No Surprise Act: Impact on Healthcare Consumers With and No Insurance; Part 5

The Consumers with Health Insurance

What the Consumer Needs to Know

The rule goes into effect for health care providers and facilities, and providers of air ambulance services on January 1, 2022, and for plan, policy, or contract years starting on or after January 1, 2022, for group health plans, health insurance issuers, and Federal Employees Health Benefits (FEHB) program carriers.

  • Bans balance billing for emergency services. Cost-sharing for emergency services must be determined on an in-network basis.
  • Requires that patient cost-sharing, such as copayments, co-insurance, or a deductible, for emergency services and certain non-emergency services provided at an in-network facility cannot be higher than if such services were provided by an in-network provider, and any cost-sharing obligation must be based on in-network provider rates.
  • Prohibits Out Of Network charges for items or services provided by an Out Of Network provider at an in-network facility, unless certain notice and consent is given. Providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an OON basis before that provider can bill the patient more than in-network cost-sharing rates.

The Consumer Without Health Insurance: Good Faith Estimates for Uninsured or Self-pay Patients

What the Consumer Needs to Know

  • The regulation establishes the process for providing uninsured and self-pay patients good faith estimates prior to all scheduled services or by request if the patient is shopping for care and not yet at the point of scheduling. The rule clarifies that the good faith estimates must include all expected charges for the items or services that are reasonably expected to be provided together with the primary item or service, including items or services that may be provided by other providers and facilities. The “convening provider,” defined as the provider/facility that is responsible for scheduling the primary item or service or receives the initial request for a good faith estimate, will be responsible for coordinating the estimates from all providers and delivering the estimate to the patient. The convening provider also will be responsible for notifying uninsured and self-pay patients of the availability of a good faith estimate.
  • The rule details the information that must be included in the good faith estimate, including:
  • The patient’s name and date of birth;
  • A description of the primary item or service;
  • An itemized list of other items or services, grouped by each provider/facility, reasonably expected to be provided with the primary item or service during the period of care;
  • Applicable diagnosis and service codes, with expected charges listed with each item/service;
  • The name, National Provider Identifier (NPI), and Taxpayer Identification Number (TIN) of each provider/facility included in the good faith estimate;
  • A list of items/services the convening provider anticipates will require separate scheduling, before or after the primary service (e.g., physical therapy); and
  • Several disclaimers, including one alerting the patient to their right to initiate a patient-provider dispute resolution process if the billed charges are “substantially in excess” of the good faith estimates.
  • Notably, the rule makes clear that the expected charges must reflect any available discounts or other relevant adjustments that the provider or facility expects to apply to an uninsured or self-pay individual’s billed charges. The rule also discusses the applicable period of care covered by the good faith estimate, defined as the day or multiple days during which the primary item(s) or service(s) are delivered (e.g., inclusive of anesthesia during surgery, but not including pre-surgery consultations or post-surgery physical therapy).
  • The rule establishes that the good faith estimates must be provided in writing, either on paper or electronically, based on the patient’s preference. The convening provider is required to request good faith estimate information from all other providers within one business day, and deliver the complete good faith estimate to the patient within one business day if the scheduled service is within 3-9 days or three business days if the scheduled service is in 10+ days or has not been scheduled yet.
  • These requirements go into effect on Jan. 1, 2022. However, HHS plans to exercise enforcement discretion through Dec. 31, 2022, and encourages states to do the same, as it relates to incorporating the good faith estimates from outside providers or facilities. HHS recognizes that there is not an established process for the convening provider and other providers to share information on expected charges, and asks for comment on how this could be accomplished.
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