Members constantly ask us about surprise medical bill legislation. Many are unaware that 30 states have enacted surprise medical bills laws, but less than half provide comprehensive legislation.
In 2020, Colorado, New Mexico, Texas, and Washington have added comprehensive surprise medical bill protection for consumers. Surprise medical bill legislation applies to fully-insured commercial insurance plans. Employer self-insured plans are excluded from state surprise medical bill legislation and instead regulated at the federal level. So far, no federal laws exist to prevent surprise medical bills.
Although the details vary by state, comprehensive legislation generally hits on the following points:
• Provisions for emergency and nonemergency events
• Coverage for HMO and PPO plans
• Reimbursement policies that establish an independent baseline for out-of-network charges (in some cases application of in-network rates must applied to the out-of-network charges)
• Consumers must be informed when an out-of-network provider has been called into an in-network situation
• Provision for providers and payers to arbitrate or resolve disputes without involving consumers
The onus for adhering to the legislation resides with payers and providers, but we’ve seen cases of nonconformance. Often they are simply unaware of the unique requirement or have yet to implement the change to technology or processes. Regardless, consumers are confused when they receive a surprise medical bill and it generally reflects poorly on the system at large.
NOTE: The Public Health Emergency has just been extended for 90 days. Although providers can practice across state lines, state surprise medical bill legislation of the service location applies, not the provider’s primary location.