SB 5986 — Protecting consumers from out-of-network health care services charges.

S-4778.1S-3842.1 SUBSTITUTE SENATE BILL 5986 State of Washington 68th Legislature 2024 Regular Session By Senate Ways & Means (originally sponsored by Senators Cleveland, Muzzall, Hasegawa, Kuderer, Mullet, Nobles, Randall, Salomon, Valdez, and Wellman)Wellman READPrefiled FIRST01/04/24. TIME 02/05/24.

Read first time 01/08/24.

Referred to Committee on Health & Long Term Care.

1 SSBSB 5986 or failure to provide or make payment that is based on a determination of an enrollee's or applicant's eligibility to participate in a plan, and including, with respect to group health plans, a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit resulting from the application of any utilization review, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be experimental or investigational or not medically necessary or appropriate.

2 SSBSB 5986 agencies, emergency evaluation and treatment, outpatient care, and timely and appropriate inpatient care to persons suffering from a mental disorder, and which is licensed or certified as such by the department of health;

3 SSBSB 5986 1302(c)(1) of P.L.

4 SSBSB 5986 (a)(i) A medical screening examination, as required under section 1867 of the social security act (42 U.S.C.

5 SSBSB 5986 Poststabilization services relate to mental health or substance use disorder treatment necessary in the short term to avoid placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

6 SSBSB 5986 amended by the health care and education reconciliation act, P.L.

7 SSBSB 5986 (a) A person regulated under Title 18 or chapter 70.127 RCW, to practice health or health-related services or otherwise practicing health care services in this state consistent with state law;

8 SSBSB 5986 is guaranteed renewable while the covered person is enrolled as a regular full-time undergraduate or graduate student at an accredited higher education institution, after a written request for such classification by the carrier and subsequent written approval by the insurance commissioner;

9 SSBSB 5986 (((38))) (40) "Out-of-pocket maximum" or "maximum out-of-pocket" means the maximum amount an enrollee is required to pay in the form of cost-sharing for covered benefits in a plan year, after which the carrier covers the entirety of the allowed amount of covered benefits under the contract of coverage.

10 SSBSB 5986 not formed primarily for purposes of buying health insurance, and in which a bona fide employer-employee relationship exists.

11 SSBSB 5986 (((48))) (50) "Wellness activity" means an explicit program of an activity consistent with department of health guidelines, such as, smoking cessation, injury and accident prevention, reduction of alcohol misuse, appropriate weight reduction, exercise, automobile and motorcycle safety, blood cholesterol reduction, and nutrition education for the purpose of improving enrollee health status and reducing health service costs.

12 SSBSB 5986 provisions of this chapter that provide greater protection for consumers;

13 SSBSB 5986 (b) If the hospital, ambulatory surgical facility, ((or)) behavioral health emergency services provider, or ground ambulance services organization does not maintain a website, this information must be provided to consumers upon an oral or written request.

14 SSBSB 5986 be responsible for any costs in excess of those allowed by the health plan;

15 SSBSB 5986 the commissioner of the results of the review, including whether the violation was substantiated and any enforcement action taken as a result of a finding of a substantiated violation.

16 SSBSB 5986 (1) For health plans issued or renewed on or after January 1, 2025, a nonparticipating ground ambulance services organization may not balance bill an enrollee for covered ground ambulance services.

17 SSBSB 5986 (3) The allowed amount paid to a nonparticipating ground ambulance services organization for covered ground ambulance services under a health plan issued by a carrier must be one of the following amounts:

18 SSBSB 5986 A local governmental entity may submit to the office of the insurance commissioner, in the form and manner prescribed by the commissioner, the rate set by the local governmental entity as authorized in RCW 35.27.370, 35.23.456, or 52.12.135, or chapter 35.21 RCW, for purposes of section 8 of this act.

19 SSBSB 5986 informal disciplinary action as permitted under the authority of the department.

20 SSBSB 5986 (2) The report must include the findings of the actuarial analysis described in this section and recommendations related to whether the services described in this section should be treated as covered services under health plans issued or renewed in Washington state and health benefit programs for public and school employees administered under chapter 41.05 RCW.

(1)(a)(1) The Washington state institute for public policy, in collaboration with the department, the health care authority, and the office of the insurance commissioner, shall conduct a study onand thedevelop extentrecommendations toon whichwhether otheremergency statesmedical fundservices orshould havebe consideredtreated fundingas emergencyan medicalessential serviceshealth substantiallyservice orprovided entirelyby throughstate federal,and state, or local governmental fundingentities and thefunded currentexclusively landscapeby offederal, emergencystate, medicalor serviceslocal ingovernmental Washington.entities as a public health service.

(b)(2) The institute shall consider the following elements in conducting the study:

(i)(a) Trends in the number and types of emergency medical services available and the volume of 911 responses and interfacility transports provided by emergency medical services organizations over time and by county in Washington state;

(ii)(b) Projections of the need for emergency medical services in Washington state counties over the next two10 years;

(iii)(c) Identification of geographic areas in Washington state without access to emergency medical services within an average 25-30- minute response time;

(iv)(d) Estimates for the cost to address gaps in emergency medical services so all parts of the state are assured a timely response;

(v)and (e) Models for funding emergency medical services that are used by other states;states.

and(3) (vi)In Existingconducting researchthe andstudy, literaturethe relatedinstitute toshall fundingconsult modelswith foremergency medical services organizations, local governmental entities, hospitals, labor organizations representing emergency medical services.services personnel, and other interested entities as determined by the institute in consultation with the department, the health care authority, and the office of the insurance commissioner.

(c) In conducting the study, the institute shall consult with emergency medical services organizations, local governmental entities, hospitals, labor organizations representing emergency medical services personnel, and other interested entities as p.

21 SSBSB 5986 determined(4) byThe thereport instituteand inrecommendations consultationmust withbe thesubmitted department,to therelevant healthpolicy care authority, and thefiscal officecommittees of the insurancelegislature commissioner.on or before October 1, 2026.

(d) A report detailing the results of the study must be submitted to the department and the relevant policy and fiscal committees of the legislature on or before June 1, 2026.

(2) The department, in consultation with the health care authority, the office of the insurance commissioner, and the entities referenced in subsection (1)(c) of this section, shall develop recommendations, based on the report completed pursuant to subsection (1) of this section, on whether emergency medical services should be treated as an essential health service provided by state and local governmental entities and funded exclusively by federal, state, or local governmental entities as a public health service.

The report must be submitted to the relevant policy and fiscal committees of the legislature on or before December 1, 2026.

22 SSBSB 5986