In response to growing constituent pressure, lawmakers in more states are proposing legislation to regulate surprise bills from the balance billing practices of out-of-network medical services.
Health plans with narrowly-constructed provider networks are common and result in many patients receiving care outside of the provider network covered by their plan. In some cases, these patients have received services from out-of-network medical specialists at in-network facilities or emergency care from out-of-network practitioners at in-network emergency departments. In such instances, patients may be billed the portion of the physician’s fee not covered by the health plan.
These costs are often unexpected and have led consumer advocates to call for an end to “balance billing” practices, which are attracting scrutiny from state legislators, insurance regulators and the media. The resulting legislative responses may have been well-intentioned, but many have unfortunately not focused on balance billing’s primary cause: inadequate preferred provider insurance products and the failure of insurers to appropriately disclose coverage gaps to their customers.
Many state legislative proposals would place physicians at a disadvantage by restricting their billing practices and denying them fair compensation. Many of the same bills do not require health insurers to disclose the limitations of their plans. Payers would be incentivized to set reasonable rates if network adequacy requirements were enforced and transparency mechanisms on fair provider reimbursement for out-of-network services were established. When physicians are compensated adequately, they are less likely to balance bill.
State legislatures have considered more than 100 bills related to out-of-network billing, transparency, and network adequacy in their 2017 and in 2018 sessions. Here are summaries of 23 bills introduced in 16 states:
Alaska SB 129
An act relating to the determination by an insurer of a final payment for a covered service or supply; annulling regulations relating to determination by an insurer of a final payment for a covered service or supply based on geographical areas.
Georgia HB 678
Relating to insurance, to provide for consumer protections regarding health insurance; to provide for definitions; to provide for disclosure requirements of providers, hospitals and insurers; to provide for billing, reimbursement and arbitration of certain services.
Georgia SB 359
Relating to insurance, to establish standards for carriers and health care providers regarding payment under a managed care plan in the provision of emergency medical care; to provide for applicability and related matters.
Hawaii HB 914
Requires a health carrier with a network plan to maintain a network that provides sufficient practitioners and services to meet the needs of the enrollees or members.
Idaho HB 495
Adds to existing law to enact the Health Care Billing Equity Act. In enacting this chapter, it is the intent of the legislature to protect Idaho residents from unexpected balance billing for health care services performed by out-of-network providers at in-network health care facilities.
Iowa SB 2083
An act relating to reimbursement of in-network and out-of-network providers under Medicaid managed care.
Kentucky SB 79
To define "balance billing," "cost sharing," "emergency health care services," "emergency medical condition," "health care service," "insured, maximum allowable cost," and "usual and customary rate"; create a new section of Subtitle 17A of KRS Chapter 304 to require the commissioner of insurance to collect information from insurers regarding billed charges, and either to select a nonprofit to distribute the information to or to publish the information annually on its website; create a new section of Subtitle 17A of KRS Chapter 304 to define unanticipated out-of-network care, and to require an insurer to reimburse for unanticipated out-of-network care at the usual and customary rate for the service; prohibit any lower reimbursement; prohibit balance billing from a provider who has been reimbursed in accordance with this section; allow a provider to bill for any applicable cost-sharing requirements owed by the insured.
Massachusetts HB 2164
An act to ban hospital facility fees and surprise billing.
Missouri HB 1518
Changes the laws regarding rates charged by health care providers.
Missouri HB 2136
Establishes the Missouri Freedom to Choose Health Care Act.
New Hampshire HB 1643
Relative to balance billing.
New Jersey AB 450
Limits payments under health benefits plans to in-network amounts in certain circumstances; prohibits out-of-network health providers from charging carriers more than 150 percent of Medicare rate in certain circumstances.
New Jersey AB 1920
Requires certain disclosures to consumers regarding health care costs.
New Jersey AB 2039
"Out-of-network Consumer Protection, Transparency, Cost Containment and Accountability Act."
New Jersey SB 978
Act establishes New Jersey All-Payer Claims Database and arbitration process for reimbursing out-of-network health care providers.
New York AB 6119
Requires hospitals to inform emergency care patients whether the attending physician participates in the insured's insurance policy; requires insurance companies to cover the cost of out-of-network care for patients who are unconscious or otherwise unable to provide informed consent.
New York AB 7332
Requires notification to insureds that an out-of-network physician may be used in their procedure, test or surgery and such physician's services shall not be covered by their insurance policy; requires such services must be covered if the insured person does not receive notification prior to such services or procedure.
Oklahoma HB 3228
An act relating to insurance; creating the Patient Protection Act; prohibiting the health care insurer from imposing advantages or penalties when certain non-network providers agree to accept certain reimbursement rates; prohibiting balance billing in certain circumstances; specifying certain actions of an insurer shall not be prohibited or required; defining terms; prohibiting insurer from terminating, refusing to issue or renew a physician contract under certain circumstances.
Tennessee HB 2258
As introduced, removes any private right of action to collect unauthorized charges by a physician from a patient.
Tennessee HB 2353
As introduced, enacts the "Network Adequacy and Out-of-Network Balance Billing Transparency Act."
Virginia HB 1584
Prohibits an out-of-network health care provider from charging a covered person who is insured through a health benefit plan an amount for ancillary services that is greater than the allowed amount the carrier is obligated to pay to the covered person. The measure defines "ancillary services" as screening, diagnostic or laboratory services provided in connection with or arising out of other health care services that the covered person receives from or at an in-network provider. The measure requires an in-network provider to provide certain notices regarding the provision of ancillary services by an out-of-network provider. The measure has a delayed effective date of Jan. 1, 2019.
Washington HB 2114
Establishes the balance billing protection act. Addresses the protection of consumers from charges for out-of-network health services.
West Virginia HB 2327
Protecting consumers from surprise bills by health care providers.