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No Surprises Act Information
Overview of the No Surprises Act:
The Consolidated Appropriations Act of 2021 was enacted on December 27, 2020, and contains many provisions to help protect consumers from surprise bills, including the No Surprises Act. The No Surprises Act of the Consolidated Appropriations Act (NSA) creates new requirements that apply to health insurance plans/issuers, healthcare providers (including air ambulance providers), and facilities, regarding such topics as cost-sharing rules, prohibitions on balance billing for certain items and services, notice and consent requirements, and requirements related to disclosures about balance billing protections.
Surprise Billing (Balance Billing):
A surprise bill is an unexpected bill from a health care provider or facility. This can happen when a person with health insurance unknowingly gets medical care from a provider (including air ambulance providers) or a facility outside their health plan's network.
Need a quick answer to a question about the No Surprises Act? Visit our FAQs.
Balance Billing:
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. Balance billing isn’t allowed for emergency care, even at out-of-network hospitals, emergency departments, or air ambulance companies.
If you go to an in-network hospital or ambulatory surgical center for non-emergency care, balance billing isn’t allowed for any of these ancillary* services:
- Anesthesiology, pathology, radiology, or neonatology.
- Care from assistant surgeons, hospitalists, or intensivists.
- Diagnostics like radiology or laboratory services.
- Any other item or service from an out-of-network provider, if an in-network provider wasn’t available.
*Ancillary services are medical services or supplies that are not provided by acute care hospitals, doctors, or health care professionals.
Consent for Out-of-Network Billing:
When you receive emergency care from an out-of-network provider at an in-network facility, they can only send you a balance bill if all of these are true:
- The provider isn’t on the ancillary services list above.
- They give you a plain-language explanation of your rights.
- You give written consent to give up your protections against balance billing.
Choosing to Go Out-of-Network:
If you choose to go out-of-network for specialized care in a non-emergency situation, you waive your right to balance billing protections.
Disputes Over What You Owe:
- If you’re paying for services yourself (self-pay or uninsured), you have the right to a good-faith cost estimate from the provider. If a provider bills you $400 or more above that estimate, you can challenge the bill.
- If you’re using insurance, your insurer can tell you what’s covered 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.
Enforcement and Consumer Appeals:
- The SCDOI has enforcement over issuers (insurance companies and HMOs), while providers and facilities will be under federal enforcement.
- Consumers will 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 the plan upholds its decision, an independent external reviewer will make a final determination.
- If you believe you have received a surprise medical bill from a provider for the services specified above, you have several options to consider.
- If your insurance is denying the claim, you can contact the Office of Consumer Services here at the SCDOI. Please call 803-737-6180 to speak with an Insurance Regulatory Analyst. You can also email your question to consumers@doi.sc.gov or file an online complaint here.
- If your issue is with the provider or healthcare facility, contact the federal government by visiting CMS.gov/nosurprises to file a complaint or by calling 800-985-3059 (toll-free).
Arbitration Between Providers and Insurers:
The No Surprises Act provides insurance companies and health care providers a fair process to resolve [out-of-network] bills without additional cost to patients, meaning, you don’t need to be involved in negotiations or disputes between providers and your insurer. If they disagree over a payment, they need to either work it out themselves or use a new arbitration process.
What isn't Covered by the No Surprises Act:
The No Surprises Act doesn’t ban all surprise and out-of-network bills. Here are two important exceptions:
- Ambulances: The act covers air ambulances, but not regular ground ambulances.
- Facilities: The act applies to care provided in hospitals, emergency departments, and ambulatory surgical centers. Other facilities like clinics and urgent care centers aren’t included but might be added later.
These protections don’t apply to those who are covered by Medicare, Medicaid, TRICARE, Veterans Affairs Health Care or Indian Health Services as these plans already are protected against surprise medical bills.
Compliance Deadlines:
The No Surprises Act’s provisions for health plans to provide Advanced Explanation of Benefits documents (AEOB) and publish in-network rates, prescription prices, and out-of-network charges for full transparency to consumers were delayed by agreement between federal regulators and the health insurance industry. While the majority of the No Surprises Act went into effect on January 1, 2022, the AEOB and Transparency in Coverage components will go into effect in July of 2022. This gives the industry time to put these processes into place.
Changes to Workflow:
- Providers can no longer bill patients more than the applicable in-network cost-sharing amount. A penalty of up to $10,000 will be assessed for each violation.
- The billing process has changed. Providers will have to find out the patient’s insurance status and submit the out-of-network bill directly to their insurance plan. The provider is encouraged to include all applicable information regarding whether NSA protections apply to the claim and whether the patient has consented to waive their protections.
- Health plans must respond within 30 days, advising the provider of the applicable in-network amount for the claim in question (which is based on the median in-network rate the plan pays for the services rendered) 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.
- 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 to patients that receive services covered by the law.
Insurer and Health Plan Responsibilities:
The insurer and health plan have certain responsibilities if a member gets out-of-network notice from a provider prior to service, including:
- Include in-network and out-of-network deductibles and the in-network and out-of-network out-of-pocket max on the ID Card.
- Count all cost-share toward plan deductible and out-of-pocket max unless the member agreed to receive out-of-network care.
- Cap member cost-share at the plan’s network cost-share level.
- Provide an estimate of the cost of care and member cost-share if the member chooses to go out-of-network.
- Provide information to members on how to receive the items and services in-network.
Patient Consent and Waivers:
- The law provides for patients to waive their rights under the No Surprises Act. Providers can refuse care if the patient refuses to give consent to waive their NSA protections. However, this is intended for use under limited circumstances, such as when a patient chooses to seek care from an out-of-network provider despite in-network alternatives and must not be used to circumvent consumer 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.
- The patient 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.
Enforcement and Consumer Appeals:
- The SCDOI has enforcement over issuers (insurance companies and HMOs), while providers and facilities will be under federal enforcement.
- Consumers will 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 the plan upholds its decision, an independent external reviewer will make a final determination.
Overview of Cost Calculations and Resolution:
A critical element of balance billing prohibitions is how the cost-share for patients is calculated. It has been decided that 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.
The reimbursement amounts for out-of-network providers by the health plans can either be reached with consent by both the parties or they can raise an Independent Dispute Resolution (IDR), which is conducted by a CMS-approved IDR entity by appointing an arbiter to decide on the final amount the payer has to pay to the provider.
Report a Surprise Bill:
Contact the federal government by visiting CMS.gov/nosurprises to file a complaint or by calling 800-985-3059 (toll-free).
Or contact the Office of Consumer Services here at the SCDOI by calling 803-737-6180, emailing your question to consumers@doi.sc.gov, or you can file an online complaint here.
Find Out More:
- CMS Ending Surprise Medical Bills
- NAIC Comments on the No Surprises Act
- Center for Consumer Information and insurance overview of the No Surprise Act.