Regulatory Resources

No Surprises Act: ID Cards, Plan Documents, Advance EOBs and Continuity of Care

he No Surprises Act provides requirements for ID cards, plan documents, advance explanations of benefits (EOBs) and continuity of care. The law is part of the Consolidated Appropriations Act, 2021, which was enacted in December 2020. The requirements generally become effective for plan years beginning on or after Jan. 1, 2022.

The No Surprises Act includes various other requirements, which we will address in future articles.

ID Cards and Plan Documents
On any physical or electronic plan or insurance identification card, group health benefit plans and health insurers (group or individual) must provide in clear language:

  • Any deductible applicable to the coverage.
  • Any out-of-pocket maximum applicable to the coverage.
  • A telephone number and website address that individuals can use to seek consumer-assistance information, such as which hospitals and urgent care facilities have a contractual relationship with the plan.

 

Advance EOBs
Group plans and health insurers must provide an advance EOB, in clear and understandable language, to a participant (through mail or electronic means, as requested by the participant), within:

  • One business day of receiving notification from a provider when an item or service is scheduled at least three business days in advance or,
  • Three business days of receiving notification from a provider when an item or service is scheduled at least 10 business days in advance (or in the case of a request made by a participant,).

 

The advance EOB must include the following:

  • Whether or not the provider or facility is a participating provider/facility
  • The contracted rate of a participating provider/facility
  • How the participant can obtain information on in network providers and facilities (if the claim is out of network)
  • A good-faith estimate of expected charges included in the notification received from the provider or facility
  • A good-faith estimate of the amount the plan or coverage is responsible for paying
  • A good-faith estimate of the amount of any cost-sharing
  • A good-faith estimate of the amount that the participant has incurred toward meeting the participants’ cost-share limits (including deductibles and out-of-pocket maximums)
  • In the case such item or service is subject to medical-management (including concurrent review, prior authorization, and step-therapy or fail-first protocols) for coverage, a disclaimer that coverage for such item or service is subject to such medical management
  • A disclaimer that the information provided in the notification is only an estimate
  • Any other information or disclaimer the plan or coverage determines appropriate that is consistent with information and disclaimers required under this section.

 

There is regulatory authority to modify timing requirements in the case of items and/or services with low utilization or significant variation in costs.

Continuing Care Patient
The new law identifies a continuing care patient as an individual who:

  • is undergoing a course of treatment for a serious and complex condition from a provider or facility;
  • is undergoing a course of institutional or inpatient care from a provider or facility;
  • is scheduled to undergo nonelective surgery from the provider, including postoperative care;
  • is pregnant and undergoing a course of treatment for the pregnancy from a provider or facility; or
  • is or was determined to be terminally ill and is being treated by a provider or facility.

 

If a continuing care patient is receiving care with a contracted provider or facility and the contractual relationship is terminated; benefits provided under the plan or coverage regarding the provider or facility are terminated; or if a contract between a plan or insurer is terminated, resulting in a loss of benefits provided under the plan regarding the provider or facility, the plan or insurer must:

  • Notify each continuing care patient of the right to elect continued care from the provider or facility;
  • Permit the patient to elect to continue to have benefits provided under the plan or coverage, under the same terms and conditions as would have applied to the items and services that would have been covered under the plan or coverage had the termination not occurred, with respect to the course of treatment furnished by the provider or facility relating to the individual's status as a continuing care patient during the period beginning on the date on which the notice is provided, and ending on the earlier of: 90 days later or the date on which the individual is no longer a continuing care patient with the provider or facility.

 

The healthcare provider or healthcare facility must:

  • Accept payment from the plan or insurer (and cost-sharing from the patient, if applicable) as if it remained an in-network healthcare provider as payment in full for items and services; and
  • Continue to adhere to all policies, procedures and quality standards imposed by the plan or insurer regarding the individual and items and services in the same manner as if such termination had not occurred.

 

For additional summaries of sections of the Consolidated Appropriations Act, 2021 (CAA), click here. Luminare Health will share additional information as it becomes available.