Billing Protections Effective January 1, 2022

As of January 1, 2022, new billing protections are in place for consumers receiving emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. These rules aim to minimize excessive out-of-pocket expenses for consumers. Emergency services are now covered without requiring prior authorization and irrespective of whether the provider or facility is in-network.

Higher Expenses in Emergency Situations and Hospital Stays

Before these changes, if a consumer with health insurance received care from an out-of-network provider, their insurance usually wouldn’t cover the full cost. This often led to higher expenses for consumers, particularly in emergency situations or when receiving care from out-of-network providers at in-network hospitals.

The Issue of Balance Billing

The practice of charging consumers the difference between the billed amount by the out-of-network provider and what the insurance covered, known as “balance billing,” often resulted in “surprise bills.”

Protection Through the Consolidated Appropriations Act

The Consolidated Appropriations Act of 2021, enacted on December 27, 2020, includes provisions like the No Surprises Act to protect consumers from such unexpected charges.

What is a Surprise Medical Bill?

If you’ve ever received a bill that was much higher than expected after visiting a healthcare provider, you’ve encountered a ‘surprise medical bill.’ This typically happens when you get care from an out-of-network provider.

How Does This Rule Help Consumers?

Key Features:

• Consumer-Centric Payment Disputes: The rule creates a system to resolve payment issues between healthcare providers and insurance companies, leaving consumers out of the fray.

• Cost Estimates for Uninsured or Self-Pay Patients: The rule mandates healthcare providers to offer cost estimates to uninsured or self-pay patients.

• Extended Rights for Appeals: This rule expands your ability to appeal denied claims, particularly those related to surprise billing.

Who Benefits?

• For uninsured or self-pay individuals, this rule provides mechanisms to understand costs upfront and dispute high bills.
• If you have employer-sponsored health coverage, are part of a multi-employer plan, or have purchased a plan through federal or state-based marketplaces, this rule applies to you. 

How Does the Rule Work in Practice?

• Payment Disputes: The new guidelines establish a 30-business-day negotiation period between your health plan and the out-of-network provider to agree on payment terms. If no agreement is reached, an independent entity steps in to resolve the dispute.

• For Uninsured or Self-Pay Individuals: Providers are required to give a ‘good faith estimate’ of charges. If the final bill exceeds this estimate by $400 or more, a dispute resolution process is triggered.

• Expanded External Reviews: You now have the right to an external review for more types of denied claims, including those related to surprise billing protections under the No Surprises Act.

When Does It Take Effect?

These consumer protections take effect on January 1, 2022.

How Do I Stay Up To Date?

Please note that additional updates are expected. Feel free to visit CMS’s dedicated webpage on the No Surprises Act (https://www.cms.gov/nosurprises) for more information.