CMS issues interim final rule to address surprise and balance billing
Will this be the end of out-of-network billing?
The Biden administration on Thursday issued an interim final rule that restricts excessive out-of-pocket costs to consumers from surprise billing and balance billing.
“No patient should forgo care for fear of surprise billing,” HHS Secretary Xavier Becerra said. “Health insurance should offer patients peace of mind that they won’t be saddled with unexpected costs. The Biden-Harris administration remains committed to ensuring transparency and affordable care, and with this rule, Americans will get the assurance of no surprises.”
Related: No Surprises Act: Practical effects of independent dispute resolutions
Among other provisions, the new rule:
- Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
- Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
- Bans out-of-network charges for ancillary care (such as an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
- Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.
“No one should ever be threatened with financial ruin simply for seeking needed medical care,” Labor Secretary Marty Walsh said. “Today’s interim final rule is a major step in implementing the bipartisan No Surprises Act that will protect Americans from exorbitant health costs for unknowingly receiving care from out-of-network providers.”
The new regulations will take effect for health care providers and facilities on Jan. 1, 2022. For group health plans, health insurance issuers and Federal Employees Health Benefits Program carriers, the provisions will take effect for plan, policy or contract years beginning on or after Jan. 1, 2022.
“Facing a difficult medical situation is challenging enough — no one should then face a surprise medical bill when they get home,” said Kiran Ahuja, director of the Office of Personnel Management. “This interim rule helps to protect Americans from financial ruin and honors federal employees, retirees, their covered family members and other enrollees who receive health care through the FEHB Program, the largest employer-sponsored plan, by giving them new protections from unexpected medical bills.”
The ERISA Industry Committee responded to the announcement, seeing the new rule as a win for employers and employees. “Employers work hard to protect our employees from ever-increasing health care costs, and surprise bills too often undermined the protection and peace of mind that employee benefits should provide,” said James Gelfand, senior vice president of Health Policy for the ERISA Industry Committee. “Because of the strong regulations released today, January of 2022 will mark the end, once and for all, of these predatory billing practices – and will do so without burdening patients with higher health insurance premiums.”
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