Many of us love surprises except when it comes to medical costs. The No Surprises Act, which went into effect on January 1st, aims to restrict surprise billing for patients in employer-sponsored and individual health plans and those who are uninsured (self-pay). It does not affect patients covered by Medicare, Medicaid, Indian Health Services, the VA or Tricare because these programs have other protections in place that accomplish the same thing.
In a nutshell, this new rule will:
- Ban (for health plan enrollees):
- Surprise billing for emergency services by non-network providers.
- Out of network cost-sharing for emergency and certain non-emergency services. Also, in these situations, the patient’s cost for the service cannot be higher than if the services were rendered by an in-network provider, and the coinsurance and deductible must be based on in-network provider rates.
- Out of network charges and balance billing for ancillary care like anesthesia services provided in an in-network facility.
- Certain other out-of-network charges and balance billing without advance notice written in plain language that explains the patient must consent to out-of-network care before he/she can be billed.
- Require providers to give uninsured (self-pay) individuals a good-faith estimate (GFE) of expected charges for scheduled health care services. You can read more about the GFE here, but in summary:
- No specific specialties, facility types or sites of service are exempt from this requirement; all must comply.
- The GFE is required for all scheduled services, which are defined as those that are scheduled at least three days in advance.
- The GFE must be provided in writing, either on paper or electronically based on the patient’s requested method of delivery, and in clear and understandable language. If you provide the GFE verbally, you must follow-up with a written copy. For patients who may be housing insecure and have limited or no internet access, a paper GFE can be provided in person.
- Even if the patient has no financial responsibility, the provider must provide a GFE to every uninsured patient.
Finally, the No Surprises Act requires a way to appeal certain health plan decisions (regarding out-of-network care and charges) as well as a patient-provider dispute resolution process for uninsured patients to determine their costs.