Draftpriority healthPolicy N/A

Surprise billing protections (Michigan House Bill 4459)

Defines protections against surprise billing for covered persons when nonparticipating providers deliver emergency services or certain nonemergency services at participating facilities; establishes payment standard and prohibition on balance billing and possible fines. Applies to health benefit plans and providers in Michigan.

Policy Summary

Payerpriority health

PolicySurprise billing protections (Michigan House Bill 4459)

Policy CodePolicy N/A

Change TypeMaterial additions (payment benchmark, balance-billing ban, enforcement)

Effective DateN/A

Next Review DateN/A

Key ActionNonparticipating providers must accept 125% of Medicare as payment in full and may not balance-bill patients beyond coinsurance, copayments, or deductibles.

SourceLink

POLICY UPDATE CHANGES

Nonparticipating providers must accept as payment in full 125% of the Medicare rate for covered emergency services and certain nonemergency services provided at participating health facilities when the patient cannot choose a participating provider.

Nonparticipating providers are prohibited from collecting amounts in excess of applicable coinsurance, copayments, or deductibles from the covered person.

The department may impose administrative fines on licensed providers for violations.

125% Medicarepayment standard for nonparticipating providers

0allowed patient balance beyond coinsurance/copay/deductible

emergency + specified nonemergencyservice scope

fines possibleenforcement

When Coverage and Payment Apply

Coverage and payment criteria

When a nonparticipating provider delivers covered services under the specified conditions, the following payment and patient billing rules apply:

Service scope: Covered emergency services provided by a nonparticipating provider at a participating or nonparticipating health facility; OR covered nonemergency services provided by a nonparticipating provider at a participating health facility when the covered person does not have the ability or opportunity to choose a participating provider, or the only provider available at the health facility to perform the service is a nonparticipating provider.

Source defines participating/nonparticipating providers and facilities.

Payment to provider: The nonparticipating provider must accept as payment in full 125% of the amount that would be covered by Medicare for the service in that Medicare fee locality, excluding any in-network coinsurance, copayments, or deductibles.125% of Medicare

Patient billing restriction: The nonparticipating provider shall not collect or attempt to collect from the covered person, directly or indirectly, any excess amount other than applicable coinsurance, copayments, or deductibles.

Policy Summary

Payerpriority health

PolicySurprise billing protections (Michigan House Bill 4459)

Policy CodePolicy N/A

Change TypeMaterial additions (payment benchmark, balance-billing ban, enforcement)

Effective DateN/A

Next Review DateN/A

Key ActionNonparticipating providers must accept 125% of Medicare as payment in full and may not balance-bill patients beyond coinsurance, copayments, or deductibles.

SourceLink

On This Page

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Billing Rules and Provider Obligations

Billing Rule

Payment and balance-billing prohibition — nonparticipating providers

Nonparticipating providers are prohibited from balance billing members beyond the member's applicable cost-sharing. When a covered emergency service is provided by a nonparticipating provider at any facility listed below, or when a covered nonemergency service is provided by a nonparticipating provider at a participating health facility and the member did not have the ability or opportunity to choose a participating provider (or the only provider available to perform the service was nonparticipating), the nonparticipating provider must accept as payment in full 125% of the Medicare rate for the service in the applicable Medicare fee locality (excluding any in‑network coinsurance, copayments, or deductibles). Providers may only collect the member's applicable coinsurance, copayment, or deductible and may not bill or attempt to collect any additional amount from the covered person. Violations may result in administrative fines by the department.

Applies to nonparticipating providers at participating health facilities and nonparticipating health facilities for emergency services
Applies to nonparticipating providers at participating health facilities for nonemergency services when the member could not choose a participating provider or the only provider available was nonparticipating
Payment in full = 125% of the Medicare rate for the service in that Medicare fee locality (excludes in‑network coinsurance/copays/deductibles)
Providers may only collect applicable coinsurance, copayment, or deductible from the member — no additional balance billing permitted
Department may impose administrative fines for violations

Key Terms

inv-05: Covered person — define who is a covered person for this policy

Definition"Covered person" means a policyholder, subscriber, enrollee, or other individual participating in a health benefit plan.

Relationship to planA covered person is someone enrolled in or participating in the health benefit plan to which these protections apply.

Rights under policyCovered persons are protected from balance billing beyond applicable coinsurance, copayments, or deductibles when covered services are provided by nonparticipating providers under the specified circumstances.

inv-06: Nonparticipating provider — definition of provider who does not have a contract with the plan but provides services at a participating facility

Definition"Nonparticipating provider" means a provider who provides health care services at a participating health facility who does not have a contract with the health benefit plan to provide services at a prenegotiated rate.

Typical circumstanceOccurs when a provider at a participating facility has not contracted with the patient's plan — e.g., specialists or ancillary clinicians without a plan agreement.

Billing implicationWhen covered services are provided under the statute's conditions, nonparticipating providers must accept the statutory payment rate and may not balance‑bill the covered person beyond applicable cost‑sharing.

inv-07: Participating health facility — define participating health facility and its relationship to the plan

Definition"Participating health facility" means a health facility that has contracted with the patient's health benefit plan to provide services under the covered person's policy.

ExamplesIncludes, but is not limited to: hospitals; freestanding surgical outpatient facilities; skilled nursing facilities; physician offices or other outpatient settings; laboratories; radiology or imaging centers.

Role under policyParticipating health facilities are the settings where nonparticipating providers may deliver covered services that trigger the statute's payment and billing rules when the covered person cannot choose a participating provider.

OpenPayer

Surprise billing protections (Michigan House Bill 4459)

When Coverage and Payment Apply

Payment Benchmark and Rate

Billing Rules and Provider Obligations

Key Terms