376.789. Definition of actual charge and actual fee.
Definition of actual charge and actual fee.
376.789. 1. (1) This section applies to an individual or a groupspecified disease insurance policy issued to any person that contains theterms "actual charge" or "actual fee" without containing an expressdefinition of the term.
(2) "Actual charge" or "actual fee" when used in an individualspecified disease insurance policy in connection with the benefits payablefor services rendered by a health care provider or other designated personor entity means the amount the health care provider or other designatedperson or entity:
(a) Agrees to accept under a network or other participation agreementwith the health insurer, third-party administrator, or other third-partypayor, or other person, including the insured, as payment in full for thetreatment, goods, or services provided to the insured; or
(b) Agrees, or as obligated by operation of law, to accept as paymentin full for the treatment, goods, or services provided to the insured undera provider, participation, or supplier agreement under Medicare, Medicaid,or any other government-administered health care program where the insuredis covered or reimbursed by this program.
(3) "Payment in full" includes the actual charge or actual fee thatwas actually paid for the health care provider's treatment, goods, orservices on behalf of the insured by Medicare, Medicaid, any othergovernment-administered health care program, any other health insurer,thirty-party administrator, or other third-party payor and, whereapplicable, any remaining portion of the actual charge or actual fee thatwas applied or assessed against the insured by Medicare, Medicaid, anyother government-administered health care program, any other healthinsurer, third-party administrator, or other third-party payor for theapplicable deductions, coinsurance requirements, or co-pay requirements.
(4) If paragraphs (a) and (b) of subdivision (2) of this subsectionapply, the actual charge or actual fee shall be the lesser of the amountsdetermined 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 insurancepolicy shall not pay a claim of benefit under the applicable policy in anamount in excess of the actual charge or actual fee as defined in thissection.
(L. 2009 H.B. 481)