CMS on Thursday released an interim final rule as part of the No Surprises Act which will effectively ban surprise medical billing for emergency services, as well as out-of-network cost-sharing for both emergency and non-emergency services.
According to Politico Pro, this interim final rule is the first of a series the Biden administration will release to enforce the new law. The rest of the rules are expected to be released before a January 1, 2022, deadline for the law's provisions to take effect.
The interim rule applies to "providers, air ambulance providers, group health plans, health insurance issuers and Federal Employees Health Benefits Program carriers," Modern Healthcare reports. The rule do not apply to ground ambulance providers.
Most of the rule's provisions will not take effect until January 1, 2022, but the rule itself technically takes effect in 60 days. CMS is accepting comments on the rule through September 1.
Details on the rule
Under the interim rule, health plans covering emergency services will no longer be permitted to require prior authorization for those services and will be required to pay their part regardless of whether the health care provider is in-network or an emergency facility.
Insurers will also not be allowed to charge patients out-of-network rates for "ancillary" care, in which an out-of-network provider treats a patient at an in-network facility. All cost-sharing for emergency services will also have to count toward a patient's in-network deductible and out-of-pocket maximums, according to the rule.
In addition, insurers will have to calculate out-of-pocket expenses based on state law or a state's all-payer model. "If neither … apply, the lesser amount of either the billed charge or the qualifying payment amount, which is generally the plan's or issuer's median contracted rate" will apply, according to CMS.
Similarly, if state laws do not say how much insurers should pay for a service, providers and insurers will need to agree upon an amount or do so through a dispute-resolution process. According to Modern Healthcare, the Biden administration is still determining how such a dispute-resolution process would work, although the No Surprises Act in broad terms gives providers and insurers 30 days to agree on a price for medical services rendered. If they cannot agree, they must enter arbitration, during which an arbitrator will pick between the final offers provided by each side.
In addition, the rule states that if a patient elects to see an out-of-network provider, the provider will not be permitted to bill the patient the balance unless they have notified the patient that they are out-of-network and given the patient an estimate of charges in advance. The patient would then need to consent to paying higher rates for out-of-network care.
"No patient should forgo care for fear of surprise billing," HHS Secretary Xavier Becerra said in a statement. "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." (Brady, Modern Healthcare, 7/1; Luhby, CNN, 7/1; Armour, Wall Street Journal, 7/1; Roubein, Politico Pro [subscription required], 7/1)