No Surprises Act Summary: Implementation, Enforcement, and Compliance

The No Surprises Act is a federal law that protects patients from surprise medical bills. It was enacted on December 27, 2020, as part of the Consolidated Appropriations Act, 2021.

To be eligible for No Surprises Act protections, patients must receive emergency services or scheduled services at an in-network facility. This includes services provided by out-of-network providers at in-network facilities.

The law applies to emergency services, including air ambulance services, and applies to all patients, regardless of their insurance coverage.

Surprise Billing is a real concern for many people, and it's essential to understand what it is and how it works. A surprise bill is an unexpected bill from a health care provider or facility, often due to receiving care from someone outside your insurance plan's network.

This can happen when you unknowingly get medical care from a provider or facility outside your plan's network, such as an air ambulance provider. You may receive a surprise bill for the difference between what your insurance plan agreed to pay and the full cost of the service.

The No Surprises Act bans balance billing for emergency services and some non-emergency services. As of January 1, 2022, your insurance has to cover emergency services as in-network with no prior authorization. This means you won't receive a surprise bill for emergency care, even at out-of-network hospitals or air ambulance companies.

However, if you receive non-emergency care at an in-network hospital or ambulatory surgical center, balance billing isn't allowed for certain ancillary services, such as:

To avoid surprise bills, it's crucial to understand your rights and the protections in place. The No Surprises Act provides patients with protections against receiving surprise medical bills for emergency services and certain scheduled services without prior patient consent.

As a consumer, you have rights under the No Surprises Act to resolve disputes over what you owe for out-of-network services.

If you're paying for services yourself, you have the right to a good-faith cost estimate from the provider, and can challenge the bill if it's more than $400 above that estimate.

You can also dispute your insurer's decision to deny a claim because it says certain services aren't covered.

A critical element of balance billing prohibitions is how the cost-share for patients is calculated. The patient's in-network co-insurance for an out-of-network emergency or provider's services is to be calculated based on the 'Recognized Amount' for the service rendered.

The recognized amount is treated as the 'Qualifying Amount', which is the median of a plan's contracted rates on January 31, 2019, that is recognized by the plan as total maximum payment for the service furnished by a provider in the same specialty or same geographic region where out-of-network service was provided.

Insurance companies and health care providers have a new arbitration process to resolve out-of-network bills without additional cost to patients. This means you don't need to be involved in negotiations or disputes between providers and your insurer.

If providers and insurers disagree over a payment, they can either work it out themselves or use the arbitration process. This ensures a fair process to resolve out-of-network bills without putting patients at risk of surprise medical bills.

The No Surprises Act has put in place a system for enforcement and compliance. The South Carolina Department of Insurance (SCDOI) has enforcement over insurance companies and HMOs, while providers and facilities will be under federal enforcement.

Consumers have the right to appeal health plan denials and decisions that bill them for an amount higher than allowable under the law. If the plan upholds its decision, an independent external reviewer will make a final determination.

If you believe you've received a surprise medical bill from a provider, you have several options to consider.

So, you want to know about enforcement mechanisms? Well, the South Carolina Department of Insurance (SCDOI) has enforcement over issuers, which includes insurance companies and HMOs.

They have the authority to oversee these companies and ensure they comply with the law. This includes monitoring their practices and taking action if they're not following the rules.

Consumers have the right to appeal health plan denials, which means if a plan denies a claim or bills a patient for more than they should, the consumer can dispute it. This is a crucial step in ensuring that patients aren't unfairly charged.

Here are the steps to follow if you want to appeal a health plan denial:

The SCDOI also ensures that providers and facilities are held accountable under federal enforcement. This means that these healthcare providers will be subject to federal regulations and oversight.

The No Surprises Act's provisions for health plans to provide Advanced Explanation of Benefits documents have been delayed.

The deadline for these provisions, along with publishing in-network rates, prescription prices, and out-of-network charges for full transparency to consumers, is July 2022.

This delay gives the industry time to put these processes into place, as agreed upon by federal regulators and the health insurance industry.

The majority of the No Surprises Act went into effect on January 1, 2022, but the AEOB and Transparency in Coverage components will be delayed until July 2022.

As a patient, it's essential to understand your rights and responsibilities under the No Surprises Act. You have the right to receive a notice from your health plan if you receive care from an out-of-network provider prior to service, which must include information on in-network and out-of-network deductibles and out-of-pocket max.

If you receive a surprise medical bill, you have the right to appeal the health plan's decision and have an independent external reviewer make a final determination if the plan upholds its decision. You can also expect to be given an estimate of the cost of care and your cost-share if you choose to go out-of-network.

Here are some key patient rights and responsibilities:

You have the right to waive your rights under the No Surprises Act, but this is only allowed in limited circumstances. Providers can refuse care if you refuse to give consent to waive your NSA protections.

Consent waivers are not permitted for emergency services, ancillary services, urgent medical needs, and services from an out-of-network provider if there's not an in-network provider available for that service at a given facility.

You must waive consent at least 72 hours in advance of a scheduled procedure when possible. Providers cannot seek consent to waive NSA rights from a patient impaired or otherwise incapable of making an informed decision.

Here are some key things to know about patient consent:

In some cases, you may be asked to give written consent to receive out-of-network care. This is only allowed if the provider gives you a plain-language explanation of your rights and you give your consent in writing.

The No Surprises Act is a game-changer for patients. It protects you from receiving surprise medical bills due to receiving care from an out-of-network facility or provider during an emergency.

You're protected from surprise bills for most emergency services, even if you get them out-of-network and/or without approval beforehand. This means you won't be stuck with a huge bill for emergency care.

If you get health coverage through your employer or have an individual or family health plan, you're entitled to certain protections. Here are some key benefits:

These protections are crucial, especially in emergency situations where you can't control who is involved in your care.

Under the No Surprises Act, you're protected from surprise medical bills for emergency services and certain scheduled services without prior patient consent.

Emergency services, including air ambulance companies, are now considered in-network with no prior authorization. This means you won't receive a surprise bill for emergency care, even if you receive it at an out-of-network hospital or emergency department.

If you go to an in-network hospital or ambulatory surgical center for non-emergency care, balance billing isn't allowed for certain ancillary services. These services include anesthesiology, pathology, radiology, or neonatology, as well as care from assistant surgeons, hospitalists, or intensivists.

You have the right to receive a good faith estimate of your potential bill for medical services when scheduled at least three days in advance. This applies to patients who don't have insurance or who are not using insurance to pay for care.

Here's a list of protected services under the No Surprises Act: