In accord with recent efforts to increase price transparency and provide patients with some relief from unexpected medical bills, Congress passed provisions establishing several new requirements for healthcare providers and facilities, and providers of air ambulance services, to protect consumers from surprise medical bills as a part of the Consolidated Appropriations Act of 2021. These requirements are collectively referred to as “No Surprises Act”. The No Surprises Act, and rules promulgated to implement the Act, generally impacts providers in three ways, by:

  • Restricting surprise billing for in-network providers and limit cost-sharing for out-of-network patients;
  • Providing out-of-network, uninsured, and self-pay (e.g., insured patients electing to not utilize their health plan for care received) patients with good faith estimates of expected charges ahead of rendering medical services; and
  • Outlining the process to engage in dispute resolution with insurance plans, self-insured, and uninsured patients.

In efforts to implement the No Surprises Act before it went into effect on January 1, 2022, the U.S. Departments of Health and Human Services, Labor, and the Treasury (the Departments) released two sets of interim rules. In July, 2021, the Departments released an interim final rule to restrict surprise billing for patients in job-based and individual health plans who receive emergency care, non-emergency care from out-of-network at in-network facilities, and air ambulance services from out-of-network providers.

In October 2021, the Departments released a second set of interim final rules which provided additional nuances on protections against surprise medical bills.

Pursuant to outcomes resulting from recent litigation, in August 2022, the Departments issued a set of final rules revising the requirements under the July 2021 interim final rules relating to information that group health plans and health insurance issuers offering group or individual health insurance coverage must share about the qualifying payment amount (QPA).

These NSA final rules apply to all healthcare entities, including facilities such as hospitals, critical access hospitals (CAHs), freestanding emergency departments (EDs), and ambulatory surgical centers (ASCs), and providers that furnish services to patients in facilities, including clinics operated as a hospital outpatient department. The final rules do not apply to physicians not providing services at facilities. In addition, the final rules cover health insurance issues and health plans, including:

  • Group coverage – insured and self-insured plans, ERISA plans, non-federal government plans, church plans, and traditional indemnity plans; and
  • Individual coverage – exchange and non-exchange plans and student health insurance coverage.

The NSA does not apply to Medicare Advantage, managed Medicaid, health reimbursement arrangements, plans with reference-based pricing, health sharing ministries, short term limited-duration insurance, or retiree-only plans.

Download our comprehensive No Surprises Act Whitepaper for a detailed expert analysis of the NSA.  For assistance, please contact Advis through our website, or by calling (708) 478-7030.

Published: October 9, 2022