Understanding the No Surprises Act Effective Date and Its Impact

The No Surprises Act has finally taken effect, and it's about to change the healthcare landscape in a big way. On January 1, 2022, this new law kicked in, bringing with it a slew of new protections for patients.

Patients are now shielded from surprise medical bills, which can be a huge relief for those who've experienced unexpected charges in the past. According to the No Surprises Act, patients can't be charged more than the in-network cost-sharing amount for out-of-network care.

The No Surprises Act applies to emergency services, as well as non-emergency services that are provided by out-of-network providers at in-network facilities. This means that patients can't be hit with surprise bills for things like lab tests or imaging services, even if the provider isn't part of their insurance network.

The No Surprises Act is a law that protects consumers from surprise bills, which can happen when a person receives care from an out-of-network provider or facility without knowing it.

This law was enacted as part of the Consolidated Appropriations Act of 2021 on December 27, 2020. The law creates new requirements for health insurance plans, healthcare providers, and facilities to protect consumers from surprise bills.

The No Surprises Act requires health insurance plans/issuers, healthcare providers, and facilities to follow new rules, including prohibitions on balance billing for certain items and services. This means that patients won't receive surprise bills for care they receive from out-of-network providers or facilities.

The law also requires providers and facilities to give patients notice and consent before providing out-of-network care. This is an important step in protecting patients from surprise bills.

Medicare and Medicaid have their own protections against balance billing, which are separate from the No Surprises Act. However, the law provides additional protections for consumers who receive care from out-of-network providers or facilities.

The No Surprises Act has some key provisions that are essential to understand. The law applies to health insurance plans starting in 2022, including self-insured plans offered by employers and plans from health insurance companies.

Emergency services must be covered without prior authorization, regardless of whether the provider or facility is in-network. This means you won't receive surprise bills for emergency care, even if the facility or provider is out-of-network.

Surprise bills are not allowed for covered non-emergency services performed by an out-of-network provider at an in-network facility. This protection also extends to ancillary services like x-rays, lab tests, or other services.

You can't be asked to waive your protections and agree to pay more for out-of-network care at an in-network facility. This includes care related to emergency medicine, anesthesiology, pathology, radiology, or neonatology, as well as services provided by assistant surgeons, hospitalists, and intensivists.

Here are some key provisions of the No Surprises Act:

If you do choose to receive care from an out-of-network provider, you'll be responsible for paying the balance bill, as well as your out-of-network coinsurance, deductibles, and copays.

Under the No Surprises Act, both patients and insurers have responsibilities to ensure that patients receive fair and transparent care.

Patients have the right to appeal health plan denials and decisions that bill the patient for an amount higher than allowable under the provisions of the law.

If a patient receives an out-of-network notice from a provider prior to service, the insurer and health plan must provide an estimate of the cost of care and the patient's cost-share if they choose to go out-of-network.

The insurer and health plan must also cap the patient's cost-share at the plan's network cost-share level.

Patients will have access to independent external reviewers to make a final determination if the plan upholds its decision.

Here are some key responsibilities for patients and insurers:

The cost calculations for out-of-network emergency services are based on the 'Recognized Amount' for the service rendered. This amount is used to determine the patient's in-network co-insurance.

The Recognized Amount is essentially the median of a plan's contracted rates on January 31, 2019, which is recognized by the plan as the total maximum payment for the service furnished by a provider in the same specialty or geographic region.

This means that the reimbursement amount for out-of-network providers is determined by the health plan's contracted rates, not by the actual cost of the service. The plan's contracted rates are used to calculate the Qualifying Amount.

The Qualifying Amount is the median of the plan's contracted rates, and it's used to determine the patient's in-network co-insurance for out-of-network services. This ensures that patients are protected from surprise medical bills.

If a patient and a provider can't agree on the reimbursement amount, they can raise an Independent Dispute Resolution (IDR). An IDR entity, approved by CMS, will appoint an arbiter to decide on the final amount the payer has to pay to the provider.

If you're paying for services yourself, you have the right to a good-faith cost estimate from the provider.

This estimate will help you avoid surprise medical bills. If a provider bills you $400 or more above that estimate, you can challenge the bill.

You can also dispute your insurer's decision if they deny a claim because they say certain services aren't covered.

Here's a summary of your options:

If you're paying for services yourself, you have the right to a good-faith cost estimate from the provider. This estimate should be accurate, so if a provider bills you $400 or more above that estimate, you can challenge the bill.

You're also entitled to know what services are covered by your insurance and estimate your out-of-pocket costs. If your insurer denies a claim because it says certain services aren't covered, you can dispute that decision.

Here are some key rights to keep in mind:

The South Carolina Department of Insurance (SCDOI) has enforcement over insurance companies and Health Maintenance Organizations (HMOs), while healthcare providers and facilities will be under federal enforcement.

If your health plan denies a claim or charges you more than the law allows, you have the right to appeal. You can dispute a decision and an independent external reviewer will make a final determination.

You can appeal a health plan denial or decision that bills you more than allowed under the law. If the plan upholds its decision, an independent external reviewer will make a final determination.

Here are some options to consider if you receive a surprise medical bill from a provider:

The No Surprises Act has brought significant changes to the way providers and payers operate. The law now requires providers to bill patients no more than the applicable in-network cost-sharing amount, with a penalty of up to $10,000 for each violation.

The billing process has undergone a major overhaul. Providers must now find out the patient's insurance status and submit the out-of-network bill directly to their insurance plan. This new process encourages providers to include all applicable information regarding whether NSA protections apply to the claim and whether the patient has consented to waive their protections.

The health plan must respond within 30 days, advising the provider of the applicable in-network amount for the claim in question, along with an initial payment. The health plan then sends the consumer notification of the claim and the amount owed to the out-of-network provider. At this point, the out-of-network provider can bill the patient.

Here are the key changes to the billing process:

The No Surprises Act's provisions for health plans to provide Advanced Explanation of Benefits documents were delayed, but they will go into effect in July 2022.

This delay gives the industry time to put these processes into place, allowing for a smoother transition.

Providers can no longer bill patients more than the applicable in-network cost-sharing amount, and a penalty of up to $10,000 will be assessed for each violation.

The billing process has been updated. Providers must now find out the patient's insurance status and submit the out-of-network bill directly to their insurance plan.

Here are the key steps in the new billing process:

Providers and payers must also identify bills protected by the No Surprises Act and disclose applicable protections to patients, both on their website and on an individual basis.