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Expanding Health Coverage and Protecting Consumers, Even as Costs Rise

With more than 200 bills this year, state legislatures addressed health care costs, coverage and delivery in the commercial market.

By Samantha Scotti  |  November 6, 2023

States enacted over 206 bills this year affecting health care costs, coverage and delivery in commercial markets.

Here is a look at the issues addressed in those bills, including health care coverage and network adequacy, individual and small-group marketplaces, surprise billing, medical debt and more.

Ensuring Health Insurance Coverage and Network Adequacy

Health care coverage improves access to care, which leads to positive health outcomes. Uninsured people are more likely than those with coverage to postpone or forego health care.

Several states enacted new insurance mandates this year, requiring state-regulated health plans to cover certain benefits or providers. For example, Arkansas, Maryland, Nevada, New Mexico, Oklahoma and Texas all required insurers to include coverage for medically necessary biomarker testing (e.g., tests examining genes) for diagnosis, treatment and ongoing monitoring of cancer.

With nearly 1 in 5 Americans experiencing mental illness annually, several states now require insurers to provide one annual mental health and wellness visit for adults and children at no cost.

With nearly 1 in 5 Americans experiencing mental illness annually, some states are expanding mental health insurance coverage. Illinois now requires plans to provide one annual mental health and wellness visit for adults and children at no cost, joining four other states that require private health plans to cover annual mental health wellness exams, similar to annual primary care visits, without patient cost sharing. New Mexico and Virginia now require coverage for mental health and substance use disorder benefits, and require those benefits to be covered in parity with medical benefits.

Wyoming and Oklahoma required plans providing mental health and substance use disorder benefits to reimburse benefits delivered through the psychiatric Collaborative Care Model. This approach integrates behavioral health services into the primary care and pediatric settings, and has demonstrated success in identifying and treating mental health conditions.

Other states are ensuring access to health care services by addressing network adequacy. Georgia set new adequacy standards for access to primary and specialty care, behavioral health care, and pharmacy services based on geographic proximity and provider-to-patient ratios. Tennessee amended its standards to require managed care insurers to report network adequacy changes to the Department of Commerce and Insurance. Texas amended current statute by requiring insurers to monitor and meet certain network adequacy standards prior to offering the networks. Starting in 2025, Washington will require insurers to provide access to behavioral health specialists in a manner “sufficient to meet network access standards set forth in rules established by the office of the insurance commissioner.”

Implementing Federal Health Care Requirements

A handful of states enacted legislation related to various federal health care provisions.

Federal regulation requires nonprofit hospitals to demonstrate they provide some level of charity care or other community benefit to retain tax-exempt status.

Colorado and Montana both established new reporting requirements for nonprofit hospitals, including sharing their community benefit activities at public meetings and annually submitting their financial assistance policies and community benefit plans to the state. Texas will examine tax-exempt hospital revenue streams and the value of hospital community benefits provided.

Oregon and Rhode Island codified preventive services coverage mandates related to the Affordable Care Act.  

Stabilizing Individual and Small-Group Markets

At least six states—Colorado, Connecticut, Illinois, New Mexico, Oregon and Rhode Island—enacted legislation to ensure patients have access to affordable marketplace plans. Colorado enacted changes to the way public option plans are displayed on its state-based exchange. The state is one of three offering a government-designed plan to compete with private plans on the marketplace. New Mexico will study the feasibility of implementing a state-administered health coverage plan.

Connecticut created a special enrollment period on its health care exchange for people whose health care coverage is terminated by an employer as a result of a labor dispute, and New Hampshire updated regulations governing the individual health insurance market to support the affordability and accessibility of health insurance.

Illinois and Oregon enacted bills facilitating the transition from to state-based exchanges.

Curbing Medical Debt and Surprise Billing

A recent survey found that 41% of adults have debt caused by medical or dental bills. Researchers and policymakers often cite surprise billing—when a patient is billed for services after unknowingly seeing an out-of-network provider—as a common source of medical debt for consumers.

Colorado lawmakers built on changes they made to the way medical debt is reported and capped interest rates on medical debt at 3% annually. Texas set requirements for itemized billing and now prohibits providers from pursuing debt collection against a patient unless the provider has submitted an itemized bill meeting said requirements. Illinois required hospitals to screen patients for public health insurance programs and financial assistance before pursuing collection action.

This year, Texas added municipal ground ambulance services to state surprise billing protections, and required certain health plans to pay for out-of-network ground ambulance services at either the provider’s billed charge or 325% of the Medicare rate. Louisiana enacted legislation that includes a minimum allowable reimbursement rate by insurers for out-of-network ambulance service. And New Mexico extended the sunset date for requirements that insurers reimburse nonparticipating providers for care rendered.

Reforming Health Care Payment and Delivery

With rural hospitals continuing to close, several states—Arkansas, Illinois, Iowa, Nevada and West Virginia—enacted licensure requirements for rural emergency hospitals, the new Medicare provider designation. That brings to 16 the total number of states providing for rural emergency hospital licensure.

New Mexico limited cost-sharing and coinsurance for chiropractic physician services, and Arkansas exempted certain health care providers from prior authorization requirements.

For updates on legislative action, see NCSL’s Health Care Costs, Coverage and Delivery Database.

Samantha Scotti is a project manager in NCSL’s Health Program.

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