Substitute Bill No. 6871 seeks to regulate out-of-network health care costs for individuals with 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 specified cost-sharing amounts in their health benefit plans and mandates that any savings from reduced provider payments be passed on to consumers. The bill requires health care providers to submit data to the Office of Health Strategy for compliance monitoring, which will maintain confidentiality and report biannually on health care cost trends. Certain rural hospitals and federally qualified health centers are exempt from these cost limitations.

Additionally, the bill introduces new enforcement provisions for the Office of Health Strategy, including a process for issuing violation notices to individuals, health care providers, or health carriers. These notices must detail the nature of the violation, 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 post-service billing, with relevant records required to be available for these audits. The Office is also empowered to adopt regulations to implement these provisions, while the commissioner can establish interim policies during the regulatory development process. The bill includes new legal language to enhance enforcement and streamline processes, while deleting outdated provisions.