In a memo to Wisconsin lawmakers
, Wisconsin Hospital Association (WHA) President and CEO Eric Borgerding and Senior Vice President of Government Relations Kyle O’Brien expressed support for several COVID-19 insurance coverage provisions included in recent legislation circulated by Governor Evers’ related to telehealth and prohibiting health plans from implementing out-of-pocket costs for COVID-19 diagnosis, testing, treatment and vaccination.
“As hospitals have, unfortunately, become both the frontline of battle and the last line of defense to COVID-19, their perspective is important on public policies impacting patient insurance coverage and costs. As you consider the health care coverage proposals included in LRB 6522/1 from Governor Evers or other proposals developed by lawmakers in the Assembly and the Senate, we ask you to understand and support the following perspective from our state’s hospitals,” said WHA in the memo.
The memo reminded lawmakers how regulatory and payment policy must align to sustain and improve access to care. “Practice, policy and payment must all align for a resource like telehealth to be used to treat patients—if one of those elements is missing it will become a barrier for providers to deliver care and a patient’s ability to access care.”
In addition, Borgerding and O’Brien raised objections to how health plans portrayed the governor’s proposal establishing a benchmark rate to settle billing disputes between patients, providers and a health insurer that chooses not to contract with the patient’s provider. The governor’s proposal, limited in its scope to the diagnosis and treatment of COVID-19, establishes the benchmark rate for out-of-network care at 250% of Medicare’s rate, requires the provider to accept this payment as payment in full and prohibits the provider from charging the patient an additional amount for the service beyond what the health insurance company has paid.
Borgerding and O’Brien stated that WHA has been neutral on this limited provision in the interest of the current public health emergency, but objected to lawmakers using benchmark rates more broadly in any future public policies to settle disputes for out-of-network provider bills when an insurer doesn’t contract with a patient’s provider.
In a Nov. 20 memo to the state Legislature
, three insurance company trade associations in Wisconsin—America’s Health Insurance Plans, Alliance of Health Insurers and the Wisconsin Association of Health Plans—wrote that the governor’s proposed benchmark rate was “simply too high” and countered that other states like California, Massachusetts and Michigan had legislated benchmark rates that were far lower at 125%, 135% and 150%, respectively.
“Health insurers have indicated that a benchmark rate of 250% of the Medicare rate is too high. We disagree. The health insurers compare Medicare rates in Wisconsin to other states, which is not a valid comparison to make,” wrote Borgerding and O’Brien in their memo. “The concerns about inequitable Medicare payments and how Medicare sets its rates geographically are widely known. Simply, Medicare rates are low in Wisconsin compared to other states,” they continued.
The group of health insurers propose that the benchmark rate be established individually by each health plan’s median in-network rate for its geographic region.
WHA’s memo objected to the health insurance company’s median in-network proposal. “The health insurers propose using each respective plan’s median in-network rate for a specific geographic region. This black box approach provides no transparency to the provider nor to the state Office of the Commissioner of Insurance. WHA strongly opposes requiring out-of-network providers to accept a payment derived from an unknown data source,” stated the memo.
Later in the day on Dec. 1, Assembly Republicans offered an alternative proposal to Governor Evers’ proposal which rejected the health plans recommendation but offered a lower proposed benchmark rate at 225% of Medicare. Governor Evers and legislative leaders continued discussions about potential legislation, but any floor action in either the Assembly or Senate remains uncertain.