Some Oregonians will save tens of thousands of dollars — and in some cases hundreds of thousands of dollars — in medical costs this year under a new federal law.
the law without surprise, which took effect on January 1, prevents insurers from charging customers extra fees for out-of-network providers or services in hospitals. The law applies to emergency care, airlifts to emergency services and hospital care. The law marks a major step forward for consumers and will prevent many people from going deep into medical debt, advocates say.
Healthcare policies set coverage rates, for example, paying 90% for hospital care or $100 for an emergency room visit. Policies also set deductibles, which cap out-of-pocket expenses.
But deductibles generally only apply to network providers who have signed a contract with the insurer, agreeing on rates. Out-of-network providers set their own fees and they are not limited by the deductible, which means patients have to pay significantly more than expected. In recent years, there have been many stories of patients who have been saddled with astronomical bills they weren’t expecting because their insurer charged them extra for out-of-network services, like an anesthesiologist. People had to take out loans to pay the bills, racking up debt. Experts estimate that one in five patients have been hit with a surprise medical bill.
This will no longer happen in hospitals provided that patients are treated in network facilities.
The law applies to emergency rooms, free-standing emergency departments, and urgent care facilities licensed to provide emergency care. It includes emergency and non-emergency care in network hospitals, including surgeries.
The law applies to insurance policies, including renewals, which entered into force this year. They include private employer-sponsored plans – which represent most coverage and plans sold in the federal market. It also applies to the insurance of government employees, teachers and their dependants.
Philip Schmidt, spokesman for the Oregon Health Authority, said the Public Employees’ Benefit Board and the Oregon Educators Benefit Board, which together cover nearly 300,000 people, “will be responsive to member complaints about violations of this new legislation and will work with our plans to ensure these issues are proactively addressed.
In addition to banning out-of-network surcharges, the law requires hospitals to give patients who pay cash a good faith estimate before treatment, which was sometimes difficult to obtain in the past. Suppliers cannot charge more than $400 more than their estimate.
The law does not affect patients covered by Medicaid or Medicare, which already prohibited out-of-network surcharges, a practice known as balanced billing.
There are, however, a few exceptions. The law does not apply to birthing centers, outpatient clinics, hospices, addiction treatment centers, nursing homes or urgent care centers that do not provide emergency care.
He also has another loophole. It does not cover land ambulances. Ten states offer patients some protection against a surprise land ambulance bill — but not Oregon, Washington, Idaho or California.
“It’s still a work in progress,” said Maribeth Guarino, health care advocate for OSPIRG, the Oregon State Public Interest Research Group.
OSPIRG suggests that patients ask, where possible, whether a service or provider is part of the network.
One thing to note: When scheduling treatment in advance, some out-of-network providers may ask patients to sign a “surprise billing protection form.” By signing the document, patients agree to pay the out-of-network fee. The form must include a good faith estimate with detailed costs and is usually provided three days prior to treatment. The form should also include a list of network providers who can provide the same care.
OSPIRG advised patients to think carefully before signing the form. That means they waive protections under the law with no surprises.
Emergency physicians or emergency departments, assistant surgeons, anesthesiologists, radiologists, hospitalists or physicians employed by a hospital and intensivists, who are certified to treat critically ill patients, are not permitted to request patients to sign the waiver.
Patients who believe they have received an incorrect bill should contact the provider and their insurer as soon as possible. They can also file a complaint with the federal Medicare and Medicaid Service Centers or call 800-985-3059.