No Surprise Act: Impact on Healthcare Consumer; Part 2

Beginning January 1, 2022, out-of-network (“OON”) hospitals and free-standing emergency facilities are prohibited from balance billing a patient for more than the patient would pay if the facility were in the patient’s health plan network.

What Medical Services Will Be Affected

The No Surprises Act applies to several classes of out-of-network or otherwise non-contracted medical services, including:

  • Air ambulance services
  • Emergency services (except for ground ambulances)
  • Services provided to stabilize a patient post-trauma
  • Banning out-of-network charges for ancillary care (like that provided by an anesthesiologist or assistant surgeon) at an in-network facility.
  • Out-of-network nonemergency items and services provided in in-network facility
  • Out-of-network services at an in-network facility if the provider didn’t notify the patient that the services were out-of-network and obtain patient approval of the same

Will patients be on the hook while their health care provider and their health plan argue about payment?
• No. Patients will only be responsible for their usual in-network cost-sharing amounts and deductibles
and can go on with their lives.
• With the patient out of the middle, the No Surprises Act creates a fair process for providers and plans to
settle payment between themselves.
• This bill provides for enhanced consumer protections including the ability for patients to appeal a
surprise medical bill decision made by their insurer.

How does the law address the surprise medical bill issue for consumers?

The No Surprises Act contains key protections to hold consumers harmless for surprise bills.

1. Health plans must cover surprise bills at in-network rates.

Private health plans must cover surprise medical bills for emergency services and out-of-network provider bills for treatment at in-network hospitals and facilities.

2. Balance billing is prohibited.

Out-of-network providers are not allowed to bill patients for costs above the applicable in-network cost sharing amount for surprise bills resulting from an emergency treatment. This also applies to out-of-network providers, like anesthesiologists, who render non-emergency services at an in-network hospital or other facility.

3. Out-of-network providers cannot send patients bills for excess charges.

The onus is on out-of-network providers to determine a patient’s insurance status and the applicable in-network cost sharing for the medical bill.

4. Oversight and enforcement activities are required.

For private health plans, enforcement of the No Surprises Act is similar to the rules for the Affordable Care Act (ACA). States regulate non-group health plans and fully-insured employer-sponsored plans and the federal government provides oversight and enforcement for self-insured group health plans.

Enforcement for healthcare providers and facilities also begins with the states. Where a state fails to enforce the provider requirements, the federal government may enforce the requirements.

The Healthcare Consumer and Additional Consumer Protections

The following are additional consumer protection areas:

  • Member ID Cards. Health plan member ID cards must include the member’s in-network and out-of-network deductible amounts and maximum out-of-pocket cost limits, as well a phone number and website address where the member can find a participating provider directory and regularly update the directory.
  • Price Comparison Tools. Health plans will be obligated to have up-to-date online price comparison tools on their websites and a mobile application so plan members can compare their anticipated out-out-pocket costs for a service or items across multiple providers.
  • Advanced EOBs. Upon receiving a provider’s good faith estimate for a member’s scheduled service, the plan must issue an “Advanced Explanation of Benefits.” Advanced EOBs are to inform the plan member of whether the provider is in-network, and of an in-network provider’s contracted rate for the service based on the billing and diagnostic codes in the good faith estimate. If the provider is out-of-network, the Advanced EOB must tell the member where they can get information on participating providers that perform the same service. The EOB must also include “good faith estimates” of the expected charge for the service, the amounts the plan and the member will pay, and the extent to which the member has met their deductible and maximum out of pocket amounts. Finally, the Advanced EOB has to contain a disclaimer that the estimated amounts are based on information known to the plan at the time and could change as the result of medical management.
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