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 stipulates that charges for inpatient or outpatient hospital services from out-of-network providers cannot exceed 240% of the Medicare reimbursement rate for similar services in the same geographic area. It also prohibits providers from charging patients more than the specified cost-sharing amounts in their health plans. Furthermore, any savings resulting from reduced payments to health care providers must be passed on to consumers and reflected in the annual rate filings of health carriers. The bill exempts rural hospitals and federally qualified health centers from these cost limitations.

In addition to cost regulations, the bill establishes a framework for the enforcement of health care regulations by the Office of Health Strategy. It outlines a process for issuing notices to violators, detailing the alleged violations, 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 of Health Strategy is empowered to adopt regulations to implement these provisions, while the commissioner can create interim policies during the regulatory development phase. The bill includes new legal language to enhance enforcement and streamline processes, while deleting outdated provisions.