Ohio’s Surprise Billing Law – Impact on Health Plans
Ohio’s Surprise Billing Law, R.C. § 3902.51, became effective January 12, 2022, but its impact on health plans is still evolving. The law strives to prevent patients from receiving and paying surprise medical bills, specifically those stemming from unanticipated out-of-network care. While the Ohio Surprise Billing Law intends to shield insureds from surprise medical costs, health plans and insurers may end up paying these costs in some instances. These additional costs are expected, at least in large part, to be ultimately borne by employers through increased reimbursement rates and higher premiums.
Under the Ohio Surprise Billing Law, cost-sharing amounts – such as coinsurance, copayments, and deductibles – are limited to the patient’s in-network amounts. However, the Ohio law also mandates that applicable health plans must reimburse certain providers for emergency out-of-network care at the highest of three statutory rates unless independently negotiated.
In addition, the law outlines procedures for rate calculation and rate negotiation between insurers and health care providers or facilities for out-of-network services rendered. Providers and payors may resolve disputed rates through arbitration. The Ohio Department of Insurance (ODI) is charged with administering and enforcing the Ohio law, which applies to certain health plans, insurance companies, multiple employer welfare arrangements, non-federal governmental health plans, and other entities subject to the jurisdiction of the ODI. The ODI’s Administrative Rule governing reimbursement for unanticipated out-of-network care details the process for determining reimbursement rates and for resolving disputes between health plan issuers and providers.
The Ohio Surprise Billing Law would require insurers to reimburse medical providers for these expenses:
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An out-of-network provider for unanticipated out-of-network* care provided at an in-network facility;
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An out-of-network provider or emergency facility for emergency services provided at an out-of-network emergency facility;
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An out-of-network ambulance for emergency services provided in an out-of-network ambulance;
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An out-of-network provider or facility for clinical laboratory services provided in connection with unanticipated out-of-network care or emergency services.
* “Unanticipated out-of-network care” means health care services, including clinical laboratory services, that are provided under a health benefit plan and that are provided by an out-of-network provider when either of the following applies:
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The covered person was unable to request such services from an in-network provider.
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The services provided were emergency services.
R.C. § 3902.50
Ohio’s law is similar to the No Surprises Act: a federal surprise billing law that became effective January 1, 2022, raising questions of federal preemption. The federal version of the No Surprises Act is enforceable against self-funded health plans subject to ERISA and individual plans purchased directly or through the Health Insurance Marketplace. The Ohio law, however, is enforced by the ODI and only against health plans and other entities and arrangements regulated by the ODI.
