BillTracker

Protecting consumers from charges for out-of-network health services (Cody, Pollet)

Establishes the balance billing protection act. Addresses the charges for out-of-network health services.

1ST SUBSTITUTE COMPARED TO ORIGINAL:
The substitute bill:
-limits the nonemergency services for which balance billing is prohibited;
-requires carriers to calculate cost-sharing using the average contracted rate, rather than 125 percent of the amount Medicare would reimburse
-removes provisions establishing the rates for payment to out-of-network providers;
-removes the requirement that the arbitrator choose between the parties' final offers, provides factors for the arbitrator to consider, requires the fees to be divided equally (unless the Commissioner adopts a rule), requires the parties to sign a nondisclosure agreement, and requires the Commissioner to prepare an annual report;
-adds notification requirements for facilities, providers, and carriers; and
-applies the balance billing provisions to health plans offered to public employees and their dependents.

EFFECT OF STRIKER AMENDMENT:
(1) Clarifies that an out-of-network provider or facility may not balance bill a covered person for the specified health care services. Modifies the nonemergency services for which balance billing is prohibited by removing reference to invasive medical procedures and removing services by an out-of-network provider without the covered person's consent. (2) Applies cost-sharing and dispute resolution provisions to health care facilities, in addition to health care providers. Requires carriers to calculate the in-network cost-sharing rate using the carrier's median (rather than average) contracted rate. Requires carriers to make payments directly to providers and facilities. (3) Requires carriers to pay a billed amount of less than $300. Permits, when the billed amount is $300 or more, a carrier and outof-network provider or facility to use mediation or, if the amount in dispute is $2000 or more, arbitration. Requires mediation expenses to be divided equally among the carrier, provider, and facility, if the amount in dispute is less than $2000. (4) Removes language providing that arbitration is binding and not subject to appeal. Prohibits consolidation of multiple claims, and limits each arbitration proceeding to one episode of care and one provider or facility. Requires the nonrequesting party to provide its final offer within 30 days (rather than upon receipt), and requires the arbitrator to issue a decision selecting one party's final offer. Remove factors related to the provider's training and disproportionate pattern of involvement in arbitration. Requires arbitration expenses to be paid by the party whose final offer was rejected. Applies the Uniform Arbitration Act to balance billing arbitrations, except in cases of conflict. Expires the section requiring the Insurance Commissioner (Commissioner) to report arbitration information on January 1, 2023. (5) Requires a nonemployed provider group providing surgical or ancillary services to notify facilities regarding its network status. Requires hospitals and ambulatory surgical facilities to notify the carriers with which they contract of the network status of their contracted provider groups. Requires the notice to include, for each type of surgical or ancillary service, whether at least 75 percent of the providers providing the service were in-network during the previous three months. Requires the carrier to treat the facility as out-of-network for nonemergency services if the 75 percent thresholdis not met, and requires the carrier to notify the Commissioner if the 75 percent threshold is not met. (6) Requires the Commissioner, in consultation with stakeholders, to develop standard template language for notifying consumers of the circumstances under which they may not be balance billed. (7) Modifies transparency requirements applicable to facilities to: (a) Apply the requirements to hospitals and ambulatory surgical facilities (rather than all health care facilities); (b) Modify the information facilities must post on their web sites to include whether each nonemployed provider group providing surgical or ancillary services contracts with the same carriers as the facility; (c) Require notice to be provided when a patient is scheduled for nonemergency health care services (rather than for nonemergency health care services involving an invasive medical procedure when not all scheduled providers are in-network); (d) Require the notice to be provided 10 days before the service (instead of the earlier of 10 days before or within two days of the service being scheduled); (e) Require notices from in-network facilities to: Advise the patient that he or she may request an in-network provider; disclose the names and network status of providers who will provide surgical or ancillary services; advise the patient of his or her rights under the bill using the standard template language; and provide an estimated range of the cost (rather than include names for scheduled providers and advice to contact the carrier regarding requests for in-network providers); and (f) Remove the requirement that a facility make a good faith effort to identify and schedule in-network providers upon request. (8) Modifies transparency requirements applicable to providers to: (a) Require notice to be provided when a patient is scheduled for nonemergency health care services at an out-of-network hospital or ambulatory surgical facility (rather than for nonemergency health care services involving an invasive medical procedure); (b) Require the notice to be provided 10 days before the service (instead of the earlier of 10 days before or within two days of the service being scheduled); (c) Require the notice to include an estimated range of the cost of services and the amount the provider may bill; and (d) Require in-network providers to submit accurate information to a carrier regarding network status in a timely manner. (9) Modifies transparency requirements applicable to carriers to: (a) Require provider directories to be updated within 30 (instead of 20) days, and remove the requirement to cover services if a covered person reasonably relied on an inaccurate provider directory; (b) Remove the notice requirement applicable to scheduled nonemergency health care services involving an invasive medical procedure; (c) Require the carrier to provide a covered person with notice of his or her rights under the bill using the standard template language; and (d) Remove the requirement that a carrier provide the covered person with providers' names when the covered person receives preauthorization for certain services. (10) Clarifies that the Commissioner's enforcement authority extends to providers, hospitals, and ambulatory surgical facilities. (11) Excludes Medicaid plans from the bill. (12) Modifies definitions and phrasing and corrects typographical errors.

Hearing Date: Friday, March 31, 2017 -- 1:00 pm

WA State Legislature Link:
http://app.leg.wa.gov/billsummary?BillNumber=2114&Year=2017    (opens a new browser tab)