Health insurance companies may soon be required to cover out-of-network doctor’s visits at no additional cost to patients if no in-network physician is readily accessible under a new proposal put forward by Assemblywoman Ellen Spiegel.
Spiegel’s bill, introduced into the Assembly on Monday, would allow patients to seek care from a provider outside of their health insurance network if they were unable to make an appointment with an in-network doctor within 25 miles of their residence and within 30 days of requesting to be seen. In a brief interview, the Democratic assemblywoman said she introduced the bill to address the increasing prevalence of narrow health insurance networks where patients are only given a select roster of physicians they can see.
“One of the things that’s been going on, that we’ve been noticing anecdotally, is that networks are narrowing,” Spiegel said. “That made it, in my mind, vital that we ensure we have network adequacy for people.”
Nationwide, health insurance networks have narrowed as insurance companies seek to offer lower cost plans to patients but with limited flexibility. The Legislature’s interim health committee discussed the issue of narrow networks over the summer, with the state medical association arguing that narrow networks cut costs but at the expense of patients’ ability to actually access care.
Spiegel pointed to the growing number of so-called EPO, or exclusive provider organization, plans that offer no out-of-network coverage compared to PPO, preferred provider organization, plans that encourage patients to stay in-network with lower copays but also offer out-of-network coverage at higher rates. She said patients on EPO plans have expressed increased difficulty in securing an appointment with one of their plan’s approved providers.
“From my perspective, if you can’t get an appointment it doesn’t matter how many providers are in the directory,” Spiegel said. “This bill is designed to give relief to patients without, from my perspective, without unduly burdening insurance companies.”
If approved, the legislation, AB170, would give insurance companies one business day to assist a patient in making an appointment with an in-network provider and, if they’re unable to, would require them to cover the cost of an out-of-network doctor’s visit at the same price the patient would have paid to see an in-network one.
“We’re not penalizing them, but we are making them deliver what they are promising to people who are paying premiums, which is coverage,” Spiegel said.
The bill also would require the out-of-network provider to collect the patient’s normal copay and then bill the insurance company for the balance of the service. If a health insurance company fails to pay the bill within 30 days, it would be required to pay the amount billed plus interest, as well as any costs the provider incurs in trying to collect the amount due.
The legislation also would allow a patient to refuse to pay any remaining bill received from his or her insurance company for the out-of-network service and take the matter to court.
The health insurance trade association, America’s Health Insurance Plans, and the Nevada State Medical Association, which represents the state’s medical doctors, had not yet taken positions on the bill as of Tuesday.
Spiegel also introduced a separate bill on Monday, AB185, that would require health insurance companies to apply any cash price a patient pays for a prescription instead of using his or her health insurance coverage to his or her deductible. She said the idea came out of a National Council of Insurance Legislators event she attended last summer during which similar legislation from Colorado was discussed.
“Sometimes people’s copays are extremely high and sometimes it is less expensive for them to pay the cash price than to put it though their insurance,” Spiegel said. “In that case especially, they’re self insuring and they should be getting some benefit from that.”
No hearings have yet been scheduled on either bill, which have both been referred to the Assembly Commerce and Labor Committee.