In December of last year, after years of heated debate, Congress passed legislation to ban surprise medical bills in a law known as the No Surprises Act.
The No Surprises Act provides sweeping protections from unexpected charges for patients—which accompany 20-44% of elective surgeries and hospital visits and range from a few hundred dollars to well above $100,000.
What is a Surprise Medical Bill?
Surprise medical bills happen when a patient with commercial insurance receives care at an out-of-network facility or from an out-of-network provider without realizing it. That facility or provider is then able to bill the patient outside of the limits of in-network rates. If the insurer refuses to cover the charge in full, the patients are often left on the hook for the bills.
The No Surprises Act
The No Surprises Act will go into effect on January 1, 2022. It prohibits out-of-network providers and facilities from balance billing patients—whether in an emergency or non-emergency settings, including out-of-network air ambulances, but not ground ambulance transport. In a nutshell, once the act goes into effect, patients will no longer be responsible for paying more than the in-networking cost-sharing rate. This rate may include a commercial insurance plan’s deductibles, coinsurance, and copayment.
Consumer Protections Under the No Surprises Act
There are key provisions contained in the law to protect consumers against the cost of surprise medical bills, including:
- A requirement for health plans to cover surprise bills at in-network rates. The new law requires surprise bills to be covered without prior authorization, and in-network cost-sharing must apply.
- Balance billing is prohibited. Out-of-network providers for emergency care are prohibited from balance billing patients beyond the applicable In-network cost-sharing amount for surprise bills.
- Out-of-network providers can’t send patients bills for excess charges. The law defines that providers “shall not bill or hold the patient liable” for any amount that is more than the in-network cost-sharing amount for such services.
The law also includes several additional provisions to help consumers get information ahead of time about how their health plans will work in practice, in addition to promoting transparency for medical care practices in general.
- Health plans are required to provide an advanced explanation of benefits. Starting in 2022, consumers can request advance information about how services will be covered before they are provided.
- Health plans are required to provide transitional continuity of coverage if a provider leaves the network. The new law states that health plans and issuers must notify enrollees when a provider and/or facility leaves the plan network while it is providing ongoing care. In certain situations, health plans will also be required to provide transitional coverage for up to 90 days or until treatment ends (whichever comes first) at in-network rates.
Beyond the No Surprises Act requirements, the federal government is granted comprehensive general authority to require reporting on surprise medical bill claims under ACA transparency data reporting provisions. Using this authority can also help track surprise medical bill trends that don’t use the IDR process.
Bedsiide is Here for You
Have more questions about surprise medical bills, navigating the healthcare system, or simply getting advice on the next steps in your medical journey? We can help! Contact a Bedsiide Health Assistant today!