Indiana and Maine have passed laws detailing additional requirements for reimbursing health care providers for out-of-network services. Maine also passed an expanded scope of practice bill for physician assistants.
Indiana’s Gov. Eric Holcomb signed H 1004 into law. It will require the health care facility or provider to issue the enrollee a form that will include:
- The text: "[Name of facility or practitioner] intends to charge you more for [name or description of health care services] than allowed according to the rate or amount of compensation established by the network plan applying to your coverage. [Name of facility or practitioner] is not entitled to charge this much for [name or description of health care services] unless you give your written consent to the charge."
- A good faith estimate of the amount that the facility or practitioner intends to charge for the health care services provided to the covered individual.
- The text: "The estimate of our intended charge for [name or description of health care services] set forth in this statement is provided in good faith and is our best estimate of the amount we will charge."
The patient will be required to receive the form at least five days before the health care services are scheduled to be provided.
Maine’s Gov. Janet Mills signed H 1501 into law. For enrollees subject to coinsurance, the bill will require out-of-network providers to calculate coinsurance amounts based on the median network rate for that health care service under the enrollee's health plan.
An out-of-network provider is also subject to the following with respect to any overpayment made by an enrollee.
- If an out-of-network provider provides health care services covered under an enrollee's health plan, and the out-of-network provider receives payment from the enrollee for health care services for which the enrollee is not responsible, the out-of-network provider shall reimburse the enrollee within 30 calendar days after the earlier of the date that the provider received notice of the overpayment and the date the provider became aware of the overpayment.
- An out-of-network provider that fails to reimburse an enrollee for an overpayment as required by the preceding paragraph will pay interest on the overpayment at the rate of 10% per annum beginning on the earlier of the date the provider received notice of the overpayment and the date the provider became aware of the overpayment. An enrollee is not required to request the accrued interest from the out-of-network provider in order to receive interest with the reimbursement amount.
Except for ambulance services, unless the carrier and out-of-network provider agree otherwise, a carrier shall reimburse the out-of-network provider or enrollee, as applicable, for health care services rendered the greater of:
- The carrier's median network rate paid for that health care service by a similar provider in the enrollee's geographic area; and
- The median network rate paid by all carriers for that health care service by a similar provider in the enrollee's geographic area as determined by the all-payer claims database maintained by the Maine Health Data Organization or, if Maine Health Data Organization claims data is insufficient or otherwise inapplicable, another independent medical claims database.
If an out-of-network provider disagrees with a carrier's payment amount for a surprise bill for emergency services or for covered emergency services, the carrier and the out-of-network provider have 30 calendar days to negotiate an agreement on the payment amount in good faith. If the carrier and the out-of-network provider do not reach agreement on the payment amount within 30 calendar days, the out-of-network provider may submit a dispute regarding the payment and receive another payment from the carrier determined in accordance with the independent dispute resolution process.
Scope of Practice
Maine’s Gov. Janet Mills also signed S 537 into law. It will permit carriers to allow physician assistants, without the supervision of a physician, to serve as primary care providers for managed care plans.