January 20, 2021

States Begin 2021 Legislative Sessions

Legislatures across the country introduce measures related to coverage for breast cancer screening, out-of-network provision changes, and scope of practice for physician assistants and physical therapists.

Breast Cancer Screening

In Connecticut, HB 5189 was referred to the House Joint Committee on Insurance and Real Estate. The bill would require coverage for diagnostic mammograms, ultrasound screenings, and magnetic resonance imaging of breasts and breast biopsies for both women and men. It would also reduce the minimum age at which a carrier is required to provide coverage for a baseline mammogram from 35 to 30 years of age; and require coverage for the detection and diagnosis of breast cancer in an individual who has been treated for a childhood cancer and received radiation treatment that was directed at the individual's chest as part of the treatment for said childhood cancer, regardless of such individual's age.

Out-Of-Network Billing

Ohio’s Gov. Mike Dewine signed HB 388 into law. The bill will 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 will be the greatest of the following amounts:

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

Providers will 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 will 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 Oregon, HB 2042 had its first reading in the House chamber. The bill would prohibit out-of-network providers from billing or attempting to collect payment from an enrollee covered by a health benefit plan for:

  • Emergency services provided at an in-network or out-of-network healthcare facility; or
  • Other inpatient or outpatient services provided at an in-network healthcare facility.

Carriers would be required to reimburse out-of-network providers according to rules by the Department of Consumer and Business Services for the aforementioned services.

In the event an enrollee chooses to receive services from an out-of-network provider, the provider would be required to inform the enrollee that the enrollee will be financially responsible for coinsurance or out-of-pocket expenses from selecting an out-of-network provider.

The Department of Consumer and Business Services would be required to adopt rules for calculating the reimbursement for providers. The reimbursement would be required to equal the median allowed amount paid to in-network providers by commercial carriers in the state. The Department may adjust the reimbursement amount based on differences in allowed amounts paid to providers in certain geographic areas of the state.

Scope of Practice

In New York, AB 1837 and its companion bill, SB 1591 were referred to their respective Health Committees. The bills seeks to permit physician assistants (PAs) to perform fluoroscopy, provided that the PA has successfully completed an educational program consisting of at least 40 hours of didactic and 40 hours of clinical training with successful completion of a competency exam, as approved by the department.

In North Dakota, SB 2122 passed the Senate chamber. The bill seeks to permit physical therapists to order musculoskeletal imaging consisting of plain film radiographs provided the physical therapist holds a clinical doctorate degree in physical therapy or has completed a board-approved formal medical imaging training program.

In Virginia, HB 2039 was referred to the Health Professions Subcommittee. The measure seeks to change the practice agreement between a physician assistant and physician to a collaborative agreement. Additionally, the physician in the collaborative agreement would not be liable for the actions or inactions of the PA.