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No Surprises Act Key Facts

December 30, 2020 No Surprises Act Key Facts

Congress passed the No Surprises Act ("Act") as part of the recent stimulus bill and it was signed into law on December 28. The major provisions of the Act go into effect January 1, 2022.

The Act
  • Applies to the 135 million people with self-funded coverage, as well as those in fully -insured plans.
  • Makes patients responsible for only cost sharing amount that they would pay to in-network providers in either an emergency or nonemergency setting.
  • Bars providers from holding patients responsible for higher amounts unless the patient specifically agrees to be balance billed.
  • Extends balance billing protection to patients utilizing federally regulated provides including Air Ambulance services, but not ground ambulances.
  • Makes payors responsible for paying an amount above the patient responsibility based on an amount negotiated with the provider.
  • Requires health plans to provide an Advance Explanation of Benefits for scheduled services at least three days in advance to give patients transparency into which providers are expected to provide treatment, the expected cost, and the network status of the providers.
  • Ensures continuity of care by requiring a 90-day period of continued coverage for patients with complex care needs when their provider changes network status.
  • Requires the Secretary of Health and Human Services to devise a system for determining how much providers are paid.

    • Providers and payers will have 30 days to privately, voluntarily negotiate a payment amount.
    • If no agreement can be reached, either party can request an independent dispute resolution within 4 days of payment by the payor. If the provider does not make that request, they are accepting the payor's payment as adequate.
    • Baseball-type arbitration will be utilized when an independent dispute resolution is requested.
    • The losing party pays the cost of arbitration.

30 states already have No Surprise Billing laws in place. Importantly, while self-funded plans are not regulated by the states, some state's laws allow self-funded plans to opt-in to be governed by these laws.

HHC Group can help. We've been successfully negotiating in and out-of network medical bills, including surprise bills, since 1995. To have us start negotiating medical bills for you call (301) 962-2001 or connect here.

More Detail: Surprise! Congress Takes Steps to Curb Unexpected Medical Bills | Kaiser Health News (khn.org)