Unexpected medical bills have been a major affordability concern for millions of American families for decades, so much so that it can even make some patients forgo care. To ensure that no American ever takes such a step for fear of increased financial hardships, No Surprises Act has been framed.
The Act, which takes effect January 1, 2022, has multiple provisions to keep consumers harmless from the cost of unanticipated out-of-network medical bills. These provisions strive to provide patients with financial peace of mind while seeking emergency care and safeguard them from unknowingly accepting out-of-network care and subsequently incurring surprise billing expenses.
In the run-up to the January rollout, the Biden administration this month came out with “Requirements Related to Surprise Billing; Part I,” an interim final rule that will restrict excessive out of pocket costs to consumers stemming from unanticipated bills.
In this first of a two-part blog series, we are sharing an overview of the key provisions of the upcoming Act, how this rule will help, and who stands to benefit.
The Centers for Medicare & Medicaid Services (CMS) has stated that the first rule implements several important requirements for group health plans, group and individual health insurance issuers, carriers under the Federal Employees Health Benefits (FEHB) Program, health care providers and facilities, and providers of air ambulance services.
Provisions for Greater Protection
- The interim final rule mandates that emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
- It bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
- Out-of-network charges for ancillary care at an in-network facility will not be allowed in all circumstances.
- The rule prohibits other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.
Key Benefits
If a particular health plan provides or covers benefits for emergency services, this rule requires these services to be covered without any prior authorization and regardless of whether a provider or facility is in-network.
The Act also protects people from excessive out-of-pocket costs by limiting cost sharing for out-of-network services to in-network levels, requiring cost sharing for these services to count toward any in-network deductibles and out-of-pocket maximums, and prohibiting balance billing under certain circumstances.
The protections in this rule apply to most emergency services, air ambulance services from out-of-network providers, and non-emergency care from out-of-network providers at certain in-network facilities, including in-network hospitals and ambulatory surgical centers.
Additionally, this rule requires certain health care providers and facilities to furnish patients with a one-page notice on the requirements and prohibitions applicable to the provider or facility regarding balance billing and any applicable state balance billing prohibitions or limitations. It also has provisions to inform patients about how to contact appropriate state and federal agencies if they believe the provider or facility has violated the requirements described in the notice.
Who Benefits and Who Doesn’t
The surprise billing protections apply to those who get the coverage through their employer (including a federal, state, or local government), or through the federal Marketplaces, state-based Marketplaces, or directly through an individual market health insurance issuer.
The rule does not apply to people with coverage through programs such as Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs already prohibit balance billing.
Conclusion: A strict regulation to shield patients from a sudden financial burden stemming from surprise medical bills was long-overdue. Unexpected medical bills and balance bills affect many Americans, particularly when people with health insurance unknowingly get medical care from a provider or facility outside their health plan’s network. This can be common in emergency situations, where people usually end up at the nearest health facility without considering their health plan’s network. Patients in emergency situations may have little or no choice when it comes to who provides their care. Billing patients for services despite their health insurance covering emergency care is neither justifiable nor acceptable.
