Jul 07, 2021
The Biden Administration issued an interim final rule to restrict out-of-pocket costs from surprise billing and balance billing. The regulations will take effect for health care providers and facilities on January 1, 2022. The provisions will take effect for plan, policy, or contract years beginning on or after January 1, 2022 for group health plans, health insurance issuers, and carriers for Federal Employee Health Benefits Programs.
Billing for emergency services has been a significant issue for consumers. A 2019 study by the Government Accountability Office reveals that air ambulance providers charged a median of $36,400 to over $40,000. More than 70% of these transports were out-of-network, meaning that most or all costs fell to the insured.
Among other provisions, the final rule bans:
- Surprise billing for emergency services. Regardless of where they are provided, emergency services must be treated as in-network without prior authorization.
- High out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or deductibles, cannot be higher than if such services were provided by an in-network doctor. Any coinsurance or deductible must be based on in-network provider rates.
- Out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
- Other out-of-network charges without advance notice. Health care providers and facilities must give patients a plain-language notice that they need to consent to receive care on an out-of-network basis before a provider can bill at a higher out-of-network rate.
CMS Resources
Interim Final Rule With Request For Comments
What You Need to Know About the Biden-Harris Administration’s Actions to Prevent Surprise Billing
Requirements Related to Surprise Billing; Part I Interim Final Rule with Comment Period
