Employee Assistance Program (EAP)/Professional Standards Committee
- New rules that went into place on January 1, 2022 will provide new billing protections related to some medical care expenses.
- The new rules provide expanded protections against the practice of “balance billing” by providers in certain instances.
- You can read more about these new protections at www.cms.gov/nosurprises/consumers.
Starting January 1, 2022, consumers will 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 will be 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. The Consolidated Appropriations Act of 2021 contains many provisions to help protect consumers from surprise bills starting in 2022, including the No Surprises Act under title I and Transparency under title II.
What are surprise medical bills?
If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the entire out-of-network cost. This can leave you with higher costs than if you got care from an in-network provider or facility. In the past, in addition to any out-of-network cost sharing you might owe, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.
What are the new protections if I have health insurance?
If you get health coverage through your employer, the Health Insurance Marketplace®, or an individual health insurance plan you purchase directly from an insurance company, these new rules will:
- Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
- Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
- Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at an in-network facility.
- Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive and options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.
Are there exceptions to these protections?
Some health insurance coverage programs already have protections against high medical bills. You’re already protected against surprise medical billing if you have coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE.
If you would like to learn more about protections for consumers, understanding costs in advance to avoid surprise bills, and what happens when payment disagreements arise after receiving medical care go to www.cms.gov/nosurprises/consumers.