Ohio advances and South Carolina introduces bills modifying out-of-network provisions.
In Ohio, passed the Senate Committee on Insurance and Financial Institutions. The bill would require carriers to reimburse out-of-network providers for emergency out-of-network care for services provided to an enrollee at an in-network or out-of-network facility.
The reimbursement would be the greatest of the following amounts:
- In-network amount in the geographic region under the issuer.
- Amount for service calculated generally used to determine out-of-network services, such as the usual, customary and reasonable amount.
- Medicare reimbursement fee.
Providers would be prohibited from charging enrollees for the difference between the carrier’s reimbursement and provider’s charge for emergency out-of-network care services. Carriers would be prohibited from charging enrollees at a rate higher than the in-network service rate.
Out-of-network providers at an in-network facility would be permitted to charge the difference between the carrier’s out-of-network reimbursement and provider’s charge if:
- The provider informs the enrollee that the provider is not in-network;
- The provider provides to the enrollee a good faith estimate of the cost of services, including a disclaimer the enrollee is not required to obtain service from that provider; and
- The enrollee consents to receive the services.
In the event of a payment dispute, both parties may request for arbitration to the superintendent of insurance. The non-prevailing party would pay 70% of the fees, and the remaining 30% would be paid by the prevailing party.
In South Carolina, and were pre-filed in the Senate and House, respectively. Both bills would prohibit carriers from charging enrollees a coinsurance, copayment, deductible or other out-of-pocket expense for emergency services, provided by an out-of-network healthcare provider greater than the in-network rate.
In the event an enrollee receives emergency services from an out-of-network provider, the carrier must reimburse the provider the greatest of the following amounts:
- The in-network rate;
- The usual, customary and reasonable rate; or
- The Medicare reimbursement rate.
However, a carrier and out-of-network provider would be permitted to agree on a greater reimbursement amount.
Enrollees would only be required to pay out-of-network providers the applicable coinsurance, copayment, deductible or other expense at the in-network rate.
The Senate bill was referred to the Senate Banking and Insurance Committee while the House bill was referred to the House Committee on Labor, Commerce and Industry.