Bad news: You fell off your bike last year, broke your ankle, and needed immediate surgery. You’re on the mend now, but a $15,000 bill came in the mail from the out-of-network orthopedist who treated you. It was an emergency! What were you supposed to do?
Last year, you’d be on the hook for $15,000. Fortunately, no more. The No Surprises Act took effect on January 1, 2022, and it’s a big win for health care consumers—you and your people included. No longer can doctors, health care facilities, and insurance companies charge you for out-of-network care that you didn’t approve ahead of time.
How the No Surprises Act Works
It’s not your fault if you visit an in-network hospital and then get treated by an out-of-network doctor. In fact, an expansive 2020 joint study by The Peterson Center on Healthcare and the Kaiser Family Foundation found that it was common. The practice, called balance billing, happened to participants of large employer plans in 18% of emergency room visits and 16% of in-network hospital stays.
That’s where the No Surprises Act comes in. It protects consumers from balance billing in two circumstances: medical emergencies (like your bike mishap) and visits to in-network facilities.
Here’s a nonemergency example. You plan a month in advance to get shoulder surgery. You go to your insurance carrier’s website and find an in-network hospital. You have surgery and the procedure is a success. You did everything right.
But wait! The anesthesiologist who knocked you out wasn’t part of your plan’s network. A few weeks later, you get a $12,000 bill for the difference between what your anesthesiologist charged and what your insurance carrier agreed to pay.
That’s balance billing. And it’s a thing of the past, unless you consent in writing to receive out-of-network care.
Next Steps for Plan Sponsors
Self-funded plans and third-party administrators must make information about the No Surprises Act available on a public website, which means username and password protections aren’t allowed. And, if you’re a plan sponsor, it’s important to act now. The Department of Labor will start enforcing the following requirements for plan years beginning on or after January 1, 2022:
- Post a notice of No Surprises Act requirements online. Both the plan’s public website and all Explanation of Benefits statements for these claims must spell out a patient’s rights under the No Surprises Act’s balance billing prohibitions. You may want to start with the Department of Labor’s model notice for this.
- Make network provider directories available. Include a list of contracted network providers and facilities on a public website (or a link to the medical plan network provider’s website). Print directories must refer to a website where this information is available.
- Upload documents with rate information. These files must disclose in-network rates and past out-of-network charges for covered items and services. They also must be machine-readable and uploaded to the plan’s public website by July 1, 2022 (or be available by a link from the plan’s public website to the medical plan provider’s website).
The No Surprises Act protects consumers from receiving many life-altering medical bills when they’re most vulnerable. Regular communication will help your people take to heart the enormity and importance of this change.
Continue to stress in-network care. Consumers aren’t protected from balance billing if they actively choose an out-of-network facility or doctor in nonemergency situations.
Emergencies are covered. With the exception of ground ambulance services, out-of-network doctors and facilities cannot balance bill for care during a medical emergency.
Health literacy is still low. Health care concepts are complex and generally unfamiliar. Talk to your people about health care often, and sprinkle easily digestible messages about the No Surprises Act throughout your communications.
Add information about the No Surprises Act to your organization’s benefits website. Balance billing was common just a few weeks ago. Communicating what’s changed and explaining how it affects your people reinforces that you care about their needs, health, and finances. If your organization doesn’t have a password-free benefits website yet, now is a great time to get one up and running! It makes communicating everything else more effective.
We're proud to work with organizations that value their people. If you want to learn more, we’d love to talk.