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Per CMS: As of January 1, 2022, consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.

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This chart below compiles all recent laws and rules concerning Surprise Billing Laws as of January 1, 2022. Providers should consult with legal counsel as to the application of any particular law or regulation to their health plan.

No Surprises Act: emergency services

Plans must cover emergency services at non-participating facility, services/items provided by non-participating provider at a participating facility, or non-participating provider air ambulance services with the same participant cost-sharing

whether the services are from a participating or non-participating provider or facility. Providers

and facilities are banned from balance billing.

Plans must cover emergency services at non-participating facility, services/items provided by non-participating provider at a participating facility, or non-participating provider air ambulance services with the same participant cost-sharing

whether the services are from a participating or non-participating provider or facility. Providers

and facilities are banned from balance billing.

Plan years beginning on or after January 1, 2022

Group health plans* and health insurers

No Surprises Act: independent dispute resolution

Plans must pay non-participating providers within 30 days or deny payment. Parties may request independent dispute resolution

Plan years beginning on or after January 1, 2022

Group health plans and health insurers

No Surprises Act: qualifying payment

amount

Federal agencies must issue rulemaking establishing the amount methodology to determine "qualifying payment amount," differentiating by large and small group markets.

No later than July 1, 2021

ID card requirement

Plans must include plan deductibles, out-of-pocket (OOP) maximums and consumer assistance contact information (phone number and website) in clear writing on any physical or electronic plan or insurance identification card.

Plan years beginning on or after January 1, 2022

Group health plans and health insurers

External review

External review applies to adverse determinations concerning emergency services or air ambulance services covered by the No Surprises Act.

No later than January 1, 2022

Unclear — probably non-grandfathered group health plans and insurers

* Covered group health plans generally include those subject to federal health care reforms under ERISA, the Internal Revenue Code and the Public Health Service Act. Certain health plans otherwise excepted from federal health laws, e.g., small group health plans, excepted benefits and retiree-only plans, would appear to be exempt from these requirements, but applicability should be clarified in regulatory guidance. It appears that the requirements of this law apply to grandfathered group health plans, but this should also be addressed in regulatory guidance.

Provider fee disclosure

When a patient schedules a service, providers must provide a timely notification in clear and understandable language of the good-faith estimate of the expected charges for providing items and services to the plan or insurer (or if uninsured, the individual).

January 1, 2022

Healthcare providers and facilities

Advanced Explanation of provider/facility of estimated Benefits disclosure

After receiving notice provider/facility of estimated charges, plans must provide the participant an Advanced Explanation of Benefits (EOB) including rate and cost-sharing information.

Plan years beginning on or after January 1, 2022

Group health plans and health insurers

Notice of continuity of care

Plans must notify individuals who are "continuing care patients" of the right to continue to receive care after termination of a provider/facility contract. The notice places rules on contract terms and plan rules.

Plan years beginning on or after January 1, 2022

Group health plans and health insurers

Provider directory requirements

Plans must create a process to verify the accuracy of their provider databases and update at least every 90 days. If the participant was informed the provider was a participating provider when in fact a non-participating provider, the plan cannot impose higher cost-sharing that would apply for participating provider, and must apply the participating deductible and OOP.

Plan years beginning on or after January 1, 2022

Group health plans and health insurers

Gag clauses prohibited

Plans may not enter into an agreement with a provider, network, TPA or other service provider that would directly or indirectly restrict the plan from providing provider-specific cost or quality information to referring providers, plan sponsors, participants or electronically accessing de-identified claims.  Requires annual attestation of compliance

Unclear

Group health plans and health insurers

Disclosure of broker and consultant compensation

Amends ERISA Section 408(b)(2) to require disclosure of compensation

December 27, 2021,

with transition period for executed contracts

ERISA-governed plans

Mental Health Parity and Addiction Equity Act (MHPAEA) assessment required

Plans must perform and document comparative analyses of the design and application of non-quantitative treatment limitations (NQTLs) and make them available upon request to the secretary of the DOL or HHS as applicable

February 10, 2021 (45 days after  enactment)

Plans subject to the MHPAEA

Reporting on prescription drug costs

Plans must submit prescription drug cost information to the federal government.

No later than December 27, 2021; for each year thereafter, no later than June 1

Unclear — probably non-grandfathered group health plans and insurers

For questions or to set up a free consultation intro call contact rick@revenuemasters.com 

or call direct at 877-591-2590 or

RevenueMasters offers turnkey SaaS and services compliance solutions.

This resource is for informational purposes only and does not constitute legal, tax or investment advice. You are encouraged to discuss the issues raised here with your legal, tax and other advisors before determining how the issues apply to your specific situations.

© 2022 by Revenue Masters

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