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Monday, 11 June 2018 15:41

Colorado Among States with Protections Against Balance Billing

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When consumers need to access emergency health care services, they usually do not have the time nor presence of mind to determine whether a provider treating them is in-network or not. When those emergencies expose them to out-of-network providers, the provider or facility may “balance bill” the consumer for amounts beyond what the insurer paid. This out-of-network balance billing can create financial burdens and undermine the consumer’s confidence that health insurance will protect them from financial hardship.

With no federal protections in place against balance billing, some states have stepped in to protect consumers. Some completely prohibit balance billing by providers, others require insurers to hold enrollees harmless from balance-billing charges by paying the entire charge if necessary, and some do both. Six of the states (California, Connecticut, Florida, Illinois, Maryland, and New York) have a comprehensive plan in place to protect consumers. Colorado is one state that limits protections to emergency department settings, non-emergency care in network hospitals, and certain HMO and PPO plans. Twenty-nine states and the District of Columbia have no laws or regulations to protect consumers from balance billing by out-of-network providers working in emergency rooms.

See Exhibit 1 (map) and Exhibit 2 (chart) in this article to see which states have some type of consumer protection.

The ACA requires all health plans to cover emergency care “without regard to whether the healthcare provider furnishing the emergency services is a participating network provider with respect to the services.” Therefore, any health plan that doesn’t cover out-of-network care will make an exception for emergency care.

Colorado has what is known as “hold harmless” protection, which states that consumers are not liable for out-of-network provider balance billing when services are received at an in-network facility.  However, if the facility is out-of-network, balance billing is generally not prohibited even in the case of an emergency. In other words, a provider can send a bill, but the patient does not have to pay it. As a result, some patients get provider bills and blindly send in payment because they don’t understand that they are not liable to pay it. Some providers send balance bills in the hope that patients will complain to their insurer or state insurance department. As you can imagine, this is very confusing for patients.

State and/or Federal action is needed to protect American consumers and limit their financial risk. A Federal solution might accomplish more, since most individuals with private insurance are in employer-sponsored self-insured plans, which are regulated primarily under Federal law.

Employers can empower employees to reach out to their insurance carrier (or call their Fall River Account Manager) if they have any questions on how a claim was processed, or if an unexpected invoice was received. Until there is legislative action to protect consumers against balance billing in emergency situations, they have to be their own advocate.


Read 1283 times Last modified on Wednesday, 27 June 2018 16:16
Juliet Fitzgibbons

Juliet joins Fall River as an Account Executive and brings over 15 years of prior broker and account management experience. Her experience brings extensive knowledge on employee benefit programs, account management and creative cost-saving strategies and compliance solutions for employers of various sizes.

She is responsible for new business proposals, client renewals including plan benchmarking, rate analysis and mid-year reviews. She helps clients navigate healthcare systems and educates employers and employees through open enrollment meetings and day-to-day service requests. Juliet joined Fall River in 2015.