20-1072

20-1072. Nonliability of enrollees for
provider or hospital charges; penalty

A. Every written contract between a health care services organization and a
provider or hospital shall set forth that if the organization fails to pay for covered
health care services as set forth in the enrollee's evidence of coverage or contract the
enrollee is not liable to the provider or hospital for any amounts owed by the
organization and the provider or hospital shall not bill or otherwise attempt to collect
from the enrollee the amount owed by the organization.

B. If the written contract between the contracting provider or hospital and the
organization fails to contain the required prohibition stated in subsection A, the
enrollee is not liable to the contracting provider or hospital for any amounts owed by
the organization.

C. No contracting provider or agent, trustee or assignee of the contracting
provider or hospital may maintain an action at law against an enrollee to collect any
amounts owed by the organization for which the enrollee is not liable to the contracting
provider under subsection A.

D. Nothing in this section impairs the right of a provider or hospital to charge,
collect from, attempt to collect from or maintain an action at law against an enrollee
for any of the following:

1. Copayment or coinsurance amounts.

2. Health care services not covered by the organization, including out of area
claims that are not paid by an organization on behalf of an enrollee.

3. Health care services rendered after the termination of the contract between the
health care services organization and the provider or hospital, unless the health care
services were rendered during confinement in an inpatient facility and the confinement
began prior to the date of termination, or unless the provider has assumed
post-termination treatment obligations under the contract.

E. Nothing in this section prohibits an enrollee from seeking health care services
from a contracting or noncontracting provider or hospital and accepting financial
responsibility for these services.

F. No provider or hospital may charge an enrollee of a health care services
organization more than the amount the provider or hospital contracted to charge the
enrollee pursuant to the provider's contract or hospital's contract with the health care
services organization.

G. Nothing in this section prohibits any person from informing an enrollee of
either the cost of health care services performed or the status of any bill submitted to
an organization in connection with health care services provided to an enrollee. Any
information provided to an enrollee pursuant to this subsection shall include a statement
that the information is not a bill and is for the enrollee's information only. The
statement shall include the following disclosure prominently displayed at the top of the
page in all capital letters: "Do not pay this statement. This is not a bill. The
information provided below is for information purposes only."

H. Unless preempted under federal law or unless federal law imposes greater
requirements than this section, this section applies to a provider sponsored health care
services organization.

I. The director shall impose a penalty against any health care provider or hospital
in violation of this section of up to three times the amount of the provider or hospital
charges at issue.

J. The director shall investigate any complaint filed pursuant to this section and
enforce the requirements of this section.