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Understanding CT's "SURPRISE BILL" HEALTHCARE LAW 7/1/16
What you need to know before receiving healthcare services!
New CT Healthcare Law Took Effect on 7/1/16
CT Public Act No. 15-146
AN ACT CONCERNING HOSPITALS, INSURERS AND HEALTH CARE CONSUMERS.
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CT passed a new law in 2015, which took effect on July 1, 2016.
This new law includes a number of provisions that will affect hospitals and health systems, health care providers, and health carriers.
Find out what's happening in Greenwichfor free with the latest updates from Patch.
The new law focuses on increased transparency regarding the price of medical care, restrictions on facility fees, the establishment of a statewide health information exchange, changes to the Certificate of Need approval process related to hospital sales, as well as several other changes regarding health care providers.
The statute of this new law, that I would like to focus on in this article is referred to as the “Surprise Bill”.
Before I discuss this new “Surprise Bill” law, I would like to provide a basic overview of the difference between the medical insurance terms In-Network and Out-of-Network.
IN-NETWORK vs. OUT-OF-NETWORK
When you selected your insurance company and read your policy, you most likely saw a section on “In-Network” and “Out-of-Network”.
How do these two networks affect your coverage, and how much you will have to pay out of pocket?
IN-NETWORK
A health insurance company compiles a group of doctors, hospitals, surgery centers, and other healthcare providers who have contracted with your insurance company; to provide their services at a pre-negotiated price.
These particular healthcare providers are referred to as your “Network”.
Your network providers have agreed with your insurance company to accept a contracted rate of reimbursement for services rendered. This fee includes how much the provider will receive from your insurance company, plus how much you as the patient are responsible to pay out of pocket for your co-pay and deductible.
An example:
Your doctor determines that you need a medical procedure.
You have already met your $2500 individual deductible for the year.
The cost for your medical procedure is $1000.
You have a $40 co-pay for this service which you are responsible to pay, and your insurance company pays the remaining pre-agreed upon cost with the medical provider.
OUT-OF-NETWORK
The term “Out-of-Network” refers to doctors, hospitals, surgery centers, and other healthcare providers whom have not contracted with your insurance company, and therefore they have not agreed to provide their services at a pre-negotiated reduced price.
These providers are considered to be Out-of-Network, and in most cases you will pay more money out of pocket to see an Out-of-Network healthcare provider.
PA # 15-146 - “SURPRISE BILL”
In recent years, it’s become all too common for a patient to verify that a healthcare provider is In-Network before receiving services, only to later discover that they were actually treated by an Out-of-Network provider.
The end result is a surprise bill, and higher costs.
HEALTHCARE PROVIDERS
The new “Surprise Bill” law is designed to protect patients from unexpected charges that may occur, when a patient goes to an In-Network facility for services, and unknowing is treated by an Out-of-Network provider.
Effective July 1, 2016 if a patient receives a “surprise bill” from a health insurer for Out-of-Network services provided at an In-Network facility - the patient will only be responsible to pay the co-insurance, co-payment, deductible, or other out of pocket expense that would apply - if the services had been provided by an In-Network provider.
This law defines surprise bill, as “A bill for health care services, other than emergency services, received by an insured for services rendered by an Out-of-Network health care provider, where such services were rendered by such Out-of-Network provider at an In-Network facility during a service or procedure performed by an In-Network provider or during a service or procedure previously approved or authorized by the health carrier and the insured did not knowingly elect to obtain such services from such Out-of-Network provider.”
It’s Important to Note:
The term “surprise bill” does not include emergency services or services that the patient knowingly elected to receive from an Out-of-Network provider, and for which an In-Network provider was available.
EMERGENCY SERVICES
In respect to emergency services, PA # 15-146 requires that when emergency services for a patient are provided by an Out-of-Network provider, the provider can only require a patient to pay the equivalent of what the patient would be charged at their In-Network rate.
In other words, the Out-of-Network provider may only charge the patient:
- The same coinsurance, copayment, deductible or other out-of-pocket expense that the patient would have been charged had s/he been seen by an In-Network health care provider
- The same fee that Medicare reimburses for those services
- The standard customary and reasonable rate for the provided services
It’s Important to Note:
The term “surprise bill” does not include emergency services or services that the patient knowingly elected to receive from an Out-of-Network provider and for which an In-Network provider was available.
UNFAIR TRADE PRACTICE
Under the new “Surprise Bill” law, if a healthcare provider provides a surprise bill to a patient in excess of the patient’s legal obligation without the words “This is not a bill” printed on the statement; then the health care provider’s actions constitute unfair trade practices under the Connecticut Unfair Trade Practices Act.
Source: Public Act No. 15-146 “An Act Concerning Hospitals, Insurers and Health Care Consumers”
If you would like to read the complete Public Act No. Health Care - An Act Concerning Hospitals, Insurers and Health Care Consumers visit:
https://www.cga.ct.gov/2015/act/pa/pdf/2015PA-00146-R00SB-00811-PA.pdf
OFFICE OF THE CT HEALTHCARE ADVOCATE
Help is just a phone call away!
According to the Office of Healthcare Advocate’s website:
“The Office of the Healthcare Advocate can assist Connecticut residents with their healthcare coverage.
If you have questions about enrollment into healthcare coverage, need to understand the referral or pre-authorization process or need assistance with the appeal/grievance procedures, we are here to help!”
When to Contact Us
- If you’re not sure who to call to help you with a healthcare enrollment or coverage situation.
- If you need specific explanations about a benefit, program or coverage definition.
- If you want an assessment of the plans offered in Connecticut.
- If you want to review your rights and responsibilities as a healthcare plan member.
- If you want to better understand the referral and pre-authorization procedures required by your plan.
- If you need assistance with your plan’s internal and external appeals processes.
Office of the Healthcare Advocate
P.O. Box 1543
Hartford, CT 06144
http://ct.gov/oha/cwp/view.asp?a=4363&q=518588
866-466-4446
Fax: 860-331-2499
Source: Office of the CT Healthcare Advocate
Photo from Microsoft
The information in this article is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be patient education, does not create any patient provider relationship, and should not be used as a substitute for professional diagnosis and treatment.
Please consult your health care provider for an appointment, before making any healthcare decisions or for guidance about a specific medical condition.
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Linda Ziac is the owner and founder of The Caregiver Resource Center. The Caregiver Resource Center is a division of Employee Assistance Professionals, Inc. which Linda founded in October 1990. The Caregiver Resource Center provides a spectrum of concierge case management and advocacy services for seniors, people with special needs and families.
Linda’s professional career spans more than 40 years in the health and mental health field as a CT Licensed Professional Counselor, CT Licensed Alcohol and Drug Counselor, Board Certified Employee Assistance Professional, Board Certified Case Manager, and Board Certified Dementia Practitioner. In addition, Ms. Ziac has 15 years of experience coordinating care for her own parents.
Linda assists seniors, people with special needs and their families; in planning for and implementing ways to allow for the greatest degree of health, safety, independence, and quality of life. Linda meets with individuals and family members to assess their needs, and develop a Care Team, while working with members of the Team to formulate a comprehensive Care Plan (a road map). Once a plan is in place, Linda is available to serve as the point person to monitor
and coordinate services, and revise the plan as needed. This role is similar to the conductor of an orchestra; ensuring that there is good communication, teamwork, and that everyone remains focused on the desired goal.
