- Beginning in 2019, patients can submit bills to an “informal” review process.
- If not resolved, then binding arbitration between the provider and the health insurer is the next step.
- Only bills of at least $1,000 for services provided at a hospital that is typically in-network for the insurer are eligible for review.
- Currently prohibited for emergency services under DMHC-administered plans
- Also prohibits non-emergency “surprise bills". Consumers can only be billed for their in-network cost-sharing, when they use an in-network facility.
- Prohibits emergency and surprise billing situations when consumers are treated at in-network facilities and referrals for inadequate network situations. (Colo. Rev. Stat. §10-16-704(3)(b))
- Prohibits balance billing enrollees of managed care plans.
- Prohibits reporting to a credit reporting agency an enrollee’s failure to pay a bill for medical services when a managed care organization has primary responsibility for payment. (8 Conn. Gen. Stat. § 20-7f.
- Limits reimbursement for out-of-network emergency care by HMOs and PPOs to the lesser of the provider’s charges. (Fla. Stat. Ann. §641.513.)
- Protects patients who go to an in-network healthcare facility and inadvertently receive services from non-network providers by making the insurer solely liable for the payment of fees and the insured only liable for applicable copayments. (Fla. Stat. Ann. §627.64194(2).)
- Prohibits “surprise billing” for nonemergency services provided in an in-network facility by a non-network provider. (Fla. Stat. Ann. §627.64194(3))
- Provides protection for balance bills from out-of-network facility-based physician or other providers practicing in network hospitals or ambulatory surgery centers (215 ILCS 5/356z.3a(b) and (c).)
- Currently prohibited in emergency and surprise billing situations (MD. Code Ann. Health-Gen. §§19-710(p); 19-710.1 and 19-712.5.)
- HMOs are required to hold consumers harmless for covered services by non-network providers and pay at the prescribed rates. (MD. Code Ann. Insurance §§14-205.2 and 14-205.3.)
- Currently prohibited in emergency, inadequate network, and surprise billing situations. ( N.J.A.C. 11:24-5)
- Patients generally protected from owing more than their usual in-network cost sharing/copays for emergency services as long as the consumer assigns the provider’s claim to the insurer (N.Y. Fin. Services Law §§603 and 606.)
- Also protected in non-emergent if no in-network providers available or if provider failed to provide proper disclosures
- Currently restricted for HMO & EPO emergency services
- In emergency or inadequate network situations, PPOs and EPOs are required to pay at least the usual and customary charge for services (28 Tex. Admin. Code 3.3708.)