Regulations Released to Implement No Surprises Act

Several federal agencies, including the Office of Personnel Management and the departments of Health and Human Services (HHS), Labor and Treasury, recently released “Part 1” of the regulations to implement the No Surprises Act via an interim final rule with comment period. The rule would implement many of the law’s requirements for group health plans, health insurance issuers, carriers under the Federal Employees Health Benefits program, healthcare providers and facilities, and air ambulance service providers. Most of the provisions would take effect Jan. 1, 2022, and would:

  • Prohibit out-of-network providers from billing patients more than their in-network cost-sharing amount for emergency services and when scheduled care is provided for many nonemergent services at an in-network facility.
  • Establish a formula to calculate the “qualifying payment amount” (QPA) for use in calculating patient cost-sharing unless billed charges are less than the QPA.
  • Permit patients to waive balance billing protections if the out-of-network provider gives notice and obtains the patient’s consent using a standard notice that will be issued by the HHS.
  • Implement a process through which the departments can receive complaints about potential violations for all consumer protection and balance billing requirements with a single process applied to health plans, providers, facilities and air ambulance providers.
  • Clarify the interaction between state and federal laws and address scenarios to help identify when state versus federal law would apply, such as when the health plan license and the provider are in different states.
  • Fail to address all provisions in the No Surprises Act, such as the independent dispute resolution process. Additional regulations would be issued on those provisions.

The rule does not apply to individuals with coverage through Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care or TRICARE, since these programs already prohibit balance billing. The federal regulations also would establish requirements regarding initial payment or denial by health plans to providers, with health plans having 30 calendar days to make a payment or issue a denial notice after receiving a “clean claim.”

The MHA encourages American Hospital Association (AHA) members to register and participate in two upcoming webinars hosted by the AHA. A session to discuss the regulations will be held from 1 to 2 p.m. EDT July 21. A second webinar to discuss the association’s proposed input to the federal government will be held from 4 to 5 p.m. EDT Aug. 3.

The MHA also encourages members to review the proposed rule and contact Vickie Kunz at the MHA regarding any concerns by Aug. 27 and to submit comments on the interim final rule by Sept. 7.