Section 2-33-9 Services to Be Provided by In-Network Providers; Payment for Out-of-Network Services.

(a) A nonprofit agricultural organization providing health benefits shall ensure that all covered services are provided by in-network providers whenever possible. (b) In emergency situations where an out-of-network provider delivers emergency care, the nonprofit agricultural organization shall pay the out-of-network provider one of the following, less the enrollee’s in-network cost sharing amount: (1) The median amount of the nonprofit agricultural organization’s in-network rate for a covered service; or (2) Eighty percent of the maximum allowable charge for any service not covered by the nonprofit agricultural organization. (c) For nonemergency services, a nonprofit agricultural organization is solely liable for payment of fees to a nonparticipating provider of covered nonemergency services provided to an enrollee in accordance with the coverage terms of the health benefits, and the enrollee is not liable for payment of fees to a nonparticipating provider, other than applicable copayments, coinsurance, and deductibles for covered nonemergency services that are: (1) Provided in a facility that has a contract for the nonemergency services with the nonprofit agricultural organization providing health benefits which the facility would otherwise be obligated to provide under that contract; and (2) Provided when the enrollee does not have the ability or opportunity to choose a health care professional participating in the nonprofit agricultural organization health benefits at the facility who is otherwise available to treat the enrollee.