October 02, 2019

Out-Of-Network Legislation Advances in Massachusetts Legislature

In Massachusetts, HB 1046 passed the Joint Committee on Financial Services and was referred to the Joint Committee on Health Care Financing.

The bill would amend the public health law to include the following changes:

Prior to receiving services from out-of-network providers, enrollees would receive a disclosure informing them of the provider’s out-of-network status and that the services may result in costs not covered by the patient’s health plan issuer. The disclosure would also present a written estimate of the enrollee’s total out-of-pocket cost of care for the health care service. Additionally, the enrollee would have to affirmatively choose to receive health care services from the out-of-network provider.

In the event an out-of-network provider renders emergency services to an enrollee, the issuer would pay the greater of 115 percent of the average rate the issuer would pay for the health care service in the same or similar specialty, as determined by the commissioner of the division of insurance and 125 per cent of the Medicare rate for the service.

In the event an out-of-network provider renders health care services, other than for emergency services, to an enrollee, the issuer would pay the provider the greater of 115 percent of the average rate the issuer would pay for that health care service performed by a health care provider in the same or similar specialty and 125 percent of the Medicare rate for that service.