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The No Surprises Act for Employers

The No Surprises Act (NSA) creates new requirements and burdens for employers. Naviguard is here to help.

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What is the No Surprises Act?

The No Surprises Act is designed to increase transparency of health care costs and to protect your employees and plan members from surprise out-of-network balance billing. This has implications for employees and employers alike.

The NSA bans surprise out-of-network medical bills in many, but not all, emergency and nonemergency situations. The NSA goes into effect on or after Jan. 1, 2022, as plans renew.

Under the NSA, health plan members are not liable for most OON costs outside of their control, requiring them to only pay the statutorily limited cost-share. There is an Independent Dispute Resolution (IDR) process available for OON providers to dispute the remainder of their payment with the plan.

What the No Surprises Act Means for Employers

For employer-funded health plans, the NSA demands that significant requirements are met in provider/plan billing disputes. Check your health care plan for any restrictions on providers and other administrative particulars.

The NSA also creates some new requirements for ID cards and cost estimates, including:

  • Online and printed ID cards listing all deductibles and OON maximums, as well as insurer contact information
  • Cost estimates for services that are scheduled three days or more in advance. This estimate is based on the employee’s plan and will be sent to them via email or mail.

 

It’s a good idea to let your employees know that these changes are coming and how they will be protected once the No Surprises Act goes into effect. It is important for your employees to understand their rights under this new law.

What is Independent Dispute Resolution (IDR)?

Independent Dispute Resolution (IDR) is the process to settle any disputes related to reimbursement for the types of OON services outlined in the NSA.

Under the new legislation, if there is a dispute over the amount paid to the provider, your covered employees are only responsible for the amount they would pay if the services were provided by an in-network provider.

The provider and the insurance plan are responsible for coming to a resolution with the help of an independent arbitrator, in a process that will look like this:

FAQs

The No Surprises Act prohibits surprise medical bills for out-of-network care for most emergency situations, including out-of-network air ambulances, and out-of-network care provided at in-network facilities As a result, patients will be protected from surprise bills in most situations where they have little or no control over who provides their care.

However, the law does not apply if the member chooses to receive items and services from an OON provider. The No Surprises Act also does not apply for ground ambulance services, or when the law’s notice and consent requirements are met.

The No Surprises Act also establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between OON providers and insurers/health plans.

Under the law, effective upon plan years beginning on or after January 1 2022, out-of-network providers are prohibited from surprise medical bills in situations where they have little or no control over who provides their care, like for all emergency services (except ground ambulance), or when an out-of-network provider is involved in their care while they are at an in-network facility.

If a patient receives a service that is covered by the No Surprises Act, the law caps the patient’s cost share to what it would be if the services were provided in-network.

Patients are protected from surprise bills when you receive:

  • Out-of-network emergency services, including air ambulance (but not ground ambulance)Covered medical items and services performed by an OON provider at an INN facility (unless the provider follows the notice and consent process described above).
  • Out-of-network non-emergency, ancillary services* provided at in-network facility.
  • Non-emergency, non-ancillary services provided at in-network facility, and the provider did not get your prior consent in the way the No Surprises act requires.

 

And, for the above services, your health plan must ensure your cost-share (in other words, your coinsurance, copay, deductible):

  • Is the same as it would have been if the service was provided in-network. Out-of-network non-emergency, ancillary services* provided at in-network facility.
  • Is based on what your plan would pay an in-network provider.
  • Counts toward your in-network deductible.
  • Counts toward your out-of-pocket maximum.

 

*Ancillary services include services related to emergency medicine, anesthesiology, pathology, radiology and neonatology; certain diagnostic services (including radiology and laboratory services); items and services provided by other specialty practitioners; and items and services provided by an out-of-network provider if there is no in-network provider that can provide that service.

Remember: In-network providers are not allowed to balance bill. If you are asked to give up your protections against surprise billing through the Notice and Consent form, you have options. Contact your health plan for help finding an in-network option.

You can find an explanation of what out-of-network laws are currently in place in your state here.

The law may not pre-empt state surprise billing laws that establish a process for determining OON reimbursement for covered items and services for insurers subject to the state’s law.

Insurer and health plans: provisions applicable to insurers and health plans are enforced by the applicable federal agency (the Departments of Health and Human Services, Labor, and the Treasury).

Providers and facilities: provisions applicable to health care providers and facilities are enforced by the Department of Health and Human Services which may impose fines of up to $10,000 per violation.

States: provisions applicable to providers and facilities (including air ambulance) may be enforced by the states.

The law is effective for policy and plan years on or after January 1, 2022.  Therefore, if a plan renews during 2022, the No Surprises Act will go into effect on the renewal date (which is 12/1/22 in this example).

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