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 costs for inpatient or outpatient hospital services provided by out-of-network providers cannot exceed 240% of the Medicare reimbursement rate for similar services in the same geographic area. It also prohibits health care providers from charging patients more than the cost-sharing amounts set by their health benefit plans and mandates that any savings from reduced payments to providers 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. Violations may lead to penalties, including patient refunds and civil fines, with certain exemptions for rural hospitals and federally qualified health centers.

Additionally, the bill introduces new enforcement mechanisms for the Office of Health Strategy, including a process for issuing notices of violations to individuals, health care providers, or health carriers. These notices must 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 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, with interim policies allowed by the commissioner. The act will amend existing law to incorporate these changes.