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

DISCLAIMER: Brown & Brown, Inc. and all its affiliates, do not provide legal, regulatory or tax guidance, or advice. If legal advice counsel or representation is needed, the services of a legal professional should be sought. The information in this document is intended to provide a general overview of the topics and services contained herein. Brown & Brown, Inc. and all its affiliates, make no representation or warranty as to the accuracy or completeness of the document and undertakes no obligation to update or revise the document based upon new information or future changes.