June 20, 2019

States Finalize Imaging and Out-of-Network Billing Legislation

Several bills have passed legislative chambers or were signed into law in June. This week’s update features proposed bills and finalized laws that address out-of-network “surprise” billing and cancer screening.

Out-Of-Network Billing

In California, AB 1611 was referred to the Senate Health Committee. The bill would prohibit enrollees from paying more to an out-of-network provider than an in-network provider for the same covered services.

The bill would also require the insurer to pay an out-of-network provider for emergency services rendered pursuant to a specified formula. It would require the provider to bill, collect and make refunds in a specified manner and would provide a dispute resolution procedure, if any party is dissatisfied with payment. Reimbursements for out-of-network providers would be based on the reasonable and customary value of the hospital services or the average contracted rate on a fee-for-service basis for the same or similar hospital services in the general geographic region in which the services were rendered.

In New York, two bills are advancing in the senate. SB 1793 was amended and recommitted to the Senate Health Committee. The bill would prohibit insured individuals from incurring out-of-pocket costs outside of applicable co-payment, coinsurance or deductible for emergency medical or ambulance services. The bill would also allow enrollees the option of assigning the payment of any benefits due under their policy directly to the health care provider.

Also in New York, SB 3171 was replaced by AB 264, which passed the senate chamber and was returned to the assembly. The bill would amend the 2014 Financial Services Law by allowing insurers to pay an amount the insurer determines as reasonable for emergency services from an out-of-network provider, including for inpatient services after an emergency room visit.

An out-of-network provider or an insurer may submit a dispute regarding a fee or payment for emergency services to an independent arbitrator. In the event an insurer submits a dispute regarding a charge for an out-of-network hospital’s emergency services, the insurer would, after the initial payment, pay any additional amount it determines is reasonable directly to the hospital. The arbitrator would then make a determination within 30 days of receiving a dispute notice.

In Texas, Gov. Greg Abbott signed SB 1264 into law. The law will ban balance billing by out-of-network providers and strike out language on enrollees being a party to existing mediation provisions. The law will also allow mediation between providers and insurers for disputes regarding emergency care, out-of-network laboratory services or diagnostic imaging services. Although the law does not stipulate particular benchmarking for reimbursement, it does state the insurer would pay the provider the usual and customary rate. The law will be effective September 1, 2019.

Cancer Screening

In New York, AB 5502 passed the Standing Codes Committee and was referred to the Ways and Means Committee. The Senate companion bill, SB 3852, cleared its chamber and was referred to the Assembly’s Ways and Means Committee. Both bills would require coverage for annual mammography exams for covered persons aged 35 to 39, upon the recommendation of a physician.

In Texas, Gov. Abbott signed HB 170 into law. The law will mandate health plans that cover mammography screenings also cover diagnostic mammograms. The law will be effective September 1, 2019.