February 27, 2020

States Advance Surprise Billing and Breast Cancer Screening Legislation

State legislatures continued to work on state-mandated legislative solutions for surprise billing and mandatory breast cancer screening coverage this week.

Several states considered out-of-network provisions on reimbursement rates and good faith estimates.

State legislatures in Iowa, Minnesota and Missouri pushed bills that mandate coverage for diagnostic breast cancer screening services. Lawmakers in Kansas debated a bill that would require coverage for breast cancer screening.

Out-Of-Network Billing

Colorado

In Colorado, SB 43 is scheduled for a third and final reading on the House floor. It would change the reimbursement rate for out-of-network providers as follows:

  • 105% to 110% of the insurer’s average in-network rate for that service in the same geographic area; or
  • 60th percentile of the in-network rate instead of the previous median in-network rate for the same service in the same geographic area.

The provider would be reimbursed the greater of the above options.

Florida

In Florida, HB 959 passed the House chamber. The bill would require licensed facilities to provide in writing or electronically a good faith estimate of reasonably anticipated charges by the facility for a patient’s treatment or specific condition. The estimate would be provided to the patient or prospective patient upon scheduling a medical service, upon admission to the facility or before providing elective medical services on an outpatient basis. It would prohibit facilities from charging enrollees more than 110% of the estimate. If the facility determines such charges are warranted, the facility must provide the patient with a written explanation of the excess charges as part of the itemized statement to the patient.

Facilities would also be required to establish an internal process for reviewing and responding to patients’ grievances regarding statement charges. The facility would be required to provide an initial response to a patient grievance within seven business days after the patient formally files a grievance.

Nebraska

In Nebraska, LB 997 passed the Legislative Committee on Banking, Commerce and Insurance. The bill would prohibit providers from billing enrollees in excess of any deductible or coinsurance amount for emergency services at an in-network or out-of-network facility. Out-of-network providers may bill insurers for emergency services rendered at an in-network or out-of-network facility.

The insurer would pay the billed amount or notify the provider within 20 days after the claim date if it deems the claim as excessive. A reasonable claim would be defined as the higher of the insurer’s contracted rate or 125% of the Medicare reimbursement rate for similar services in the same geographic area. In the event the insurer considers the claim to be excessive, the insurer and provider would have 30 days to negotiate a settlement or engage in a mediation process.

Breast Cancer Screening

Iowa

In Iowa, S 2342 was introduced in the Senate. It would mandate a policy, contract or plan providing for third-party payment or prepayment of health or medical expenses to provide coverage for diagnostic breast cancer examinations. The examination may be conducted using a diagnostic mammogram, breast magnetic resonance imaging or breast ultrasound. Digital breast tomosynthesis was excluded.

Kansas

In Kansas, S 464 was referred to the Senate Committee on Financial Institutions and Insurance. The bill would require individual and group health insurers to cover diagnostic breast imaging examinations using mammography, MRI or ultrasound for suspected abnormalities. It also requires them to ensure that the cost-sharing requirements and treatment limitations applicable to a diagnostic breast cancer exam are no less favorable for an insured person than such requirements and limitations that apply to screening breast cancer exams also apply to diagnostic breast imaging procedures.

Minnesota

In Minnesota, S 3363 was referred to the Senate Committee on Health and Human Services, Finance and Policy. The bill would require insurers to provide coverage for additional diagnostic services or testing without copayments, deductibles or coinsurance for enrollees after the health care provider determines additional diagnostic services or testing are necessary after mammography.

Missouri

In Missouri, S 841 was referred to the Senate Insurance and Banking Committee. It would require insurers to cover:

  • An annual mammogram for any woman deemed by a physician to have an above-average risk for breast cancer;
  • Any additional or supplemental imaging, such as breast magnetic resonance imaging or ultrasound, deemed medically necessary by a treating physician for proper breast cancer screening or evaluation; and
  • Ultrasound or MRI services, if determined by a physician to be medically necessary for the screening or evaluation of breast cancer for any woman deemed by a treating physician to have an above-average risk for breast cancer.