Everyone likes surprises BUT not when it comes to Health Care
Back in December 2020, when the CAA (Consolidated Appropriations Act) was signed into law, one provision within the law referenced the “No Surprises Act” as it relates to health care transparency in coverage and billing.
With COVID and vaccinations continuing to take the center stage throughout the remainder of 2020 and a majority of 2021, this particular provision, wasn’t the immediate “star of the show.” However, as we’re nearing the end of 2021, it has gained more attention as the changes it brings go into effect on January 1, 2022 – less than 3 months from now. As with other changes we’ve seen in the past, the changes associated with the “No Surprises Act” are staggered and continue through January 1, 2024.
So what’s the No Surprises Act? What’s the big hype and why does it matter?
As with many of the current legislations and laws, The No Surprises Act protects the consumer from high health care costs resulting in a surprise billing for services received after the fact. Essentially, the Act prohibits “surprise billing” in almost all circumstances, with limited exceptions (ex: where an individual agrees in advance to pay a provider’s out-of-network rate). The legislation also addresses the following:
- Limits patient payment responsibility for certain out-of-network services;
- Prohibits providers and facilities from balance billing patients for the services received;
- Establishes price transparency disclosures for providers and insurers;
- Dispute resolution processes for patients, provider and insurers to address unanticipated medical bills.
For anyone who may have had to utilize an out-of-network provider and received a large balance bill after the fact, this Act will provide a relief going forward.
Other consumer protection provisions passed under the act include:
- Bans high out-of-network cost sharing for emergency services: A Group Health Plan (GHP) must treat emergency services provided by out-of-network providers or facilities as in-network for applying cost-sharing requirements. Balance billing the participant for the “difference” is prohibited. However, the balance billing is allowed for post stabilization services if a notice is provided to the participant and consent obtained for balance billing prior to receiving the services;
- Bans out-of-network charges for ancillary care at an in-network hospital or ambulatory surgery center: A GHP must treat anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist or intensivist services as in-network when applying cost sharing. As with the prior provision, balance billing is prohibited and this prohibition cannot be waived by the participant;
- Bans other out-of-network charges without advance notice: If a hospital or ambulatory surgery center is in-network and services other than those mentioned above are provided, the GHP must still treat those services as in-network with applying the participant cost sharing. However, the out-of-network provider may balance bill for these services provided the notice was given to the participant and their consent was received to be balance billed before the services are provided.
To help make cost sharing more transparent to participants and ensure compliance with the Act, beginning January 1, 2022, health insurers must provide ID cards to all participants which include:
- Plan deductibles: in and out of network amounts;
- Max limits