To help healthcare consumers avoid surprise medical bills, the No Surprises Act (part of the Consolidated Appropriations Act, 2021) established new requirements for self-funded group health benefit plans, insurers of fully insured group and individual health benefit plans, doctors and facilities. 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.

Out-of-Network Care, In-Network Costs, Balance Billing Prohibitions
Signed into law in late December 2020, the law requires:

• Costs for out-of-network emergency care will be calculated as in-network for provider reimbursement and patient obligations until the individual is stabilized, when patient notice and written consent requirements described below are met.
• Costs for non-emergency care provided at an in-network facility by an out-of-network doctor will be calculated as in-network when the provider does not follow the patient notice and written consent requirements.
• In both situations described above, providers are prohibited from balance billing for an amount exceeding a member’s in-network cost share.

 

Notice and Consent
Out-of-network providers must notify a plan participant that they are not in the participant’s PP0 network and obtain the patient’s written consent for out-of-network healthcare services before providing non-emergency care and, in the case of an emergency, after a patient is stabilized.

Prior Authorization Prohibited for Emergency Care
No prior authorization can be applied to emergency care provided by emergency departments and freestanding emergency care facilities. A member’s cost share for such out-of-network services cannot exceed the amount for which an in-network provider or facility would charge and must be applied to the in-network cost-sharing amounts (for example, the deductible and out-of-pocket maximum).

Ending Surprise Air Ambulance Bills
If a member must be transported by an air ambulance (medical transport by helicopter or airplane) by an out-of-network provider (if such services would otherwise be covered if provided by a participating provider):

• The cost-sharing requirement must be the same had services been provided in network.
• The cost-sharing amounts must be applied toward the in-network deductible and in-network out-of-pocket maximum amount.
• Out-of-network emergency service providers and providers of air ambulance services (medical transport by helicopter or airplane) are prohibited from balance billing a participant in excess of the participant’s in-network cost-sharing amount under his or her plan.

 

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