The No Surprises Act Begins January 2022:
This is What You Can Expect
The “No Surprises Act,”
which establishes new federal protections against most surprise
out-of-network medical bills when a patient receives out-of-network
services during an emergency visit or from a provider at an in-network
hospital without advance notice, will take effect next month. A new KFF
brief outlines what to expect in 2022, summarizing key
provisions that will be implemented.
Most adults (2 in 3) say they worry about unexpected medical bills and
among privately insured patients, about 1 in 5 emergency claims and 1 in
6 in-network hospitalizations include at least one out-of-network bill.
The new federal protections will apply to most surprise bills for
emergency care, as well as for non-emergency services provided at
in-network facilities, potentially helping alleviate this worry.
The No Surprises Act prohibits providers from billing patients more than
the applicable in-network cost sharing amount in these situations.
Starting in 2022, providers will need to find out patient’s insurance
status before submitting the surprise out-of-network bill directly to the
health plan. However, patients can give written consent to waive their
rights under the No Surprise Act and be billed more by out-of-network
providers. It is expected this should only happen in limited
circumstances.
The brief also describes procedures to arrive at payment amounts for
surprise bills, including use of an independent dispute resolution (IDR)
system. Under this system, it is likely that out-of-network payments will
be close to the median rate that health plans pay for in-network
services, and this would moderate health plan premiums overall. However,
suits filed by provider organizations are pending and could result in
further regulatory changes or delay implementation of the law.
If a patient receives what they believe is a surprise bill, the new brief
highlights protections, and ways to seek help. This is a complex law, with
enforcement being conducted in a variety of ways, both by federal and
state agencies.
The No Surprises Act allows consumers to appeal disputes over coverage of
surprise medical bills to an external reviewer. Another new KFF
brief looks at the process for consumer appeal rights under
the Affordable Care Act (ACA), which would also be used for surprise
bills. Federal law gives consumers the right to appeal health plan claims
denials and other adverse decisions, including the incorrect application
of cost sharing, although limits apply. This brief describes consumer
access to appeals and limits on appeal rights that have been adopted
through federal regulations.
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