S.F. _____ Section 1. NEW SECTION . 514C.16A Emergency services —— 1 coverage. 2 1. As used in this section, unless the context otherwise 3 requires: 4 a. “Arbitrator list” means a list maintained by the 5 commissioner of arbitrators approved in the state who are 6 listed in the American arbitration association roster or the 7 American health law association candidate list to provide 8 binding arbitration for purposes of this section. 9 b. “Commissioner” means the commissioner of insurance. 10 c. “Complicating factor” means an element incident to 11 the provision of a health care service that is not typically 12 involved in the provision of a health care service and is not 13 reflected in the medical procedure code submitted by a health 14 care professional. “Complicating factor” includes but is not 15 limited to the severity of a covered person’s condition, or the 16 special technical, physical, or mental effort required by a 17 health care professional to provide a health care service. 18 d. “Cost sharing” means any coverage limit, copayment, 19 coinsurance, deductible, or other out-of-pocket cost obligation 20 imposed by a health benefit plan on a covered person. 21 e. “Covered person” means the same as defined in section 22 514J.102. 23 f. “Emergency medical condition” means a medical condition 24 that manifests by symptoms of sufficient severity, including 25 but not limited to severe pain, that an ordinarily prudent 26 person, possessing average knowledge of medicine and health, 27 could reasonably expect the absence of immediate medical 28 attention to result in one of the following: 29 (1) Placing the health of the individual in serious 30 jeopardy. 31 (2) Serious impairment to bodily function. 32 (3) Serious dysfunction of a bodily organ or part. 33 g. “Emergency services” means covered inpatient and 34 outpatient health care services that are furnished by a health 35 -1- LSB 6871XC (5) 91 nls/ko 1/ 8

S.F. _____ care professional who is qualified to provide the services 1 that are needed to evaluate or stabilize an emergency medical 2 condition. 3 h. “Facility” means the same as defined in section 514J.102. 4 i. “Health benefit plan” means the same as defined in 5 section 514J.102. 6 j. “Health care professional” means the same as defined in 7 section 514J.102. 8 k. “Health care services” means the same as defined in 9 section 514J.102. 10 l. “Health carrier” means the same as defined in section 11 514J.102. 12 m. “Out-of-network provider” means a health care 13 professional that is not a participating provider who provides 14 health care services to a covered person. 15 n. “Participating facility” means a facility that has 16 entered into a contract with a contracting entity to provide 17 health care services to a covered person with the expectation 18 of receiving payment for providing the health care services 19 either directly from the contracting entity or from a health 20 carrier affiliated with the contracting entity. 21 o. “Participating provider” means a health care professional 22 who has entered into a contract with a contracting entity to 23 provide health care services to a covered person with the 24 expectation of receiving payment for providing the health care 25 services either directly from the contracting entity or from a 26 health carrier affiliated with the contracting entity. 27 2. Notwithstanding the uniformity of treatment requirements 28 of section 514C.6, a policy, contract, or plan providing for 29 third-party payment or prepayment of medical expenses shall 30 provide coverage for health care services provided to a covered 31 person by an out-of-network provider in any of the following 32 circumstances: 33 a. The health care services are emergency services. 34 b. The health care services were provided at a participating 35 -2- LSB 6871XC (5) 91 nls/ko 2/ 8

S.F. _____ facility and the covered person did not have the ability 1 or opportunity to receive the health care services from a 2 participating provider. 3 3. An out-of-network provider who provides health care 4 services under subsection 2 shall submit a claim to the covered 5 person’s health carrier no later than sixty calendar days after 6 the date the out-of-network provider provided the health care 7 services. No more than sixty calendar days after receipt of a 8 claim, the health carrier shall reimburse the out-of-network 9 provider in an amount that is the greater of either of the 10 following: 11 a. The median amount that would have been paid to a 12 participating provider who practices in the same specialty as 13 the out-of-network provider for providing the same health care 14 services, excluding any cost sharing. 15 b. One hundred fifty percent of the most recently published 16 federal centers for Medicare and Medicaid services fee schedule 17 for the health care service provided by the out-of-network 18 provider, excluding any cost sharing. 19 4. An out-of-network provider who provides health care 20 services under subsection 2 shall not bill, attempt to collect 21 from, or collect from, a covered person any amount other than 22 the cost sharing required by the covered person’s health 23 benefit plan. 24 5. a. An out-of-network provider who provides a health 25 care service under subsection 2 that involves a complicating 26 factor may submit, as part of an initial claim submitted 27 under subsection 3, a claim for reimbursement in addition to 28 the amount of reimbursement provided by subsection 3. The 29 claim for additional reimbursement must be accompanied by 30 medical records and other clinical documentation necessary to 31 demonstrate the complicating factor and justify the additional 32 reimbursement. 33 b. A health carrier that receives a claim for additional 34 reimbursement from an out-of-network provider shall, no more 35 -3- LSB 6871XC (5) 91 nls/ko 3/ 8

S.F. _____ than thirty calendar days after the date of receipt of such 1 claim, either pay the out-of-network provider an additional 2 reimbursement in an amount equal to twenty-five percent of the 3 amount paid on the initial claim under subsection 3, or issue a 4 letter of denial to the out-of-network provider that explains 5 the basis for denying the claim for additional reimbursement. 6 c. If a health carrier denies a claim for additional 7 reimbursement, the out-of-network provider may file with the 8 commissioner a written request for binding arbitration that 9 includes all of the following: 10 (1) The name and contact information of the health carrier. 11 (2) The medical records and clinical documentation 12 demonstrating the complicating factor and justifying the 13 request for additional reimbursement that the out-of-network 14 provider submitted to the health carrier. 15 (3) The letter from the health carrier denying the claim for 16 additional reimbursement. 17 d. The commissioner shall notify an out-of-network provider 18 that files a written request for binding arbitration under 19 paragraph “c” and the health carrier that denied the claim for 20 additional reimbursement, no later than thirty calendar days 21 after receipt of the request, of the acceptance or denial of 22 the request. 23 e. No more than thirty calendar days after the date of 24 receipt of the notice under paragraph “d” , the health carrier 25 shall submit written documentation to the commissioner that 26 either reconfirms the health carrier’s denial of the claim for 27 additional reimbursement, or provides an alternative payment 28 offer for consideration during arbitration. 29 f. Prior to an arbitration, the out-of-network provider 30 and health carrier shall agree upon an arbitrator from the 31 arbitrator list, and submit all documentation provided under 32 paragraphs “c” and “e” to the selected arbitrator. The 33 arbitrator shall provide a written decision regarding the 34 outcome of the arbitration to the out-of-network provider and 35 -4- LSB 6871XC (5) 91 nls/ko 4/ 8

S.F. _____ health carrier no later than forty-five calendar days after the 1 date of receipt of all documentation submitted by both parties. 2 In making a determination as to the outcome of the arbitration, 3 the arbitrator shall consider all of the following: 4 (1) The complicating factor at issue. 5 (2) The medical records and clinical documentation 6 demonstrating the complicating factor and justifying additional 7 reimbursement that the out-of-network provider submitted to the 8 health carrier. 9 (3) The letter from the health carrier to the out-of-network 10 provider denying the claim for increased reimbursement. 11 (4) The written documentation provided by the health 12 carrier that reconfirms the health carrier’s denial of the 13 claim for increased reimbursement, if any. 14 (5) All alternative payment offers the health carrier 15 offered to the out-of-network provider, if any. 16 g. The costs of arbitration shall be paid equally by the 17 health carrier and the out-of-network provider. 18 6. This section does not prohibit an out-of-network 19 provider and a health carrier from agreeing, through private 20 negotiations or an internal dispute resolution process, to a 21 reimbursement amount that is greater than the reimbursement 22 amount required by this section. 23 7. a. This section applies to the following classes of 24 third-party payment provider contracts, policies, or plans 25 delivered, issued for delivery, continued, or renewed in this 26 state on or after January 1, 2027: 27 (1) Individual or group accident and sickness insurance 28 providing coverage on an expense-incurred basis. 29 (2) An individual or group hospital or medical service 30 contract issued pursuant to chapter 509, 514, or 514A. 31 (3) An individual or group health maintenance organization 32 contract regulated under chapter 514B. 33 (4) A plan established for public employees pursuant to 34 chapter 509A. 35 -5- LSB 6871XC (5) 91 nls/ko 5/ 8

S.F. _____ b. This section shall not apply to accident-only, specified 1 disease, short-term hospital or medical, hospital confinement 2 indemnity, credit, dental, vision, Medicare supplement, 3 long-term care, basic hospital and medical-surgical expense 4 coverage as defined by the commissioner of insurance; 5 disability income insurance coverage; coverage issued as a 6 supplement to liability insurance, workers’ compensation or 7 similar insurance; or automobile medical payment insurance. 8 8. The commissioner of insurance may adopt rules pursuant to 9 chapter 17A to administer this section. 10 EXPLANATION 11 The inclusion of this explanation does not constitute agreement with 12 the explanation’s substance by the members of the general assembly. 13 This bill relates to insurance coverage for emergency 14 services, reimbursements for out-of-network providers, and 15 complicating factors. 16 The bill requires a policy, contract, or plan providing 17 for third-party payment or prepayment of medical expenses to 18 provide coverage for health care services (services) provided 19 to a covered person by an out-of-network provider if the 20 services are emergency services, or the services were provided 21 at a participating facility and the covered person could not 22 receive the services from a participating provider. “Emergency 23 services”, “out-of-network provider”, “participating facility”, 24 and “participating provider” are defined in the bill. 25 An out-of-network provider that provides services to 26 a covered person under the bill shall submit a claim to a 27 health carrier (carrier) no later than 60 days after providing 28 services. No more than 60 days after receipt of a claim, the 29 carrier shall reimburse the out-of-network provider in an 30 amount that is the greater of the median amount that would have 31 been paid to a participating provider for providing the same 32 services, or 150 percent of the fee schedule for the service, 33 excluding any cost sharing. 34 An out-of-network provider who provides services shall not 35 -6- LSB 6871XC (5) 91 nls/ko 6/ 8

S.F. _____ bill, attempt to collect from, or collect from a covered person 1 any amount other than the cost sharing required by the covered 2 person’s health benefit plan. 3 An out-of-network provider who provides a service to 4 a covered person that involves a complicating factor may 5 submit, as part of an initial claim, a claim for an additional 6 reimbursement. “Complicating factor” is defined in the bill. 7 The claim for additional reimbursement must be accompanied 8 by medical records and clinical documentation sufficient to 9 demonstrate the complicating factor and justify the request for 10 additional reimbursement. 11 A carrier that receives a claim for additional reimbursement 12 shall, within 30 days, either pay the out-of-network provider 13 an additional reimbursement in an amount equal to 25 percent of 14 the initial claim reimbursement, or issue a letter denying the 15 claim for additional reimbursement. 16 If a carrier denies a claim for additional reimbursement, 17 the out-of-network provider may file a written request 18 for binding arbitration with the commissioner of insurance 19 (commissioner) that includes the information detailed in 20 the bill. The commissioner shall notify the out-of-network 21 provider and carrier within 30 days whether the request has 22 been accepted or denied. A carrier that receives notice 23 of arbitration shall submit written documentation to the 24 commissioner, within 30 days of the notice, that either 25 reconfirms the carrier’s denial of additional reimbursement, or 26 provides an alternative payment offer for consideration during 27 arbitration. 28 Prior to an arbitration, the out-of-network provider and 29 carrier shall agree upon an arbitrator from the arbitrator 30 list, and submit documentation required by the bill to the 31 arbitrator. The arbitrator shall provide a written decision 32 regarding the outcome of the arbitration within 45 days. The 33 arbitrator shall consider the complicating factor at issue and 34 documentation required by the bill. The costs of arbitration 35 -7- LSB 6871XC (5) 91 nls/ko 7/ 8

S.F. _____ shall be paid equally by the carrier and the out-of-network 1 provider. 2 The bill does not prohibit an out-of-network provider and a 3 carrier from agreeing to a reimbursement amount that is greater 4 than the reimbursement amount required by the bill. 5 The bill applies to third-party payment provider contracts, 6 policies, or plans delivered, issued for delivery, continued, 7 or renewed in this state on or after January 1, 2027, by the 8 third-party payment providers enumerated in the bill. The bill 9 specifies the types of specialized health-related insurance 10 which are not subject to the bill’s coverage requirements. 11 The commissioner may adopt rules to administer the bill. 12 -8- LSB 6871XC (5) 91 nls/ko 8/ 8