The No Surprises Act Explained

Accidents happen. So do emergencies. If you or a loved one is or has been in an emergency situation, the last thing you are thinking about is which nurse, doctor, surgeon or specialist providing care is covered by your health insurance.

Unfortunately, sometimes your hospital’s staff are not in your network. When this happens, you can be hit with expensive surprise medical bills. Studies show this happens in about 1 in 5 emergency room visits.

Even if you go to an in-network hospital, it is still possible to get care from out-of-network provider, whether it’s an emergency or not. It is estimated that between 9% and 16% of in-network hospitalizations for non-emergency care result in surprise bills from out-of-network providers.

To protect patients from unexpected out-of-pocket medical costs, Congress passed the No Surprises Act (NSA) at the tail end of 2020.

What is the No Surprises Act?

The No Surprises Act (NSA), part of the Consolidated Appropriations Act of 2021, forbids healthcare providers from distributing surprise medical bills when a patient seeks emergency services or certain other ancillary services from out-of-network providers at in-network facilities.

The law went into effect starting January 1st, 2022.

Who is covered by the No Surprises Act?

Consumers who receive coverage through the following entities are covered by the No Surprises Act:

·       Employer-sponsored health plans (including a federal, state, or local government)

·       Health Insurance Marketplace®

·       Individual health plans

Protections do not apply to those with coverage through the following programs because as they have other protections against high medical bills.

·       Medicare

·       Medicaid

·       Indian Health Services

·       Veterans Affairs Health Care

·       TRICARE

Individuals without insurance are also protected under this law – as providers must disclose the costs of procedures to these patients before care is provided.

What protections will the No Surprises Act (NSA) provide?

Those who fall within the requirements of the above section can expect protections from:

Surprise billing for emergency services

Under the NSA, emergency services, even if they’re provided out-of-network, must be covered at an in-network rate without requiring prior authorization.

Balance billing and out-of-network cost-sharing

In these situations, the consumer’s cost for the service cannot be higher the cost of an in-network provider, and any coinsurance or deductible must be based on in-network rates.

Out-of-network charges and balance billing for ancillary care

Patients will no longer receive surprise bills for services provided by out-of-network ancillary care providers, like an anesthesiologist or assistant surgeon, if they are located at an in-network facility.

Certain other out-of-network charges and balance billing without advance notice

Health care providers and facilities are now required provide consumers with a plain-language consumer notice explaining that patient consent is required to get care on an out-of-network basis before that provider can bill the consumer.

In some situations, providers can ask patients to waive their NSA rights. When a patient willingly wants to see an out-of-network provider, the provider will ask for the patient’s consent to rights at least 72 hours before a pre-scheduled appointment, or three hours before a same-day appointment, since they are choosing to see this provider on their own terms.

Providers are not allowed to ask patients to waive NSA rights in the following situations:

·       All emergency services

·       A patient is impaired or has limited ability to make decisions

·       Urgent medical needs are discovered during routine, non-emergent treatment

·       A patient is provided ancillary services like anesthesiology, pathology, radiology, and neonatology

·       Care is provided by assistant surgeons, hospitalists, and intensivists

·       Patient is prescribed diagnostic services, including radiology or lab work

·       Items and services necessary for care are provided by an out-of-network provider when there is no in-network provider available to administer that care in that facility

What happens if a consumer receives a surprise bill they do not agree with?

While the government expects plans, care providers and facilities to act in good faith of the new law, consumers have options if they still receive a surprise bill. Patients can:

·       Appeal health plan denials

·       Contact “the applicable enforcement entity” that is disclosed on the bill by the provider

·       Call the “No Surprise Help Desk” at 1-800-985-3059

·       Report the bill to the national consumer complaints system

·       Contact your state Consumer Assistance Program (CAP)

The federal government estimates the NSA will apply to about 10 million out-of-network surprise medical bills each year. However, there is still a chance patients will receive a surprise bill for some type of care they receive.

While this legislation is a great step forward for patient protection, there is room for error that can cause lengthy appeals. Employers that provide group health coverage plans should communicate this legislation to their plan members and support those who still receive a questionable medical bill after the law passes.

We sincerely hope the NSA eliminates the stress of surprise bills, however Caravus will continue advocating for clients and their members when billing discrepancies occur.

Caravus simplifies the complex choice of health coverage so that individuals and business can navigate their health plan in a way that they feel secure, comfortable and free to focus on what matters to them. If you are an employer or individual interested in evaluating your current health plan, contact us today to see how we can service your unique needs.