Section 133 (division BB) protects members from unexpected out-of-network costs by requiring that members only be responsible for in-network cost-sharing amounts in emergency and certain non-emergency situations where members do not have the ability to choose an in-network provider.
Section also prohibits providers from balance billing members, except in limited situations with member notice and consent, and states that any out-of-network expenses for the services covered will accumulate toward a member’s in-network deductible and out-of-pocket maximum.
Market impact of this provision effects Individual Family Plan (IFP), Small Business Markets (SBM), Core, Premier, Administrative Services Only (ASO) and Shared Advantage (SA) lines of business.