On October 22, 2020, the Michigan Legislature enacted Enrolled House Bills 4459 and 4460. These rules were enacted to create limitations on out-of-network provider payments, require certain disclosures to patients related to costs of services, and to generally protect patients from balance medical billing. Balance billing occurs when a healthcare provider bills a patient for services for the amount the patient’s insurance company does not pay. The typical example of balance or surprise medical billing occurs when a patient goes to the emergency room at a hospital in the patient’s insurance network. The patient may receive care from multiple physicians and not know which is participating with the patient’s insurance, because hospitals often employ out-of-network physicians, or those that have no relationship with a patient’s health insurance. After the patient’s insurance pays its allowed amount for in-network and out-of-network services, the patient is then billed for the remaining out-of-network balance.
House Bill 4459 limits how much an out-of-network provider can collect in certain situations by implementing fee restrictions. The amount an out-of-network provider can collect from the patient is limited in certain circumstances, including:
- Where the service is provided to an emergency patient, is covered by the emergency patient’s health benefit plan, and is provided by a nonparticipating provider at either a participating health facility or nonparticipating health facility.