This blog was written by Steve Anderson, the VP of Benefits at Helpside. He has helped small businesses manage their benefits for over 20 years.
The No Surprises Act, which is a ban on surprise medical bills, will take effect on January 1, 2022. The rule was enacted as part of the Consolidated Appropriations Act, 2021, signed into law in late 2020.
The rule restricts “balance billing” by providers for patients with employer-sponsored and individual health plans and who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.
What is balance billing?
When a person with a group health plan or health insurance coverage gets care from an out-of-network provider, their health plan or insurer usually does not cover the entire out-of-network cost, leaving them with higher medical bills than if they had been seen by an in-network provider. In many cases, the out-of-network provider can bill the patient for the difference between the billed charge and the amount paid by their health plan or insurance, unless prohibited by state law. This is known as balance billing.
The new rule protects patients from surprise bills due to balance billing by out-of-network providers under certain circumstances.
When do surprise medical bills occur?
Surprise medical bills and balance bills occur particularly when people with health insurance unknowingly get medical care from a provider or facility outside their health plan’s network. This can be very common in emergency situations, where people usually go (or are taken) to the nearest emergency department without considering their health plan’s network.
Additionally, an in-network hospital still might have out-of-network providers, and patients, especially in emergency situations, have little or no choice when it comes to who provides their care.
For non-emergency care, an individual might choose an in-network facility or an in-network provider but not know that another provider involved in their care (for example, an anesthesiologist or radiologist) is an out-of-network provider.
What protections does the No Surprises Act provide to health plan participants?
This rule protects people from excessive out-of-pocket costs by limiting cost sharing for out-of-network services to in-network levels, requiring cost sharing for these services to count toward any in-network deductibles and out-of-pocket maximums, and prohibiting balance billing under certain circumstances. Cost sharing is what you pay out of your own pocket when you have insurance, such as deductibles, coinsurance, and copayments when you get medical care.
The protections in this rule apply to most emergency services, air ambulance services from out-of-network providers and non-emergency care from out-of-network providers at certain in-network facilities, including in-network hospitals and ambulatory surgical centers.
Additionally, this rule requires certain health care providers and facilities to furnish patients with a one-page notice on:
- The requirements and prohibitions applicable to the provider or facility regarding balance billing
- Any applicable state balance billing prohibitions or limitations
- How to contact appropriate state and federal agencies if the patient believes the provider or facility has violated the requirements described in the notice
The Helpside Medical Plan complies with all the health plan requirements of the No Surprises Act. Plan participants should still visit in-network providers whenever possible, as the No Surprises Act will not apply to every medical claim.