December 15, 2020

Ohio and South Carolina Address Out-Of-Network Billing

Ohio advances and South Carolina introduces bills modifying out-of-network provisions.

In Ohio, HB 388 passed the Senate Committee on Insurance and Financial Institutions. The bill would require carriers to reimburse out-of-network providers for emergency out-of-network care for services provided to an enrollee at an in-network or out-of-network facility.

The reimbursement would be the greatest of the following amounts:

  • In-network amount in the geographic region under the issuer.
  • Amount for service calculated generally used to determine out-of-network services, such as the usual, customary and reasonable amount.
  • Medicare reimbursement fee.

Providers would be prohibited from charging enrollees for the difference between the carrier’s reimbursement and provider’s charge for emergency out-of-network care services. Carriers would be prohibited from charging enrollees at a rate higher than the in-network service rate.

Out-of-network providers at an in-network facility would be permitted to charge the difference between the carrier’s out-of-network reimbursement and provider’s charge if:

  • The provider informs the enrollee that the provider is not in-network;
  • The provider provides to the enrollee a good faith estimate of the cost of services, including a disclaimer the enrollee is not required to obtain service from that provider; and
  • The enrollee consents to receive the services.

In the event of a payment dispute, both parties may request for arbitration to the superintendent of insurance. The non-prevailing party would pay 70% of the fees, and the remaining 30% would be paid by the prevailing party.

In South Carolina, SB 314 and HB 3401 were pre-filed in the Senate and House, respectively. Both bills would prohibit carriers from charging enrollees a coinsurance, copayment, deductible or other out-of-pocket expense for emergency services, provided by an out-of-network healthcare provider greater than the in-network rate.

In the event an enrollee receives emergency services from an out-of-network provider, the carrier must reimburse the provider the greatest of the following amounts:

  • The in-network rate;
  • The usual, customary and reasonable rate; or
  • The Medicare reimbursement rate.

However, a carrier and out-of-network provider would be permitted to agree on a greater reimbursement amount.

Enrollees would only be required to pay out-of-network providers the applicable coinsurance, copayment, deductible or other expense at the in-network rate.

The Senate bill was referred to the Senate Banking and Insurance Committee while the House bill was referred to the House Committee on Labor, Commerce and Industry.