On May 20, 2020, the Ohio House of Representatives unanimously passed House Bill 388, which would enact five new Ohio Revised Code sections regarding out-of-network care and reimbursement. Sponsored by Representative Adam Holes – District 97 – House Bill 388 would require a health plan issuer to reimburse the following:
- An out-of-network provider for unanticipated out-of-network care provided at an in-network facility.
- An out-of-network provider or emergency facility for emergency services provided at an out-of-network emergency facility.
- An out-of-network ambulance for emergency services provided in an out-of-network ambulance.
- An out-of-network provider or facility for clinical laboratory services provided in connection with unanticipated out-of-network care or emergency services.
As used above, "unanticipated out-of-network care" means health care services, including clinical laboratory services, that are covered under a health benefit plan and that are provided by an out-of-network provider when either of the following conditions applies: (1) the covered person did not have the ability to request such services from an in-network provider; or (2) the services provided were emergency services.
In addition to the above requirements, House Bill 388 also sets forth the following:
- Prohibits a provider, facility, emergency facility, or ambulance from balance billing a patient for unanticipated or emergency care when that care is provided in Ohio.
- Provides that a covered person’s cost-sharing responsibility for the services described above cannot be greater than if the services were provided in network.
- Establishes the default reimbursement rate as the greatest of the in-network rate, the out-of-network rate, or the Medicare rate and establishes procedures by which payees (providers, facilities, emergency facilities, and ambulances) may seek to negotiate the reimbursement in lieu of the default reimbursement rate.
- Permits certain payees to seek arbitration if negotiation is unsuccessful, and establishes criteria to be eligible for arbitration, and establishes procedures for the conduct of the arbitration. (Requires the Superintendent of Insurance to select an arbitration entity to conduct arbitrations under the bill using specified criteria).
- Requires a provider to disclose certain information to patients regarding the cost of out-of-network services that are not unanticipated out-of-network care or emergency services.
The requirements found in House Bill 388 would be effective nine months following the bill’s effective date. Any payee or issuer in violation of these requirements would face disciplinary actions and/or penalties. The bill now continues the rule making path and will be debated and voted on by the Ohio Senate.
Please contact a BMD healthcare attorney if you have any questions regarding House Bill 388, any other reimbursement question, or other general healthcare questions.