in which the hospital is a participating provider.
Hospitals also are required to post on their websites
and provide to patients at the time of registration
or admission the names and contact information of
the anesthesiology, pathology, and radiology services
with which they have contracted; the names of the
physicians employed by the hospital and whose services may be provided at the hospital and the health
care plans in which they participate; and a statement
informing the patient that a physician who provides
services in the hospital may be out-of-network and
that they should check with their physician to determine if that is the case.
•Imposes new disclosure requirements on physicians,
hospitals, and insurers to help make medical billing
more transparent and to alleviate and reduce surprise bills. Insurers and hospitals must, upon request,
indicate the anticipated fee that a nonparticipating physician will charge the patient for scheduled services.
•Requires all insurance plans, not just health maintenance organizations (HMOs), to have adequate
networks. Patients enrolled in all health insurance
plans have the right to receive treatment from a
specialist who is appropriately qualified to treat a
patient’s particular condition at no additional cost to
the patient if the network fails to include providers of
that specialty.
•Makes all bills for emergency care and other surprise
bills for care by nonparticipating physicians subject
to an independent dispute resolution process after an
insurer makes an initial reasonable payment for such
care. 2
In 2015, Connecticut’s legislature also enacted
a comprehensive health care bill addressing issues
including transparency and surprise billing. Key elements of this legislation are as follows: 3
•Health insurers are required to provide the state’s
health insurance exchange with information on how
much they pay for the most common types of care.
• When nonemergency care is scheduled in a hospital, the
hospital must let the patient know they have the right
to request cost and quality information; such requests
must be answered in three days.
• Health care providers must let nonemergency uninsured
patients know how much their care will cost.
•Insurers must provide customers with a website and
toll-free phone number to access information on cost of
care, including out-of-pocket expenses, data on quality
measures, and providers accepting new patients; provider directories must be updated at least once a month,
and insurers must notify customers in writing within
30 days when a provider opts out of the health plan.
•Insurers are required to pay for emergency services at
in-net work rates to out-of-network providers; in surprise
billing situations, patients pay whatever they would for
an in-network provider, and the insurer reimburses at
the in-network rate.
Earlier this year, Florida Gov. Rick Scott (R) signed
legislation pertaining to surprise billing in emergency
situations. H.B. 221, chapter number 2016-222, creates
a dispute resolution program, requires hospitals to
post on their websites all of the health insurers and
HMOs with which the hospital contracts as a network/
participating provider, and requires insurers to provide
coverage for emergency services and to pay nonparticipating providers of covered emergency services
in accordance with the terms of the health insurance
policy. It also mandates that online provider directories
be updated by insurers at least once a month. 4
National Association of
Insurance Commissioners
One factor that will drive the network adequacy
and surprise billing debate in state legislatures is the
National Association of Insurance Commissioners
(NAIC) updated state model bill. The Health Benefit Plan Network Access and Adequacy Model Act is
intended to establish standards for the creation and
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