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Policy Update: No Surprises Act

The No Surprises Act was enacted December 27, 2021 and took effect January 1, 2022. To protect patients from surprise medical bills, it established several new rules for providers, facilities, and providers of air ambulance services. These include:

  • Prohibiting balance billing (where a patient is charged the difference between an out-of network provider’s cash-pay rate and any payments from the patient’s insurer) in certain circumstances for providers furnishing out-of-network services at in-network facilities
  • Requiring disclosure about balance billing protections, including posting a notice at the provider’s facility and on their website, as well as providing it to the consumer
  • Requiring transparency around health care costs, including requiring outpatient providers to provide a good faith estimate of the services they provide to new and established patients who are uninsured or self-pay, or who are shopping for care
  • Providing consumer protections related to continuity of care, such as requiring health plans to notify consumers of changes to in-network status of current providers
  • Establishing requirements related to provider directories, including requiring in-network providers to inform plans when they begin a network agreement or terminate an agreement with a plan
  • Mandating dispute resolution procedures if payors and providers are unable to successfully negotiate a payment dispute in which the charges exceed the good faith estimate by $400 or more.

These requirements generally apply to items and services provided to those enrolled in group health plans, group or individual health insurance coverage, and Federal Employees Health Benefits plans. Transparency of health care costs requirements and those related to the patient-provider dispute resolution process also apply to uninsured consumers. They do not apply to those with coverage through programs like Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE, as these programs have other protections against high medical bills.

Helpful Resources:

  • Summary of provider requirements: A high-level overview of all of the No Surprises requirements
  • Detailed balanced billing rules: Information on the rules that prohibit balance billing out-of-network patients for certain services
  • Other surprise billing protections: Information on balance billing disclosure requirements; protections for certain continuing care patients whose plan terminates a contract with a provider; and requirements to protect patients and improve the accuracy of provider directory information
  • Good Faith Estimate Template: From the Office of Management and Budget and for use by health care providers

Have questions? Consult your PMH Nursing colleagues in this discussion thread on Member Bridge!