376.789. Definition of actual charge and actual fee.

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376.789. Definition of actual charge and actual fee. — 1.

(1)This section applies to an individual or a group specified disease insurance policy issued to any person that contains the terms "actual charge" or "actual fee" without containing an express definition of the term.

(2)"Actual charge" or "actual fee" when used in an individual specified disease insurance policy in connection with the benefits payable for services rendered by a health care provider or other designated person or entity means the amount the health care provider or other designated person or entity:

(a)Agrees to accept under a network or other participation agreement with the health insurer, third-party administrator, or other third-party payor, or other person, including the insured, as payment in full for the treatment, goods, or services provided to the insured; or

(b)Agrees, or as obligated by operation of law, to accept as payment in full for the treatment, goods, or services provided to the insured under a provider, participation, or supplier agreement under Medicare, Medicaid, or any other government-administered health care program where the insured is covered or reimbursed by this program.

(3)"Payment in full" includes the actual charge or actual fee that was actually paid for the health care provider's treatment, goods, or services on behalf of the insured by Medicare, Medicaid, any other government-administered health care program, any other health insurer, thirty-party administrator, or other third-party payor and, where applicable, any remaining portion of the actual charge or actual fee that was applied or assessed against the insured by Medicare, Medicaid, any other government-administered health care program, any other health insurer, third-party administrator, or other third-party payor for the applicable deductions, coinsurance requirements, or co-pay requirements.

(4)If paragraphs

(a)and

(b)of subdivision

(2)of this subsection apply, the actual charge or actual fee shall be the lesser of the amounts determined under such paragraphs.

2. Notwithstanding any other provision of law, after August 28, 2009, an insurer or issuer of an individual or group specified disease insurance policy shall not pay a claim of benefit under the applicable policy in an amount in excess of the actual charge or actual fee as defined in this section.

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(L. 2009 H.B. 481)