Posted by Nancy B. Pridgen 

Overview

On January 1, 2022, the No Surprises Act (“NSA”) will take effect.  The NSA was signed into U.S. law on December 27, 2020, as part of the Consolidated Appropriations Act, 2021.  The provisions in the NSA will boost patient protections by limiting patient responsibility for out-of-network “surprise billing.”  Surprise billing generally occurs when an out-of-network provider is unexpectedly involved in a patient's care.  This most often happens in a medical emergency when a patient cannot select a provider.  

Surprise Billing and Balance Billing

The NSA will prohibit surprise billing by out-of-network facilities and out-of-network providers of emergency services, out-of-networks providers of non-emergency services within in-network facilities (without prior notice and consent), and out-of-network providers of air ambulance services. 

Under the NSA, patients will not be held responsible for amounts above in-network rates for out-of-network emergency services and certain non-emergency services.  Instead, providers and health plans will be responsible for these types of bills.  The providers and health plans will be required to negotiate billing disputes or enter a dispute resolution process to determine financial responsibility.

Other Patient Protections

The NSA also includes a number of other protections for patients.  For example:

• Health plans must provide enrollees with an Advanced Explanation of Benefits for scheduled services including estimates of charges and cost sharing amounts
• Health plan ID cards must include deductible amounts and maximum out-of-pocket costs 
• Health plans must offer a price comparison tool for enrollees
• Health plans must maintain up-to-date provider directories including network status
• Providers must notify patients and health plans of expected charges for scheduled services

Georgia's Surprise Billing Consumer Protection Act

Georgia has its own surprise billing law that limits out-of-network billing in ways similar to the NSA.  State laws consistent with, or providing additional protections beyond those in the NSA, will continue to be applicable concurrently with the NSA.  However, the state law must be directly applicable to the particular health plan and services at issue; if it is not, then the NSA will control.  Similarly, the NSA will apply in situations where a state law is not explicitly applicable to an ERISA plan. 

If you have questions or concerns about your health insurance benefits, or how the NSA will affect your out-of-network health care services, please call Pridgen Bassett Law at 470-33-ERISA or contact us online.