Biden administration issues proposed regulation on surprise medical billing

July 2, 2021

The departments of Health and Human Services, Labor and Treasury issued a proposed rule to restrict “excessive” out-of-pocket expenses that occur from so-called surprise billing, which is also known as balance billing, the administration said.

This happens when patients unknowingly receive care from a provider, such as a pathologist, from outside their health insurance’s network. This can happen for both emergency and non-emergency care. 

Currently, balance billing is prohibited by both Medicare and Medicaid. The proposed rule codifies the No Surprises Act, which was signed into law last year, by extending similar protections to people insured through employer-sponsored and individual commercial health plans.

Among other provisions, the interim final rule states that:

·        Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization. 

·         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.

·         Network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility are not allowed in all circumstances.

·        Healthcare 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. 

CMS said the regulations will take effect for providers and facilities on January 1, 2022. For group health plans, health insurance issuers, and FEHB Program carriers, the provisions will take effect for plan, policy, or contract years beginning on or after January 1, 2022.

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