Surprise Billing Dataset Review

October 9, 2019

Agenda

• Balance Billing Protection Act - Overview Jane Beyer, OIC

• Surprise Billing Dataset – Statutory requirements Thea Mounts, OFM

• Surprise Billing Dataset - Specifications Onpoint Health Data

• Surprise Billing Dataset – Overview Onpoint Health Data

• Questions?

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Balance Billing Protection Act

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Balance Billing Protection Act

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• Chapter 48.49 RCW

• Chap. 427, Laws of 2019/2SHB 1065

• Proposed rules filed on October 2, 2019

Balance Billing Protection Act

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Starting January 1, 2020 surprise billing is prohibited for:

• Emergency services, and

• Non-emergency inpatient and outpatient ‘surgical and ancillary services’ provided by an out-of-network provider at an in-network hospital or outpatient surgical center.

• ‘Surgical and ancillary services’ include: surgery, anesthesiology, pathology, radiology, laboratory and hospitalist services.

Balance Billing Protection Act

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When surprise billing is not allowed, the following protections also apply:

• Insurers must pay out-of-network providers and facilities directly.

• Cost-sharing must be based on what an in-network provider would be paid, and the explanation of benefits must show how much is the patient’s responsibility.

• Any amount the patient pays must be applied to their deductible and out-of-pocket limit.

• A provider must refund, within 30 business days, any amount the patient overpaid an out-of-network provider.

• No provider, hospital or outpatient surgical facility can ask a patient to limit or give up these rights.

Balance Billing Protection Act

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Who does the Act apply to?• Fully-insured health plans sold in Washington state (as defined in RCW 48.43.005) –

Includes plans sold through the Exchange

• Washington state employee health plan (PEBB) and new Washington state school employee health plan (SEBB)

• Self-funded group health plans that ‘opt-in’ to certain parts of the Act.

Surprise Billing Dataset

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Second Substitute House Bill 1065, Section 26

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Second Substitute House Bill 1065, Section 26

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Second Substitute House Bill 1065, Section 26

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Second Substitute House Bill 1065, Section 6

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Summary of Key Components• The data set must provide the amounts for these services:

• Emergency services

• Nonemergency services provided at an in-network hospital or in-network ambulatory surgical facility if the services (a) involve surgical or ancillary services and (b) are provided by out-of-network providers.

• Most recently available full calendar year of data

• Commercial fee-for-service data, excludes Medicaid and Medicare

• Median in-network and out-of-network allowed amounts, and median billed charges

• By geographic area

• Update annually using CPI-M

Surprise Billing Specifications

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Geographic Rating Regions

Overview of Surprise Billing Dataset

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Questions?

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