By Samantha Barry, NoHLA Intern
This session, legislation to protect consumers from surprise bills from health care providers is back for the 4th year in a row! You might receive an unexpected surprise bill (also called an out-of-network bill or balance bill), after getting treatment that, unbeknownst to you, was from a provider not in your insurance carrier’s network. This may happen in an emergency situation, or at a hospital or outpatient facility that is in your insurance network. For example, many facilities utilize per diem and independent providers such as surgeons, hospitalists, and anesthesiologists to fully staff their facilities. These providers may not be in network with the same insurance carriers as the facility. The labs and radiology services they use may also be out-of-network. Patients receive unexpected, sometimes very high bills because their insurance company and the providers have no agreement on payment.
As Insurance Commissioner Mike Kreidler says, “consumers should not be caught in the middle of billing disputes between insurers and providers.” He has spearheaded legislation to reduce the number of surprise bills consumers receive, along with Representative Eileen Cody. SB 5031 and HB 1065, filed by request of the Commissioner and prime sponsored by Rep. Cody, would protect patients from surprise bills in two situations: when a patient receives services for an emergency medical condition, and when a person receives non-emergency surgery or ancillary services in an in-network facility. In these situations, patients receiving out-of-network services will be charged cost-sharing at the in-network rate and cannot be billed for additional amounts. The legislation also expands the definition of “Emergency medical condition” to include mental health or substance use disorder conditions, emotional distress, and severe pain. The bill applies to fully-insured plans but self-funded plans may choose to opt in.
The bills set forth a system for payment of out-of-network providers by carriers, including a dispute resolution process. This has been a sticking point in previous years, with providers and carriers both taking issue with the proposed system. This year, they indicated in testimony before the House Health Care & Wellness Committee that there had been progress on this issue but they did not yet fully support the bill.
The bills also require the Commissioner, in consultation with insurance carrier, providers, facilities and consumers, to develop language to alert the public of their rights laid out in these bills. Hospitals and ambulatory surgical centers also must provide insurance carriers with a list of nonemployed providers or provider groups who are contracted to provide surgical or ancillary services at their facilities. Health care providers must post on their website (or if there is no website the information must be provided to consumers upon a written or oral request) the consumer rights laid out in this legislation as well as a list of all the insurance networks with which they have a contract. Insurance carriers must update their website and provider directory within 30 days following the addition or termination of any providers or facilities. Carriers must also provide their enrollees with a clear description of the plan’s out-of-network health benefits as well as the rights and protections as laid out by this legislation and upon request, information about whether a provider is in- or out-of-network, as well as an estimation of the out-of-pocket costs for an out-of-network benefit. SB 5031 and HB 1065 have both had public hearings in the respective health committees, along with an additional, recently-introduced bill, SB 5699 (Sen. Cleveland) that is largely similar but revised to include provisions requested by providers.
This legislation has been a long time coming and we are hoping for its smooth progress through the Legislature and to Governor Inslee’s desk this session. 2019 may be the year!
NOTE: For latest news on the 2019 Legislative Session, see NoHLA’s Legislative Update page and click on the most recent update.