 intermediary. Notwithstanding any other law to the contrary, 27 to the extent a health carrier delegates the health carrier’s 28 responsibilities to an intermediary, the health carrier shall 29 retain legal responsibility for the intermediary’s compliance 30 with all applicable requirements of this chapter. 31 3. A health carrier shall have the right to approve or 32 disapprove the participation status of a subcontracted provider 33 in the health carrier’s network or in a contracted network 34 for the purpose of delivering covered benefits to the health 35 -25- LSB 5664YH (4) 88 ko/rn 25/ 30

H.F. 2630 carrier’s covered persons. 1 4. A health carrier shall maintain copies of all 2 intermediary health care subcontracts at the health carrier’s 3 principal place of business in the state, or ensure that the 4 health carrier has access to all intermediary subcontracts, 5 including the right to obtain copies within five calendar days 6 of the health carrier’s written request to the intermediary. 7 5. An intermediary shall transmit utilization documentation 8 and claims paid documentation to the health carrier pursuant to 9 rules adopted by the commissioner. The health carrier shall 10 monitor the timeliness and appropriateness of payments made to 11 providers, and monitor the health care services received by 12 covered persons. 13 6. An intermediary shall maintain the records, financial 14 information, and documentation related to health care 15 services provided to a health carrier’s covered persons at the 16 intermediary’s principal place of business in this state in a 17 manner pursuant to rules adopted by the commissioner. 18 7. An intermediary shall allow the commissioner access 19 to the intermediary’s records, financial information, and 20 documentation related to health care services provided to a 21 health carrier’s covered persons as necessary to determine 22 compliance with this chapter. 23 8. A health carrier shall have the right, in the event of 24 an intermediary’s insolvency, to require the assignment to 25 the health carrier of the provisions of a provider’s contract 26 addressing the provider’s obligation to furnish health care 27 services to the health carrier’s covered persons. If a health 28 carrier requires such an assignment, the health carrier shall 29 remain obligated to pay the provider for providing health care 30 services to the health carrier’s covered persons under the same 31 terms and conditions as the intermediary’s terms and conditions 32 for paying the provider prior to the intermediary’s insolvency. 33 Sec. 11. NEW SECTION . 514M.11 Filing requirements and state 34 administration. 35 -26- LSB 5664YH (4) 88 ko/rn 26/ 30

H.F. 2630 1. At the time a health carrier files an access plan 1 pursuant to section 514M.2, subsection 6, the health carrier 2 shall file with the commissioner, for the commissioner’s 3 approval, sample contract forms proposed for use with the 4 health carrier’s participating providers and intermediaries. 5 2. A health carrier shall submit any material changes to 6 a contract that may affect a provision required under section 7 514M.10, or that is required pursuant to a rule adopted by 8 the commissioner, to the commissioner for approval at least 9 thirty business days prior to the health carrier’s change to 10 the contract. 11 3. The health carrier shall maintain all provider and 12 intermediary contracts at the health carrier’s principal place 13 of business in the state, or the health carrier shall have 14 access to all of the contracts in such a manner that the health 15 carrier can provide copies of the contracts to the commissioner 16 within ten calendar days of the commissioner’s request for 17 review of the contracts. 18 4. A health carrier’s execution of a contract with an 19 intermediary, a health care professional, or any other person 20 shall not relieve the health carrier of its liability to any 21 individual with whom the health carrier has contracted for the 22 provision of health care services, or of the health carrier’s 23 responsibility for compliance with all applicable state and 24 federal laws and regulations. 25 5. All contracts between a health carrier and a health care 26 professional, or a health carrier and an intermediary, shall be 27 in writing and shall be subject to the commissioner’s review. 28 Sec. 12. NEW SECTION . 514M.12 Enforcement. 29 1. The commissioner may take any enforcement action under 30 the commissioner’s authority to enforce compliance with this 31 chapter. 32 2. The commissioner shall require a modification to a 33 health carrier’s access plan, shall institute a corrective 34 action plan for the health carrier, or shall use any of the 35 -27- LSB 5664YH (4) 88 ko/rn 27/ 30

H.F. 2630 commissioner’s other enforcement powers to obtain a health 1 carrier’s compliance with this chapter if the commissioner 2 finds any of the following: 3 a. That a health carrier has not contracted with a 4 sufficient number of participating providers to assure that 5 covered persons have accessible health care services in a 6 geographic area. 7 b. That a health carrier’s network access plan does not 8 assure a covered person’s reasonable access to covered health 9 care services. 10 c. That a health carrier has entered into an intermediary 11 contract or a provider contract that does not comply with this 12 chapter. 13 d. That a health carrier has not complied with any provision 14 of this chapter. 15 3. The commissioner shall not act to arbitrate, mediate, or 16 settle a dispute regarding any of the following: 17 a. A health carrier’s decision not to include a provider in 18 a network plan or in a provider network. 19 b. Any dispute between a health carrier and the health 20 carrier’s intermediaries. 21 c. Any dispute between a health carrier and one or more 22 providers arising under or by reason of a participating 23 provider contract, or of the termination of a participating 24 provider contract. 25 Sec. 13. NEW SECTION . 514M.13 Rules. 26 The commissioner shall adopt rules pursuant to chapter 17A 27 to administer this chapter. 28 Sec. 14. APPLICABILITY. This Act applies to all health 29 carrier health benefit plans delivered, issued for delivery, 30 continued, or renewed in this state on or after January 1, 31 2021. 32 EXPLANATION 33 The inclusion of this explanation does not constitute agreement with 34 the explanation’s substance by the members of the general assembly. 35 -28- LSB 5664YH (4) 88 ko/rn 28/ 30

H.F. 2630 This bill relates to health benefit plan network access 1 and adequacy, and substantially conforms to the national 2 association of insurance commissioners’ health benefit plan 3 network access and adequacy model act. 4 The bill establishes standards for health carriers’ 5 networks, and for the adequacy, accessibility, transparency, 6 and quality of health care services offered under a network 7 plan. “Health carrier” is defined in the bill as an entity 8 subject to the insurance laws and regulations of this state, or 9 subject to the jurisdiction of the commissioner, that contracts 10 or offers to contract, or enters into an agreement to provide, 11 deliver, arrange for, pay for, or reimburse any of the costs of 12 health care services, including a health insurance company, a 13 health maintenance organization, a hospital and health service 14 corporation, or any other entity providing a plan of health 15 insurance, health benefits, or health care services. 16 The bill establishes requirements for written agreements 17 between health carriers offering network plans, intermediaries, 18 and participating providers, and requires a health carrier 19 to obtain the insurance commissioner’s approval for the 20 health carrier’s access plan. “Intermediary” is defined in 21 the bill as a person authorized to negotiate and execute a 22 provider contract with a health carrier on behalf of a health 23 care provider or on behalf of a network. The bill defines a 24 “participating provider” as a provider that, under a contract 25 with a health carrier, or with a health carrier’s contractor 26 or subcontractor, has agreed to provide health care services 27 to covered persons with an expectation of receiving payment 28 directly or indirectly from the health carrier, in addition to 29 a covered person’s cost-sharing. A health carrier’s access 30 plan must ensure the ongoing sufficiency of the provider 31 network consistent with the requirements detailed in the bill. 32 The bill prohibits balance billing except in certain 33 circumstances as detailed in the bill. “Balance billing” is 34 defined in the bill as the practice of a provider billing for 35 -29- LSB 5664YH (4) 88 ko/rn 29/ 30