Category: No Surprises Act

NEW RULES:Bans on balance billing and out-of-network cost-sharing

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Bans surprise billing for emergency services

If a member receives emergency services, they will be covered at the in-network rate, and the services do not require prior authorization from Health Plan. This is true even if the services are received at a facility or from a provider that does not participate in their network. Additionally, members will be protected from balance billing when receiving post-stabilization services at a nonparticipating facility.

Bans balance billing and out-of-network cost-sharing for emergency services as well as certain nonemergency services performed by a nonparticipating provider (or facility on behalf of the provider) at participating health care facilities including out-of-network ancillary providers such as pathologists, anesthesiologists, and radiologists at in-network facilities: 

In these situations, the member’s cost share cannot be higher than the cost share would have been if the services were provided by an in-network provider or an in-network facility. The member’s cost share must be based on the in-network rates.

Bans balance billing for out-of-network air ambulance service

No Surprises Act

On January 1st, 2022, the No Surprises Act went into effect and it provides federal protections for patients from surprise medical bills.

On January 1st, 2022, the No Surprises Act went into effect and it provides federal protections for patients from surprise medical bills!  

For those that don’t remember, surprise medical bills can happen when someone receives a bill for care they thought should be covered by their insurance.

Very frequently this happens when patients seek emergency care for things like a heart attack or stroke, only to find out later that the emergency care provided was out-out-of-network. You have no way to know this ahead of time and the last thing you should be worried about in an emergency situation is the cost of your care.

In non-emergency situations you may have done your due diligence and sought care at an in-network hospital, only to receive a surprise bill months (can be more than a year) later because the doctor or other providers associated with your care may not work for the hospital and do not take your insurance.

Beginning this month, consumers with group or individual health plans are protected from receiving surprise medical bills for most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance providers.

Specifically, this law will:

  • Ban surprise bills for most emergency services even if you get them out-of-network and without prior authorization.
  • Ban out-of-network cost-sharing for most emergency and some non-emergency services.
  • Ban out-of-network charges for certain services like anesthesiology or radiology furnished by out-of-network providers as part of a patients’ visit to an in-network facility.
  • Require that health care providers and facilities give you an easy-to-understand notice explaining your new protections and who to contact if you have concerns.
  • Require health care providers to seek patient consent to waive surprise medical billing protections.

For a more detailed information about the new law, we encourage you to refer to CMS resources about the No Surprises Act.