February 21, 2019

More States Gear Up to Address Out-of-Network Billing

Out-of-network billing remains a hot issue with more state legislatures, Congress and the federal executive branch all looking for solutions. We are seeing additional bills on out-of-network reimbursement in Colorado, Georgia, New York and other states, as well as bills that incentivize consumer shopping for health care services and to promote health care pricing transparency in Alaska, Minnesota, Texas and elsewhere.

Use this map to identify and track pending health care legislation in your state. (If required, enable Adobe Flash Player as instructed).

Alaska SB 27 State Record. Although ultimately withdrawn by its sponsor, SB 27 called for an incentive program for consumers who elect to receive health care services for less than the average price. It would have also required health care services price disclosure. The proposed incentive program included a list of stipulated categories that included radiology and imaging services and outpatient nonsurgical diagnostic tests or procedures.

Missouri SB 103 State Record. Sponsored by Sen. Jill Schupp (D), the measure passed the Insurance and Banking Committee. This legislation revises legislation passed in FY 2018 that outlines reimbursement requirements and establishes an arbitration system for reimbursement disputes for out-of-network providers providing “unanticipated out-of-network care," defined as services received in an in-network facility from an out-of-network provider when the patient presents with an emergency medical condition. The act specifies that health care professionals shall, rather than may, utilize the process outlined in statute for claims for unanticipated out-of-network care and removes the existing January 2019 enactment provision.

New Mexico HB 207, sponsored by Rep. Nathan Small (D), and New Mexico HB 295, sponsored by Rep. Deborah Armstrong (D), both made it out of the House Health Committee. Similarly, New Mexico SB 279 from Senator Carlos R. Cisneros (D), passed the Senate Public Affairs Committee. In combination, the bills offer detailed solutions to out-of-network medical services provided in emergency room settings, health security planning, an unfair practices ban and cost containment provisions.

Oklahoma SB 1011 State Record. The measure on out-of-network surprise billing, sponsored by Sen. Marty Quinn (R), was reported “title stricken” on Feb. 28, 2019. If a legislator offers an amendment to “strike the title,” this means the measure will have to be returned to the senate and amended again. Striking the title allows the bill to move forward in the legislative while recognizing the need for further changes. The introduced version of the bill defined "usual, customary and reasonable rate" to mean the eightieth percentile of all charges for the particular health care service performed by a provider in the same or similar specialty and provided in the same geographical area as reported in a benchmarking database maintained by a nonprofit organization specified by the (insurance) commissioner. The nonprofit organization shall not be financially affiliated with an insurance carrier. The measure also stipulated availability of an independent resolution process for medical claims.

Rhode Island HB 5421. The bill was introduced on Feb.14, 2019, by Rep. Evan Shanley (D). It seeks to address unanticipated out-of-network bills for health care services (for emergency and other services) by requiring a non-participating health care provider to bill an insured party only for a co-payment or deductible. This act would provide a method for reimbursing out-of-network professionals who provide unanticipated out-of-network care and would provide guidelines for what payment out-of-network professionals may seek or accept from a patient.

Texas HB 1718 State Record. On Feb. 13, 2019, Rep. Sergio Munoz (D) filed a bill calling for greater availability of price and quality information including a requirement for health plans to allow enrollees to obtain specific information, such as quality data, estimates of out-of-pocket costs and amounts paid to participating providers. The measure proposes a requirement for the health benefit plan to provide a “good-faith” estimate of the amount the enrollee will be responsible to pay for a health care service. It also calls for an incentive program whereby the program must provide an incentive paid to an enrollee who elects to receive a health care service from a participating provider who provides that service at a lower than median cost.

Virginia SB 1763 State Record. Despite passage by both houses, a measure sponsored by Sen. Glen Sturtevant (R) was considered dead after an amendment that stipulated for this act “not [to] become effective unless an appropriation that addresses the anticipated effects of this act on the general fund is included in a general appropriation act passed in 2019 by the General Assembly that becomes law.” The measure sought to direct health plans to pay out-of-network health care providers who perform emergency services an amount that is equal to the greatest of: (i) negotiated in-network amount for emergency room service or, in the cases where more than one amount is negotiated, the carriers would have been required to pay the median of (ii) the regional average for commercial payments for emergency services as of the date of treatment or (iii) the Medicare rate.

Washington HB 1065 (SB 5031). A bill from Rep. Eileen L. Cody (D), was scheduled for public hearing in the House Committee on Appropriations on Feb. 20, 2019. The measure would ban balance billing of consumers enrolled in fully insured, regulated insurance plans and plans offered to public employees under state health care authority provisions. The measure would require out-of-network providers and carriers to negotiate out-of-network payments in good faith. The allowed amount paid to an out-of-network provider for health care services would be limited to a commercially reasonable amount based on payments for the same or similar services provided in a similar geographic area. If the parties are unable to settle on a payment, the measure provides for arbitration provisions. In reviewing the parties’ submissions and when making a decision related to payment, the measure enumerates factors that the arbitrator must consider. Among them are the median in-network and out-of-network allowed amounts and the median billed charge amount as reported in the data set prepared by the Washington state all-payer claims database as well as the established rate that Medicare would pay for the same service or procedure on a fee-for-service basis.

West Virginia HB 3019 was introduced by Delegate Dean Jeffries (R), on Feb.12, 2019. A hearing was scheduled for Feb. 21 before the Committee on Health & Human Resources. The measure calls for creating the Health Care Transparency Act and requiring the Bureau for Public Health to produce an estimate for creating and maintaining a health care price transparency tool to be accessible to the public. In addition to setting the transparency tool requirements, it would establish new disclosure rules for health care providers, hospitals and insurers. To protect the public from surprise bills, the legislation stipulates that the consumer must sign an assignment of benefits form that will enable the provider to seek payment directly from the consumer’s insurer by submitting the assignment of benefit form along with a copy of the bill believed to be a surprise bill. Providers can also dispute the amount they receive from the insurance carrier through an independent dispute resolution process established by the commissioner.