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Reform by the Numbers

An RWJF Collection

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Balance Billing: How Are States Protecting Consumers from Unexpected Charges?

How seven states (California, Colorado, Florida, Maryland, New Mexico, New York, and Texas) have approached protecting consumers from certain types of balance billing.

States have varying policies—some have none at all—to protect consumers from unexpected bills sent by hospitals, doctors, or clinics for an amount beyond what the consumer’s insurance covers, also known as balance billing.

The Issue

This analysis shows what select states are and are not doing to protect consumers from balance bills, and details instances when patients take the necessary precautions to visit a doctor or hospital that is covered by their insurance, only to have a specialist consulted during the visit who is not in the provider network of the patient’s insurance plan.

Key Findings

States primarily use four types of protections to help consumers with balance billing. However, the seven study states either use all or a combination of these strategies, or do not implement these protection strategies at all:

  • Increase levels of transparency in health insurance plan benefits and which doctors and hospitals are covered;

  • Provide a process for establishing fair payment rate from insurers to the providers billing in these situations;

  • Require insurance companies to cover the difference between the amount a consumer is charged and what the insurance company has agreed to pay; or

  • Ban balance billing altogether.  

Conclusion

The authors note that consumers share responsibility in avoiding balance billing. For example, the authors recommend that consumers, when possible, should make sure the hospital or doctor they are about to visit is in their plan's network and understand what services their insurance plan covers before seeking treatment, among other steps consumers can take to protect themselves. If consumers do receive balance bills, they should contact their doctor, insurer, and state insurance department to see if remedies are available.

About the Grantee

The Center on Health Insurance Reforms at Georgetown University’s Health Policy Institute is a nonpartisan, expert team of faculty and staff dedicated to conducting research on the complex and developing relationship between state and federal oversight of health insurance markets.

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Infographic

How to Protect Patients from Unexpected Medical Bills

How to Protect Patients from Unexpected Medical Bills

What can states do for patients, and what can patients do for themselves, to protect against balance billing?

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