Four states — Colorado, New Mexico, Texas, and Washington — began 2020 with new laws governing balance billing, or surprise medical bills.
Surprise bills typically represent charges an insurer did not cover because the patient received care from an out-of-network provider. These new laws seek to protect patients from such unexpected bills.
These four states join the ranks of dozens of other states already enforcing balance-billing laws.
Colorado
In Colorado, H.B. 19-1174 provides comprehensive patient protections for surprise bills stemming from an out-of-network emergency care visit or a nonemergency care visit in an in-network facility during which the patient unknowingly receives care from an out-of-network provider, such as an anesthesiologist. The law:
- prohibits balance billing;
- requires out-of-network emergency payments count toward out-of-pocket maximums;
- sets payment rates for select services;
- provides for an arbitration process for providers who feel they were not adequately reimbursed;
- requires refund of any overpayment if a patient receives and pays a surprise bill; and
- requires patients receive notice of their protections and when facilities can and cannot send them a bill for the balance of their care.
New Mexico
New Mexico’s “Surprise Billing Protection Act” protects patients receiving out-of-network emergency and nonemergency care. The law requires insurers to pay for all out-of-network emergency services necessary to evaluate and stabilize the patient and removes any prior authorization requirements. For nonemergency care, insurers would have to reimburse out-of-network care provided at in-network facilities, not holding the patient liable for balance billing. Further, if medically necessary care is unavailable in the insured patient’s network, insurers are required to pay for the out-of-network services.
The law also requires providers to give notice if they are out-of-network for patients seeking nonemergency care. Patients can be receive a bill if they knowingly seek care from out-of-network providers.
Last, all health care facilities are required by June to post information about patient rights and protections.
Texas
In Texas, S.B. 1264 prohibits balance billing for emergency and nonemergency care received by patients with state-sponsored plans. The law creates an arbitration process for insurers and providers to negotiate reimbursement for out-of-network care. Patients seeking nonemergency care can waive their billing protections as long as they are informed which providers are outside their network; are provided cost estimates; and have a choice between in-network and out-of-network providers.
Washington
Washington’s “Balance Billing Protection Act” prohibits balance billing for patients receiving out-of-network emergency care or out-of-network care in an in-network facility. The law also provides an arbitration process for insurers and providers to settle payment rates for services provided out-of-network. Under the law, patients must receive notice when they can and cannot be billed for the balance of their care. Last, the law requires insurers to pay out-of-network providers a “commercially reasonable amount” based on payments for the same or similar services in a geographic area.
Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.
