Substitute Bill No. 6871 seeks to limit out-of-network health care costs for individuals covered by health benefit plans, effective January 1, 2026. The bill establishes that total out-of-network costs for inpatient or outpatient hospital services cannot exceed 240% of the Medicare reimbursement rate for the same service in the same geographic area. It also prohibits health care providers from charging patients more than the cost-sharing amounts specified in their health benefit plans. Furthermore, any savings from reduced payments to health care providers must be passed on to consumers, with specific exceptions for rural hospitals and federally qualified health centers. The bill emphasizes transparency and accountability in health care pricing, aiming to enhance affordability and accessibility for residents.

To ensure compliance, the bill mandates that health care providers submit relevant data to the Office of Health Strategy, which will maintain confidentiality and report biannually on health care costs and compliance. The legislation introduces new enforcement provisions, including a process for issuing violation notices that detail the alleged violation, required corrective actions, potential civil penalties, and the right to request a hearing. The commissioner or their designee is authorized to audit compliance for up to four years after services are billed or collected. The Office of Health Strategy is also granted the authority to adopt regulations to implement these provisions, while interim policies can be established during the development of formal regulations. The bill includes new legal language to streamline enforcement and deletes outdated provisions to enhance regulatory efficiency.