California medical consumers will enjoy strong new protection against surprise out-of-network medical bills..………..
Passage of California surprise-bill legislation could spur other states to act
By Harris Meyer | September 1, 2016
California medical consumers will enjoy strong new protection against surprise out-of-network medical bills starting next July, under a hard-fought bill overwhelmingly approved by the state legislature this week. It’s widely expected that Democratic Gov. Jerry Brown will sign it.
Under the bipartisan bill, AB 72 (PDF), authored by Democratic Assemblyman Rob Bonta, patients who received care in in-network facilities would have to pay only in-network cost sharing. This would apply just to non-emergency care, since emergency physicians in California already are barred from balance billing patients. The bill’s provisions would not apply, however, to self-insured employer health plans, which are shielded from state regulations by the federal Employee Retirement Income Security Act.
Health plans would pay non-contracting physicians the plan’s average contracted rate or 125% of the Medicare rate, whichever is greater. Doctors could appeal that through a binding independent dispute resolution process, which the state Department of Managed Health Care will establish.
The bill, passed by the General Assembly on the last day of the legislative session after months of tough negotiations, also tightens requirements on health plans to offer adequate provider networks. A similar bill that would have paid out-of-network doctors 100% of Medicare rates failed last year.
Florida enacted a similar law this year, joining New York, while Georgia and other states are studying the issue or considering legislation. Observers predicted the bipartisan passage of the California law would boost legislative efforts in other states.
A recent Consumers Union survey found that one-quarter of Californians who had hospital visits or surgery in the past two years were charged an out-of-network rate when they thought their provider was in-network.
Insurers and other payers faced pressure to come up with a legislative solution because shocker out-of-network bills have undermined public support for narrow-network health plans, which have become a primary method of keeping premiums affordable. But physician groups continued to hold out for freedom to refuse to join networks and balance bill when they think plans aren’t offering adequate rates.
Earlier this week, the California Medical Association adopted a neutral rather than an adversarial position on the bill while still expressing concerns about whether it would reduce patients’ access to physician services. Groups representing plastic surgeons, cardiologists and anesthesiologists strongly opposed the bill. The California Hospital Association and the California Association of Health Plans did not declare a position.
“We understand that these are some of strongest consumer protections in nation,” said Anthony Wright, executive director of Health Access California, which pushed for the bill.
Wright said there was an urgent need for this consumer protection because more lower-income people are buying insurance and they can’t afford a large unexpected bill. “A surprise medical bill is not just an injustice but it’s financial destabilizing,” he said. “If you’re making $30,000 or $40,000 a year, a surprise bill of $2,000 is next month’s rent.”
FROM A HEALTH CARE REVOLUTIONARY
However, according to Modern Healthcare: “The bill’s provisions would not apply, however, to self-insured employer health plans, which are shielded from state regulations by the federal Employee Retirement Income Security Act.”
Not sure if that is an authoritative pronouncement as it may just be based on Modern Healthcare’s analysis. I have looked at the text of the bill.
FROM A PHYSICIAN & FELLOW HEALTH CARE REVOLUTIONARY
Yes, it would only apply to health plans subject to CA law….This law and others in NY and FL address the health plan member who goes to a hospital or other facility in their health plan’s network and inadvertently receives care from individual physicians who are not in the health plan’s network. So I don’t think it would apply to an RBR plan since there is no network, even if the plan was subject to state law.
This is the age-old problem of independent physician practices who have exclusive contracts with hospitals and other facilities to provide facility based services (radiology, pathology, anesthesia, neonatology, etc.) but who are not “controlled” by the hospital/facility and refuse to contract with health plans. In the “old days”, health plans were sometimes forced to pay their billed charges whenever the hospital/facility was in network because the member had no ability to choose an in network provider.
I think most health plans now have language that limits their liability regardless of the out of network physician’s charge. This law is essentially defining the amount that an out of network provider can charge, but only in the specific circumstance when the hospital/facility is in the member’s health plan network. It would not apply when the member chooses to use an out of network hospital/facility.
I think it could have broader impact because it defines its specified reimbursement levels as “fair” and could conceivably lend support for others who adopt the same standards….