Insurance

Requires an initiating party that submits a request for independent dispute resolution to provide written notice to the facility not later than three business days after submitting the request. Allows a health carrier to provide notice to an out of network provider and a facility if, during any 90 day period, an initiating party submits requests for independent dispute resolutions that, in the aggregate, include 25 or more qualified disputes. Provides that if a health carrier provides the notice, the health carrier, the out of network provider, and the facility shall engage in good faith efforts to negotiate a resolution. Prohibits a health carrier from assessing a facility or a provider an administrative fee or penalty related to the provision of care to an individual that involves an out of network provider. Provides that if a health carrier assesses a facility or a provider an administrative fee or penalty related to the provision of care to an individual that involves an out of network provider, the health carrier commits an unfair and deceptive act or practice in the business of insurance.

Requires, beginning January 1, 2028, a health carrier to: (1) implement a shopping and decision support program; and (2) provide incentives for covered individuals in a health plan who elect to receive a comparable health care service from a network provider that is paid less than the average allowed amount paid by the health carrier to network providers for the comparable health care service. Requires, beginning December 1, 2027, a health carrier to make available an interactive member portal that enables a covered individual to request and obtain certain information. Allows a health carrier to make the information available through a toll free telephone number. Sets forth reporting requirements for health carriers and the department of insurance concerning incentive payments made to covered individuals.

Provides that an insurer: (1) must pay a health care provider the full amount due for health care services under the health care provider's agreement with the insurer, including any cost sharing; (2) has the sole responsibility for collecting cost sharing from a covered individual; and (3) upon request of the covered individual, must collect cost sharing throughout the policy year in increments defined by the insurer. Prohibits an insurer from taking certain actions regarding the collection of cost sharing. Requires each insurer to certify to the insurance commissioner, before December 31 of each year, that the insurer has fully and completely complied with the requirements during the previous calendar year.

Prohibits the use of an artificial intelligence system to impersonate or act as a substitute for a licensed mental health professional. Requires the department of insurance to contract with an objective third party to verify that health carriers are in compliance with network adequacy standards. Sets forth notice requirements for an amendment to a health provider contract. Prohibits the use of downcoding in a specified manner. Requires an insurer and a health maintenance organization to reimburse providers of mental illness or substance abuse services at rates that are at least as favorable relative to Medicare rates as reimbursement rates are for providers of medical or surgical services relative to Medicare rates. Prohibits an insurer and a health maintenance organization from retroactively auditing a paid claim or seeking recoupment or a refund of a paid claim after a certain time frame. Sets forth a limitation on the amount that an insured or enrollee may be charged for receiving mental and behavioral care services from an out of network provider under certain circumstances.

Requires a state employee health plan to cover supplemental breast examinations. Requires a policy of accident and sickness insurance and a health maintenance organization to cover diagnostic breast examinations and supplemental breast examinations. Provides that the coverage for diagnostic breast examinations and supplemental breast examinations may not be subject to any cost sharing requirements.