November 04, 2019

Massachusetts and Michigan Consider Out-Of-Network Billing Legislation

Massachusetts’ governor introduces an out-of-network (OON) bill prohibiting hospital facility fees as Michigan’s House chamber hears testimony on legislation detailing OON consent requirements for enrollees.

In Massachusetts, Gov. Charlie Baker introduced H 4134, which would prohibit health care providers from charging, billing or collecting a facility fee except for:

  • Services provided on a hospital’s campus
  • Services provided at a facility that includes a licensed hospital emergency department
  • Emergency services provided at a licensed satellite emergency facility

Health care providers could be fined a maximum of $1,000 for non-compliance per occurrence.

In the event a provider charges a facility fee-for-service, the provider would provide the enrollee receiving such service with written notice that such a fee will be charged and may be billed separately.

Enrollees receiving emergency health care services by an out-of-network provider or health care services that result in a surprise bill would only be required to pay the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such health care services if the services were rendered by an in-network provider. For out-of-network providers that participate in the issuer’s network but do not contract for specific health benefit plans (i.e., specialists), the issuer would pay the out-of-network provider 100% of the contractually agreed-upon amount paid, minus any member cost sharing in the form of the applicable coinsurance, copayment or deductible.

For out-of-network providers that provide a health care service to an enrollee and do not contract with the enrollee’s issuer nor participate in any of the issuer’s network plans, policies or contracts, the issuer would pay that provider a payment level equal to a percentage of the Medicare reimbursement rate.

The bill has been referred to the Joint Committee on Health Care Financing.

In Michigan, the House Health Policy Committee was scheduled to hear testimony on H 4460. The legislation features the following requirements for billing enrollees from 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
  • The consent would advise the enrollee that he or she may seek care from an in-network provider or 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.