Federal agencies publish draft rule on final surprise billing

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United States: Federal Agencies Publish Interim Rule on Final Surprise Billing

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On July 1, 2021, the US Department of Health and Human Services (“HHS”), Department of Labor, Internal Revenue Service, and Office of Personnel Management released their first draft rule on final surprise billing. As explained in a previous article, the regulations implement new requirements for group health plans, health insurance issuers and providers and health establishments that were imposed by the bipartite No Surprises law, promulgated as part of the of a 2020 appropriation law. The rules, “Surprise billing requirements; Part I, ”prohibit surprise billing or balances for certain health services.

An important aspect of the new surprise billing regulations for group health insurance plan sponsors and health insurance companies is its effect on billing for emergency services, off-grid air ambulance services. and certain off-grid services provided to a network facility. If a plan or policy provides for or covers emergency services, they must Be covered:

  • without any prior authorization;
  • regardless of whether the provider is a network provider or a network emergency facility; and
  • regardless of any other term or condition of the plan or coverage, other than exclusion or coordination of benefits or an authorized membership or waiting period.

The rules also provide that consumer cost-sharing amounts for off-grid emergency services are to be calculated based on an amount determined by a template agreement with all payers, under a law of State specified, or, if none of the preceding conditions apply, the lesser of the amount invoiced or the amount of the eligible payment (generally, the median contractual rate of the plan or the insurer).

Additionally, the Surprise Billing Regulations establish a complaint process for consumers who believe their group health plan, health insurance issuer, or health care provider has violated the balance billing protections of the law. . Regulations allow consumers to file complaints, which can be resolved, for example, by referring the complainant to a federal or state resolution process, by referring the complainant to the state or federal agency with jurisdiction over the matter. enforcement, or launching an investigation for enforcement actions.

The agencies will accept comments on the interim final rule until September 7, 2021. The provisions of the regulations applicable to group health insurance plans and health insurance issuers will come into effect for the years of the plan, policy or contract starting on or after January 1, 2022.

The content of this article is intended to provide a general guide on the subject. Specialist advice should be sought regarding your particular situation.

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