November 13, 2019

Michigan and Ohio Address Out-Of-Network Legislation

Two bills on out-of-network (OON) billing were referred in the past week to a House committee in Michigan, while Ohio’s House Finance Committee prepared to hear testimony on its respective out-of-network billing legislation.

In Michigan, two bills on balance billing were re-referred to the House Committee on Ways and Means.

HB 4459 would require out-of-network emergency medical personnel who provide a covered emergency service to be reimbursed at 125% of the amount covered by Medicare for the service, excluding any in-network coinsurance, copayments or deductibles. An out-of-network provider of an emergency service or of an elective service would not collect directly or indirectly any excess amount from the enrollee other than applicable coinsurance, copayments or deductibles. Providers may receive an administrative fine for attempting to collect from the enrollee.

H 4460 lists the following requirements for billing enrollees for OON elective services:

  • The enrollee would have to consent in writing at least 24 hours in advance of the service
  • The consent could not be obtained at the time of admission or when the enrollee is being prepared for a procedure
  • The enrollee would be given a written estimate of the cost of the services, and
  • The required consent form would advise the enrollee that he or she may seek care from an in-network provider or be allowed to contact the health plan issuer to find an in-network provider.

The consent form would require a notice with the language: “Your health benefit plan may or may not provide coverage for all of the services you are scheduled to receive or the providers providing those services. You may be responsible for the costs of the services that are not covered by your health benefit plan. We have conducted a good-faith search to determine whether your health benefit plan provides coverage for these services, and if so, to order these services from a provider that participates with your health benefit plan. You have a right to request that the services be performed by a provider that participates with your health benefit plan.”

The bill also authorizes administrative fines for providers who do not obtain the required written consent.

In Ohio, the House Finance Committee will hold a hearing on H 388. The bill would require the health plan issuer to reimburse an out-of-network provider for unanticipated or emergency health care service provided at an in-network facility or out-of-network emergency facility.

The reimbursement rate would be the greatest of the following three amounts:

The median amount the issuer negotiated with in-network providers or facilities for the service in question
• The rate the issuer would pay for out-of-network services under the health benefit plan
• The rate that would be paid by Medicare

Out-of-network providers may not balance bill the enrollee unless all of the following conditions are met:

  • The provider informs the enrollee that the provider is not in-network.
  • The provider issues a good faith estimate of the cost of the services, including the provider’s charge, the estimated reimbursement by the issuer, and the enrollee’s responsibility. The estimate would require a disclaimer that the enrollee is not required to obtain the health care service at that location or from that provider.
  • The enrollee affirmatively consents to receive the services.

Out-of-network providers would also be required to disclose information to patients regarding the cost of other out-of-network services.

In the event of a dispute, an arbitrator would only award one of either party’s final offer. The non-prevailing party would pay 70% of the arbitrator’s fees and cost of arbitration, and the prevailing party would pay the remaining 30%.