As health care costs and consumer out-of-pocket expenses continue to rise, states are paying increasing attention to strategies that address consumer concerns. One issue of focus is the practice of balance or “surprise billing,” the process by which patients receive higher than expected bills from providers, often the result of receiving care out-of-network. In April 2016, NASHP published a brief detailing many factors that contribute to balance billing as well as pending state legislation to address the issue.
The chart below provides an update to this brief, summarizing enacted state legislation from the 2015-16 legislative session.
|CALIFORNIA AB1305||Applies annual out-of-pocket caps on covered benefits inclusive of out-of-network emergency care received up to the point of patient stabilization.|
|CONNECTICUT SB433||Requires carriers to establish a process to ensure that beneficiaries receive benefits at in-network levels in circumstances when there is no available provider to provide covered benefits or when covered benefits cannot be provided without unreasonable travel or delay.|
|FLORIDA HB221||Requires carriers to cover emergency services delivered in licensed facilities at in-network rates. Also requires carriers to cover non-emergency services at in-network rates in circumstances where 1) the carrier has a contract with the facility to provide the services covered by the beneficiary’s plan and 2) the beneficiary does not have the ability or is not given the opportunity to choose a participating provider at the facility.Prohibits non-participating providers from billing carriers beyond the limits specified for emergency reimbursements under Florida law or from collecting any amount in excess of this from beneficiaries.|
|UTAH SB216||Prohibits balance billing of beneficiaries in circumstances where workers’ compensation insurance or self-insured employer benefits are obligated to pay medical benefits.|
|CONNECTICUT SB433||Requires carriers to disclose the process to request covered benefits from out-of-network providers in cases when the beneficiary requires specialty care or the carrier does not have a provider (or provider that can provide services without unreasonable travel or delay) with the needed specialty to treat the consumer’s condition.|
|FLORIDA HB221||Requires hospitals to post contracted carrier information on their websites and to provide notice to patients that services may be delivered by practitioners that may bill separately or that do not participate in the same insurance networks, including names and contact information for contracted providers.Requires carriers to include disclosures that limited benefits will be paid when out-of-network providers are used with any newly issued policy.|
|FLORIDA HB1175||Requires health care facilities’ websites to include an estimated average of payments received from all payers (excluding Medicaid and Medicare) for certain bundles of services. Notice must include disclosure that the costs are an estimate and actual costs may vary by patient.Facilities must inform patients and prospective patients that they may request a personalized estimate of charges. Estimates must be delivered within seven days. Facilities also must provide names and contact information for contracted providers and recommend that patients contact each practitioner who will provide services to determine if the practitioner is in-network.Requires facilities to notify patients, when applicable, that services may be delivered by a practitioner that may bill separately or may not be participating in the patient’s plan’s network.Clarifies information that should be included on a patient’s bill to better inform the patient about the purpose and specificity of charges for services received.|
|GEORGIA SB302||Requires carriers to provide reimbursement at in-network rates in circumstances when the beneficiary relied on inaccurate information contained in a carrier’s provider directory.|
|MINNESOTA HF3142||Requires carriers to pay in-network rates in circumstances where services were provided after a provider left the plan network, but before the change was updated on the carrier’s website, unless the beneficiary was otherwise altered of the network change.|
|TEXAS SB425||Requires freestanding emergency care facilities to prominently post information stating that the facility or physician providing services at the facility may not be in the beneficiary’s network and that physicians may bill separately from the medical facility.|
|GEORGIA SR974||Creates a surprise billing practices study committee to undertake a study of the conditions, needs, and issues associated with surprise bills.|
|FLORIDA HB221||Establishes a process by which carriers and providers may settle billing disputes, including a time limit during which one must respond to a settlement offer before it will automatically go into effect.|
|TEXAS SB481||Lowers the amount at which a beneficiary can request mediation of a settlement of an out-of-network claim from $1,000 to $500.|