All state-regulated health plans and state and school employee health benefits plans are subject to the Balance Billing Protection Act, which protects their enrollees from receiving a balance or surprise bill in certain situations. Self-funded health plans are exempt unless they opt-in to follow the Balance Billing Protection Act.
If a medical provider or facility does not contract with a health plan but provides an enrollee with either emergency services or certain services during a scheduled procedure at an in-network facility, they cannot bill the enrollee. They must bill the health plan directly.
The enrollee’s cost-sharing amount is limited to what it would be if the provider or facility was in the health plan’s network and counts towards their deductible.
How to know if a health plan is subject to the Balance Billing Protection Act
All state-regulated health plans and state and employee benefits plans must follow the Balance Billing Protection Act. Self-funded group health plans are not required to follow state law but can opt-in to protect their enrollees from surprise billing.
The law also requires health insurers to have a way to inform a provider or facility (www.onehealthport.com) if its enrollees are subject to the Balance Billing Protection Act. This process can take place when determining an enrollee's coverage eligibility.
How is the allowed billed amount determined?
The amount a provider or facility is paid under the Balance Billing Protection Act must be a commercially reasonable amount and based on payments for the same or similar services in a similar geographic area.
If the health plan and provider or facility cannot agree on an amount to be paid for the service after 30 days, either party can go to arbitration. Each party pays their own attorney fees and they split the cost of arbitration. The arbitrator will choose one party's best offer.
The parties can access a data set from the All Payer Claims Database to help during the negotiation of a reasonable payment amount. The data set:
- Is based on commercial health insurance claims.
- Includes the median in-network, out-of-network and billed charges for the services covered under the law.
Consumer notice requirements for providers and facilities
Medical providers and facilities must post information (PDF, 125KB) about their provider networks on their websites and provider it to consumers, if asked. They also must:
- Refund consumers any amount they have overpaid within 30 business days.
- Not ask consumers to limit or give up their rights to prevent balance billing.
- Post a notice detailing consumers’ rights (PDF, 125KB) under the Balance Billing Protection Act.
Medical facilities must:
- Provide health insurers they contract with a list of non-employed providers under contract with the facility that provide surgical or ancillary services within 30 days of signing a contract with a health insurer.
- Notify the health insurer within 30 days of a provider’s removal from or addition to the non-employed provider list.
- Respond to a health insurer’s request for an updated provider list within 14 days.
- Medical providers must give accurate and timely information to health insurers about their status in the plan’s network.
How enforcement works
If a provider or facility continues to balance bill a consumer and we see a pattern of unresolved violations of the Balance Billing Protection Act, we will first give the provider or facility a chance to correct its behavior.
If no steps are taken to correct the balance billing, we will consider it unprofessional conduct and will refer the provider or facility to the Department of Health for enforcement.