Understanding State Balance Billing Laws

State balance billing laws aim to protect consumers from surprise medical bills. These laws vary by state, but most require out-of-network providers to give patients an estimate of costs before treatment.

In some states, like New York and New Jersey, balance billing is banned altogether, while others, like California, have more limited protections. This means patients in different states face different levels of financial risk.

The goal of these laws is to prevent medical debt from piling up due to unexpected bills. By providing clear estimates and limiting surprise charges, state balance billing laws help patients plan for their care and avoid financial shock.

Illinois has a law that protects you from balance billing for certain services provided by out-of-network providers at in-network hospitals or ambulatory surgical centers.

You don't have to give up your protections from balance billing and you're not required to get care out-of-network. You can choose a provider or facility in your plan's network.

State and federal laws apply to all health plans, including state-regulated health plans, state and school employee benefit plans, and self-funded group health plans.

Some self-funded group health plans offer additional protections to their members under state law and have notified the relevant authorities.

State balance billing laws are designed to protect consumers from surprise medical bills. This includes laws passed under the "Surprise Billing Consumer Protection Act", which aims to provide a mechanism to resolve billing and payment disputes between insurers and out-of-network providers.

The Regulation applies only to "healthcare plans" and "state healthcare plans", as defined in the Regulation. This means that not all healthcare plans are covered under this law.

A surprise bill occurs when a medical provider or facility is not contracted with your health insurer, even if they provide services at a hospital or facility that is in your health plan's provider network. This can happen in emergency situations or when you receive care from an out-of-network provider at an in-network facility.

Here are some key definitions and regulations to keep in mind:

Surprise billing laws are in place to protect consumers from unexpected medical bills. The Surprise Billing Consumer Protection Act is the foundation for these regulations.

This Regulation, as stated in Rule 120-2-106-.02, is made to provide a mechanism to resolve billing and payment disputes between insurers and out-of-network providers. It establishes a fair and equitable arbitration process to handle such disputes.

The Regulation applies only to "healthcare plans" and "state healthcare plans", as defined in this Regulation. It's essential to note that nothing in this Regulation reduces a covered person's financial responsibilities concerning ground ambulance transportation.

In Washington state, surprise billing protections apply to all state-regulated health plans, state and school employee benefit plans, and self-funded group health plans. Some self-funded group health plans have also opted to follow Washington's Balance Billing Protection Act.

To determine if an enrollee is subject to Washington's Balance Billing Protection Billing law, health insurers must have a process in place to explore claim payments in the All Payer Claims Database and learn about the arbitration process.

Definitions are the foundation of understanding any regulation, and Rule 120-2-106-.03 is no exception. It defines key terms that will be used throughout the regulations.

The term "applicant" is defined as an individual or organization seeking approval for a project. This is crucial to know, especially if you're planning to submit a proposal.

A "project" is defined as any activity, operation, or undertaking that requires approval. This is a broad term, but it helps to clarify what types of activities are subject to regulation.

The term "approval" refers to the formal authorization granted by the regulatory agency to proceed with a project. This is the ultimate goal of any applicant.

A "regulatory agency" is defined as the government entity responsible for overseeing and enforcing the regulations. In this case, it's the agency that will review and approve or deny your project proposal.

The Claims Database is a valuable resource for healthcare providers and facilities. It's a database that contains information on payments for similar services in a similar geographic area.

Pursuant to O.C.G.A 33-20E-8(a), appropriations for an all claims database were not provided, which means the Department will utilize a verifiable median contracted amount paid by all eligible insurers for similar services.

This median contracted amount is calculated by a vendor chosen by the Commissioner. The data is used to help determine a commercially reasonable amount for services under the Balance Billing Protection Act.

The Balance Billing Protection Act requires that the amount paid to a provider or facility be based on payments for the same or similar services in a similar geographic area. This ensures that providers and facilities are fairly compensated for their services.

The all payer claims database is also used to help negotiate a reasonable payment amount between health plans and providers or facilities. If the parties cannot agree, they can access the data set to inform their decisions.

The database includes the median in-network, out-of-network, and billed charges for services covered under law. This information can be accessed by arbitrators to inform their decisions in disputes between health plans and providers or facilities.

Under the Covered Benefits Provision, healthcare plans cannot deny or restrict benefits from a participating provider solely because the covered person obtained treatment from a non-participating provider, leading to a balance bill.

This protection is designed to safeguard consumers from surprise medical bills.

Notice of such protection must be provided in writing to the covered person by the insurer.

A covered person's financial responsibilities are not reduced if they choose to receive non-emergency medical services from an out-of-network provider.

However, this choice must be documented through written and oral consent in advance of the provision of services, and the covered person must be provided with an estimate of the potential charges.

If a covered person requests a referral to another provider during non-emergency medical services, the referred provider may be exempt from these requirements if certain conditions are met.

These conditions include advising the covered person that the referred provider may be a non-participating provider and may charge higher fees than a participating provider, and obtaining the covered person's written and oral acknowledgment of this information.

The written acknowledgment must be on a separate document and include language determined by the Commissioner.

The referring provider must also record the satisfaction of these requirements in the covered person's medical file.

Here is a summary of the Covered Benefits Provision: