One Step Closer to the End of Surprise Medical Bills – Maybe

Posted December 20th, 2020

After ongoing negotiations for over two years, Congress has released Discussion Draft legislative text of the proposed No Surprises Act that seeks to protect patients from receiving surprise medical bills (unexpected medical bills for out-of-network and emergency care).

Highlights of the Proposed Act
  • Patients cannot be balance billed:
    1. by out-of-network providers at in-network facilities (with limited exceptions, if consent is obtained 72 hours earlier);
    2. for out-of-network emergency care; and
    3. in cases where patients are transferred from an in-network facility to an out-of-network facility without sufficient notice and consent.
  • Requires self-insured plans to provide an Advanced Explanation of Benefits for scheduled services to patients at least three days in advance, which would include treatment, expected cost and network status of provider.
  • Providers must verify three days in advance of services, and not later than one day after scheduling, the type of coverage the patient is enrolled in and good faith estimate of service.
  • Requires health plans to provide price comparison tool for consumers.
  • Certain out of-network provides are prohibited from balance billing patients unless they give appropriate notice of network status and an estimate of charges 72 hours in advance. If the appointment is made within that time frame, the patient must receive notice the day of the appointment.
  • Prohibits air ambulance providers from billing patients more than the in-network cost sharing amount, constitutes such cost-sharing amount shall be counted towards the in-network deductible/ in-network out-of-pocket maximum, and institutes an arbitration process for out-of-network providers.
  • Creates a complex arbitration process between insurers/ self-insured plans and medical providers should a negotiated payment not be agreed upon between these payers and the providers within a 30-day time frame.

The No Surprises Act also includes a provision related to increasing the transparency of health claims through a state All Payer Claims Database (APCD). For self-insured plans, the proposal requires the Secretary of Labor to establish a national standard for plans to report to their health claims data to states that establish their own APCD

The proposal requires HHS and Treasury to establish details through rule making for the surprise billing provisions no later than July 21, 2021.

Employers need not take any action as a result of the proposed No Surprises Act, however it is important to keep abreast of the continued negotiations and movement of the Act. If passed, employers would need to update plan documents and procedures to ensure compliance with the Act.

Please be aware that the determination of the requirements and the application of specific laws and regulations to each employee welfare plan and/or employer may differ due to a number of variables. Nothing in this newsletter should be construed as tax or legal advice.

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