REQUIREMENTS UNDER THE FEDERAL NO SURPRISES ACT
The federal No Surprises Act (NSA) becomes effective on January 1, 2022 and offers new protections applicable to health insurance enrollees in Connecticut.
Depending on circumstances, enforcement of these federal law provisions and similar Connecticut Surprise Billing laws may come from one of several federal and state regulatory entities, including but not limited to the Connecticut Insurance Department. Under this framework, the Insurance Department intends to continue its responsibilities and commitment to protect consumers, including receiving complaints from consumers on issues related to the NSA and Connecticut Surprise Billing laws. These complaints may concern health plans and health care providers and facilities and may be referred, as appropriate, to other state or federal agencies for investigation and enforcement.
Connecticut passed its own NSA law in 2015 that applies to all fully insured health plans regulated by the Department of Insurance. More information on that state law is available in the following statutes, Conn. Gen. Stat. §§ 38a-477aa and 20-7f.
As part of the Consolidated Appropriations Act of 2021, on December 27, 2020, the U.S. Congress enacted legislation, the federal No Surprises Act (NSA), which contains many provisions to help protect consumers from surprise bills starting January 1, 2022. The provisions in the NSA create requirements that apply to health care providers and facilities and providers of air ambulance services, such as cost-sharing rules, prohibitions on balance billing for certain items and services, notice and consent requirements and requirements related to disclosures about balance billing protections.
These health care provider and facility and provider of air ambulance services requirements generally apply to items and services provided to individuals enrolled in group health plans or group or individual health insurance coverage, including Federal Employees Health Benefit plans. The NSA’s requirements related to the patient-provider dispute resolution process also apply to individuals with no health insurance coverage
Health Care Provider and Facility Requirements that Apply Starting January 1, 2022
Health care providers and facilities and providers of air ambulance services:
- May not balance bill for out of network emergency services (Conn. Gen. Stat. §§ 38a-477aa and 20-7f; Public Health Services Act (PHSA) section 2799B-1; 45 C.F.R. section 149.410).
- May not balance bill for non-emergency services by nonparticipating providers at certain participating health care facilities, unless notice and consent was given in some circumstances (Conn. Gen. Stat. §§ 38a-477aa and 20-7f; PHS Act section 2799B-2; 45 C.F.R. section 149.420).
- Shall disclose patient protections against balance billing (PHS Act section 2799B-3; 45 C.F.R. section 149.430).
- May not balance bill for air ambulance services by nonparticipating air ambulance providers (PHS Act section 2799B-5; 45 C.F.R. section 149.440).
- Once applicable rules are in place, shall provide a good faith estimate in advance of scheduled services, or upon request (PHS Act section 2799B-6; 45 C.F.R. section 149.610 (for uninsured or self-pay individuals).
- Shall improve provider directories and reimburse enrollees for errors (PHS Act section 2799B-9).
The Following is a Summary of Major NSA Health Care Provider and Facility Requirements Consumers Should be Aware of
- No balance billing for out-of-network emergency services
Nonparticipating providers and nonparticipating emergency facilities :
- Cannot bill or hold liable enrollees in group health plans or group or individual health insurance coverage who received emergency services at an emergency department of a hospital or an independent freestanding emergency department for a payment amount greater than the in-network cost-sharing requirement for such services.
- Post-stabilization services are considered emergency services, and are therefore subject to this prohibition, unless notice and consent requirements are met.
- Exceptions to no balance billing for out-of-network emergency services—notice and consent
Nonparticipating providers and facilities may balance bill for post-stabilization services only if the following conditions have been met:
Even if all of the conditions above are met:
- The attending emergency physician or treating provider determines that the enrollee: 1) can travel using nonmedical transportation to an available participating provider or participating health care facility; and 2) is in a condition to receive notice and provide informed consent; and
- The nonparticipating provider or non-participating facility provides the beneficiary, enrollee or participant with a written notice and obtains consent as outlined in the NSA’s regulation and guidance.
- With respect to both emergency and non-emergency services, a provider or facility cannot balance bill for items or services furnished because of unforeseen, urgent medical needs that arise at the time an item or service is furnished, regardless of whether the nonparticipating provider or facility previously satisfied the notice and consent criteria.
Nonparticipating providers of non-emergency services at a participating health care facility:
- Cannot bill or hold liable enrollees in group health plans or group or individual health insurance coverage who received covered non-emergency services with respect to a visit at a participating health care facility by a nonparticipating provider for a payment amount greater than the in-network cost-sharing requirement for such services, unless notice and consent requirements are met.
- Note: The exception for notice and consent requirements does not apply to the following list of ancillary services, for which the prohibition against balance billing remains applicable:
- Items and services related to emergency medicine, anesthesiology, pathology, radiology and neonatology;
- Items and services provided by assistant surgeons, hospitalists, and intensivists;
- Diagnostic services, including radiology and laboratory services; and
- Items and services provided by a nonparticipating provider if there is no participating provider who can provide such item or service at such facility.
- A provider or facility must disclose to an enrollee information regarding federal and state balance billing protections and how to report violations.
- Providers or facilities must post this information prominently at the location of the facility, post it on a public website, if applicable, and provide it to the enrollee in a timeframe and manner as outlined by regulation.
- Providers of air ambulance services cannot bill or hold liable enrollees who received covered air ambulance services from a nonparticipating air ambulance provider for a payment amount greater than the in-network cost-sharing requirement for such services.
- Upon an individual’s scheduling of items or services, or upon request, a provider or facility must ask if the individual is enrolled in a health benefit plan or health insurance coverage.
- If the individual has such coverage and plans to submit a claim for the item or service to the plan or issuer, the provider or facility must provide to the individual’s plan or issuer a good faith estimate of the expected charges for furnishing the scheduled item or service and any items or services reasonably expected to be provided in conjunction with those items and services, including those provided by another provider or facility, with the expected billing and diagnostic codes for these items and services.
- The good faith estimate must include expected charges for the items or services that are reasonably expected to be provided together with the primary item or service, including items or services that may be provided by other providers and facilities.
- For individuals without health insurance coverage or individuals who do not plan to file a claim for the item or service, the provider or facility must provide this notification to the individual. In addition, the good faith estimate provided directly to these individuals must include information related to the patient-provider dispute resolution process that is used to determine the appropriate payment amount when the difference between the good faith estimate provided and a bill the individual receives following the provision of the item or service satisfies the dollar threshold [established in federal regulation or for those states that have a balance billing law, the dollar threshold amount and payment methodology found in that state law or regulation] to be eligible to use the process.
Any health care provider or health care facility that has or has had a contractual relationship with a health benefit plan or health insurance issuer to provide items or services under such plan or insurance coverage must:
- Submit provider directory information to a plan or issuer, at a minimum: a) at the beginning of the network agreement with a plan or issuer, b) at the time of termination of a network agreement with a plan or issuer; c) when there are material changes to the content of the provider directory information of the provider or facility; d) upon request by the plan or issuer; and e) at any other time determined appropriate by the provider, facility or the U.S. Department of Health and Human Services (HHS).
- Reimburse beneficiaries, enrollees or participants who relied on an incorrect provider directory and paid a provider bill in excess of the in-network cost-sharing amount.
- For fully-insured health plans regulated by the Insurance Department, Connecticut Surprise Billing laws establish the process by which providers and facilities shall resolve disputes with payers related to out-of-network payment amounts and establish that the consumer will only be required to pay applicable in-network cost-sharing amount.
- For health plans not regulated by the Insurance Department, the NSA establishes an independent dispute resolution process that providers, facilities, and air ambulance providers can use in the case of certain out-of-network claims when open negotiations do not result in an agreed-upon payment amount. Providers, facilities and air ambulance providers will be required to meet deadlines, attest to no conflicts of interest, choose a certified independent dispute resolution entity, submit a payment offer and provide additional information if needed. More information on the federal independent dispute resolution process is expected to be added to the Centers for Medicare & Medicaid Services No Surprises Act home page - https://www.cms.gov/nosurprises.
Guidance and Technical Resources
- Centers for Medicare & Medicaid Services No Surprises Act home page
- Overview of NSA Rules and Fact Sheets
- Calendar Year 2022 Fee Guidance for the Federal Independent Dispute Resolution Process Under No Surprises
- Standard notice & consent forms for nonparticipating providers & emergency facilities regarding consumer consent on balance billing protections
- Model disclosure notice on patient protections against surprise billing for providers, facilities, health plans and insurers
- Paperwork Reduction Act (PRA) model notices and information collection requirements for the Federal Independent Dispute Resolution Process (Download Model Notices and Information Requirements)
- Paperwork Reduction Act (PRA) model notices and information collection requirements for the good-faith estimate and patient-provider payment dispute resolution (Download Model Notices and Information Requirements)
- Requirements for including federal agency contact information and website URL on certain documents (Download Memo of Requirements for Plans, Providers and Facilities)
Frequently Asked Questions:
- Deion fell off a ladder, hitting his head and breaking his arm. He was taken to the nearest emergency room. He needed covered imaging and radiology services as well as surgery. Now bills are starting to come in. What is he responsible for paying? How can he get help if he's receiving bills that don't match the explanation of benefits (EOB) from his health insurance plan?
- For emergency care he received, Deion is only responsible for paying his in-network deductibles, copays, and coinsurance, even if health care providers who were not in his plan network treated him or he was taken to a facility that was out-of-network. If the bills don’t match his explanation of benefits (EOB), Deion can call his health insurer first. If he isn’t satisfied with the insurer’s response, he can contact the Insurance Department’s Consumer Affairs Division to File a Complaint or Ask a Question.
If Deion is admitted to the hospital after he receives care in the emergency room, he should know that any out-of-network health care providers at the facility may ask him to consent to continuing care and to agree to pay higher amounts. They can only ask for his consent to receive out-of-network care once he is stabilized, able to understand the information about his care and out-of-pocket costs, and it is safe to travel to an in-network facility using non-emergency transportation. If those conditions are met, Deion can decide if he wants to continue with the out-of-network provider, or travel to a provider who participates in his health plan's network. If he stays with the out-of-network provider and consents to out-of-network billing, he’ll be responsible for any out-of-network deductibles, copays, or coinsurance. He’ll also be responsible for the amount the provider charges that is more than what the insurance company pays (the balance bill).
- Bill had chest pains and went to his local hospital's emergency room. The doctors there said he had to be transported to a hospital in a major city for full treatment and he had to go by air ambulance to make it in time. Bill was flown to the larger hospital and is now doing well. Bill's wife, Nancy, has heard scary stories about air ambulance costs and is starting to worry. Are there any protections for someone who is transported by air ambulance in an emergency?
- If the air ambulance company has an in-network contract with Bill’s health insurance plan, then Bill will only have to pay the in-network deductibles, coinsurance, or copays. The air ambulance company will accept their contracted amount as payment in full.
Starting in 2022, the new federal No Surprises Act protects patients even if the air ambulance company doesn’t have an in-network contract with their health insurance plan. Bill will only have to pay the deductibles, copays, or coinsurance that he would have to pay if the air ambulance were in-network. Federal law will help the air ambulance and the health insurance companies determine how to pay the rest of the bill.
- Elena is scheduled for a biopsy, a service that her health plan covers. Her hospital and surgeon are in-network with her health plan, but the hospital uses anesthesiologists and pathologists that are not in-network. Does this mean everything will be covered as in-network, or could Elena have some unexpected charges?
- Surgery for a biopsy can involve health care providers that you don’t get to choose, such as an anesthesiologist and a pathologist. Starting in 2022, when Elena chooses an in-network facility and surgeon for her procedure, all her out-of-pocket costs will be at the in-network rate. That includes the costs for any out-of-network providers she didn’t choose who participate in her care.
- Hannah changes jobs and her family is covered under a new employer health plan. Hannah and her husband's doctors are in-network with the new company, but their child’s pediatrician is not. How can they find an in-network pediatrician? Can they rely on the online provider directory for accurate information?
- Hannah can review her new health plan’s online provider directory or call the insurance company to get information. An insurance company may have different networks for different health plans. It’s important to look at the directory for your specific health plan.
Most people rely on their health plan to give them accurate information about in-network health care providers.
Starting in 2022, federal law requires health care providers to update their information with insurance companies when there is a change. In turn, insurance companies must verify that the information in their provider directories is complete.
If Hannah calls the insurance company to ask for a list of in-network pediatricians, the insurance company has one business day to give her a list. If Hannah relies on inaccurate information from the insurance company that a provider is in-network, then Hannah will be responsible only for the in-network deductibles, copays, or coinsurance.