Fundamentals of the No Surprises Act

Employee Benefits

Fundamentals of the No Surprises Act

On December 27, 2020, President Trump signed Congress’ $900 billion COVID-19 relief package. As expected, the final bill includes the language of the “No Surprises Act,” a long-anticipated, largely bipartisan bill that provides patient protections against surprise medical bills from out-of-network providers. This act will have significant impact on the health care industry, including group health plans offered by our customers. Included below is a summary of the major provisions of the landmark legislation.

Health Plan Surprise Medical Billing Requirements

  • Participants and beneficiaries cannot be required to pay anything other than the in-network cost-sharing amounts for:
    • Out-of-network emergency care,
    • Out-of-network air ambulance services,
    • Certain ancillary services provided by out-of-network providers at in-network facilities, and
    • Out-of-network care provided at in-network facilities when the patient has not provided informed consent.
  • Any cost-sharing payments by participants and beneficiaries for out-of-network emergency services and air ambulance services must be counted towards any in-network deductible or out-of-pocket maximums.
  • Participants will not be involved in billing disputes between health care providers and insurers.

Determining Out-of-Network Rates Paid by Health Plans

  • Establishes an independent dispute resolution (IDR) process when providers and insurers are unable to settle out-of-network claims within a 30-day negotiation period.

Health Care Providers Surprise Medical Billing Requirements

  • Participants and beneficiaries may not be billed by out-of-network facilities and providers for amounts exceeding the in-network cost-sharing amount for certain emergency care and ancillary services.
  • Unless the patient is given notice of the providers network status within 72 hours prior to receiving out-of-network care, and the patient consents to that care, the out-of-network provider is prohibited from balance billing the patient. When an appointment is made within 72 hours of care, the patient must receive a notice of the network status on the day the appointment is made and provide consent to receive out-of-network care.
Regulatory and Legislative Strategy Group