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No Surprises Act

No Surprises Act January 21, 2022

Published by: Sharon McReynolds, PEO and Agency Partner

On September 30, 2021 the Department of Health and Human Services, the Department of Labor, and the Department of Treasury along with the Office of Personnel Management released interim final rules related to Title 1 (the No Surprises Act).  The No Surprises Act is a part of the Consolidated Appropriations Act that establishes new protections from surprise billing and excessive cost sharing for consumers receiving health care items/services.

Most group health plans and insurance issuers that offer group or individual health insurance have a network of providers (in-network) that agree contractually to accept a certain specific payment amount for their services.  Typically, providers/facilities that are not participating in the insurance carrier plan are considered out of network and the insurance carrier does not cover the entire cost thereby leaving a difference between amount paid and what was billed.  That charge is commonly referred to as “balance billing”.

That balance bill sometimes comes as a surprise to the person who incurred the charge.  It may happen even when a person goes to a network doctor and network hospital but has no choice in x-ray technician or anesthesiologist, someone they may not have known was even involved in their care.

This provision is an attempt to protect consumers and they hope has the potential to decrease health care spending.  However, with all things legislative, there is obviously administrative costs associated with it.  The Congressional Budget Office has projected the Act will reduce private health plan premiums by .5% to 1% on average.

What is actually in the ACT?

It is actually a ruling that restricts excessive out of pocket costs to consumers that are the result of balance billing or “surprise billing”.  The rule actually went into effect for providers and facilities and air ambulance providers January 1, 2022, or contract years that start on or after January 1, 2022.

  • Bans balance bills for emergency services, must be determined on an in-network basis
  • Requires patient cost-shares (co-pays, co-insurance, deductibles) for emergency services and certain non-emergency services provided at an out of network facility can not be higher than if 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.

To protect the patients and remove them from payment disputes, the rule established that for emergency and certain non-emergency services furnished by out-of-network providers at certain in-network facilities, the patient pays a cost share rate similar to that imposed under the in -network model.  This will be determined by a QPA or qualifying payment amount.  That amount will be similar to the plan’s contracted rate for similar geographic area.  The balance will be worked out between the providers and issuer of insurance.  If they can not agree there are guidelines set up for a federal independent dispute resolution.

For more information visit https://www.cms.gov.

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