One change that some industry analysts expect to see in 2020 is the enactment of Surprise Medical Billing (SMB) legislation. The initial expectation was May 22. But now, that date has been pushed to November 22.
So, why November and not May?
One reason is that Congress failed to get legislation through in 2019 as they were still actively debating the issue and consensus still has not been reached. Another reason is that SMB brings in a lot of money that Congress uses to pay for other legislative priorities, including a series of temporary provisions known as ‘health care extenders.’ At the end of last year, Congress temporarily extended these ‘health care extenders’ to May 22, with the intention of using SMB to pay for the long-term extension of these provisions come May 22.
For this reason, many industry analysts expected to see a health care-related package enacted by May 22 that extended the ‘health care extenders’ and also included SMB legislation.
Well, in one of the recent stimulus packages, Congress temporarily extended the ‘health care extenders’ yet again – without SMB legislation – now to November 22. So, in line with the thinking discussed above, most analysts think November 22 is the new date for action on SMB.
Having said that though, there is talk about including SMB in an upcoming 4th or possibly a 5th stimulus package that Congress will likely consider as federal and state governments continue to respond to the national emergency of COVID-19.
If SMB legislation is ever passed, this legislation will determine who is responsible for the cost of out-of-network billing.
In a recent webinar, health care policy expert Chris Condeluci set out two possible formats for this legislation that we could see passed in the coming weeks.
- Arbitration only; or
- A tiered approach, along the lines of using the median in-network rate for medical services in a geographic area for health claims up to $750; and arbitration for health claims above $750.
Condeluci also noted there could be provisions for a private-equity “carve-out,” as well as possible exceptions for small health plans.
Other possible changes in 2020 could include:
- Grassley-Wyden drug pricing legislation, which could affect the private insurance market. More information about the bill can be found here.
- Transparency provisions in the Senate HELP’s Lowering Health Care Costs Act.
Condeluci explains that he believes it is unlikely that either of these proposals will be enacted before the November elections; however, both legislative changes are being actively discussed and considered, so they could be on the table in a “lame duck” session after the election.
Regulatory Changes: It’s All About Transparency
For 2019 and 2020, transparency is the name of the game when it comes to regulatory changes. Before Thanksgiving, the Trump administration issued two sets of transparency-related regulations:
1) Final HHS regulations requiring hospitals to publicly disclose the prices of up to 300 “shoppable” medical items and services on a public website.
In this context, a shoppable item is a non-emergency medical procedure that is known about in advance such as a hip replacement. This legislation is intended to help patients, researchers and regulators make informed decisions about care.
The provider community quickly filed a lawsuit to invalidate the new regulations; however, unless the regulations are legally invalidated, they will remain in effect.
2) Proposed HHS regulations requiring insurance carriers and self-insured plans to disclose information about:
- Specific cost-sharing liability information for plan and policy holders.
- The health plan/policy’s negotiated in-network rates.
- The health plan/policy’s historic payments to out-of-network providers.
Public comments for this regulation were due on January 29, 2020, so the comment period is now over. It’s likely that we’ll see final regulations by September or October of this year.
What Do the HHS Transparency Regulations Mean for Health Plans?
As you can see, there has been a tremendous regulatory push for transparency in health care. The goal behind these changes is to encourage an open health care system where consumers know precisely how much health care items will cost based on their own personal coverage and circumstances.
Of course, reaching that point will require some leg work for health plan providers.
Specifically, insurance carriers and providers of self-insured plans will have to create an online self-service tool that participants can use to determine their cost-sharing liability for any medical item or service. These tools must be participant-specific, so they’ll need to take account of:
- Each individual’s coverage
- Whether the individual has reached their deductible
- The individual’s accumulated amounts
- In-network rates for each medical item or service
- Allowed out-of-network amounts for each item or service
Naturally, creating a tool that can accommodate these requirements may require some significant administrative complexity and effort for plan providers. At the time of writing, it remains to be seen how the Trump administration will react to pushback from the health insurance carrier community.
Watch the on-demand webinar to hear more about the future of health care policy from Chris Condeluci.