No Surprises Act takes effect on January 1, 2022
December 9, 2021
This article is for acute care hospitals, ambulatory surgical centers, and out-of-network providers caring for our members
The No Surprises Act, enacted as part of the Consolidated Appropriations Act (CAA) in late 2020, provides new federal consumer protections against balance billing for medical bills under certain circumstances. Claims subject to balance billing protections may occur:
- In emergency situations when a patient can’t control who is involved in their care
- In non-emergency situations when they schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider
- When out-of-network air ambulance services are provided for services that would have been covered if the air ambulance provider was in-network
Ground ambulance claims are not included under the No Surprises Act.
We want to let you know how we’re educating our members about their rights and protections under the law. We are posting disclosures explaining the rights and protections our members have under the law to our public website in late December: https://www.bluecrossma.org/disclaimer/member-rights. Our Explanation of Benefits (EOB) when we pay bills covered by the law will direct members to the following explanation of the law:
If you have an emergency medical condition and get emergency services from an
out-of-network provider or facility, the most the provider or facility may bill
you is your plan’s in-network cost-sharing amount (such as copayments and
coinsurance). You can’t be balance billed for these emergency services.
This includes services you may get after you’re in stable condition, unless you
give written consent and give up your protections not to be balanced billed for
these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center,
certain providers there may be out-of-network. In these cases, the most those
providers may bill you is your plan’s in-network cost-sharing amount. This
applies to emergency medicine, anesthesia, pathology, radiology, laboratory,
neonatology, assistant surgeon, hospitalist, or intensivist services. These
providers can’t balance bill you and may not ask you to give up
your protections not to be balance billed. If you get other services at these
in-network facilities, out-of-network providers can’t balance bill you, unless
you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also
aren’t required to get care out-of-network. You can choose a provider or
facility in your plan’s network.
When balance billing isn’t allowed,
you also have the following protections:
- You are only responsible for paying your share of the cost
(like the copayments, coinsurance, and deductibles that you would pay if the
provider or facility was in-network). Your health plan will pay out-of-network
providers and facilities directly.
- Your health plan generally must:
- Cover emergency
services without requiring you to get approval for services in advance (prior
- Cover emergency
services by out-of-network providers.
- Base what you owe the
provider or facility (cost-sharing) on what you would pay an in-network provider
or facility and show that amount in your explanation of benefits.
- Count any amount you
pay for emergency services or out-of-network services toward your deductible
and out-of-pocket limit.
Non-participating providers’ responsibilities and rights under the law
Under the No Surprises Act, non-participating providers are prohibited from balance billing under the circumstances described above.
The statute requires providers, including hospitals, to make notice about balance billing requirements and prohibitions publicly available and provide them to consumers. The regulations supporting the No Surprises Act detail information that must be included in such notice.
The federal law also includes provisions allowing providers to request negotiation of the payor’s payment for bills subject to the No Surprises Act, and if negotiation fails, to enter into the Independent Dispute Resolution (IDR) process, also known as arbitration, to determine the allowed payment amount.
- If that 30 day open negotiation period does not result in a determination, generally the provider or facility may initiate the IDR process within 4 days after the end of the open negotiation period. To initiate the IDR process, submit requests in writing to:
Please be sure to include all information required by the No Surprises Act. For the Independent Dispute Resolution (IDR) process, the provider must furnish the Notice of IDR Initiation to the Department of Health and Human Services on the same day the notice is furnished to MultiPlan.