Effective January 1, 2022, the federal No Surprises Act (NSA) provides new protections for consumers, and new requirements for health insurance companies and medical providers, medical facilities, and air ambulance service regarding balance billing in certain situations. The Department of Insurance has been tasked with implementing the enforcement of this new act by Centers for Medicare and Medicaid Services (CMS).
The Department’s guidance on the NSA is subject to change due to updates to state or federal law. Our guidance may also change as we identify opportunities to improve existing Department processes.
The information provided below is a brief summary of the NSA provider and facility requirements. For more details regarding provider and facility requirements, please refer to the link to the CMS website below.
The NSA Applies to the following Medical Providers
- Medical facilities providing both emergency and non-emergency services.
- Medical providers providing both emergency and non-emergency services.
- Air ambulance services.
Key NSA Requirements for Insured Patients
- Emergency Services – out-of-network providers and emergency facilities cannot balance bill patients who receive emergency services at a hospital or freestanding emergency department.
- Non-emergency services – out-of-network providers cannot balance bill patients who receive non-emergency services at an in-network facility.
- Air ambulance – out-of-network air ambulance providers cannot balance bill patients who receive air ambulance services.
For items and services for which the NSA applies, patients are only responsible for their applicable in-network deductibles, co-insurance, and co-pays. Any additional amount due for the above types of claims is to be resolved between the provider and health plan. If the provider and health plan cannot agree on the final claim payment amount, either the health care provider or the health plan may open a 30 business day negotiation period to resolve any disputes. If negotiation fails, either party can initiate an independent dispute resolution (IDR) process through CMS. Key timelines include:
- Initial Payment or Notice of Denial of Payment: Must be sent by the plan, issuer, or carrier no later than 30 calendar days after a clean claim is received.
- Initiation of Open Negotiation Period: An open negotiation period must be initiated within 30 business days beginning on the day the out-of-network (OON) provider receives either an initial payment or a notice of denial of payment for the item or service from the plan, issuer, or carrier.
- Open Negotiation Period: Parties must exhaust a 30 business day open negotiation period before either party may initiate the Federal Independent Dispute Resolution (IDR) Process.
Federal IDR Initiation: Either party can initiate the Federal IDR Process by submitting a Notice of IDR Initiation to the other party and to the Departments within 4 business days after the close of the open negotiation period. Such notice must include the initiating party’s preferred certified IDR entity.
For more information prior to initiating the CMS dispute resolution process, please contact the Idaho Department of Insurance Consumer Affairs team.
Additional guidance from CMS regarding payment disputes between providers and health plans can be found at the CMS website
Key NSA Requirements for Uninsured (or Self-Pay) Patients
When an uninsured (or self-pay) patient schedules a procedure, the health care provider or health care facility must provide a “good faith” estimate to the patient prior to the procedure taking place. The “good faith” estimate must include:
- The services expected to be provided (including any other services that may be provided by other providers or facilities for the scheduled procedure).
- The diagnostic codes associated with the expected services.
- The expected charges.
If the billed amount is at least $400 above the “good faith estimate,” the patient may be eligible to start a patient-provider dispute resolution process.
For more information prior to initiating the CMS dispute resolution process, please contact the Idaho Department of Insurance Consumer Affairs team.
Additional information on how to initiate a patient-provider dispute resolution can be found at the CMS website.
Medical Provider Disclosure Requirements
Providers and facilities must disclose to patients information about the No Surprises Act, including protections and how to file a complaint.
Guidance to Providers regarding the Surprise Billing Patient Protections Notice
Idaho Model Disclosure Notice “Your Rights and Protections Against Surprise Medical Bills”
Accurate Provider Directory Information
In-network providers and facilities must submit provider directory information to a health insurance company and the patient:
- at the beginning of the network agreement with the insurance company,
- at the time of termination of a network agreement,
- when there are material changes to the content of the provider directory, and
- upon request of the insurance company.
If an insured patient relies on incorrect information concerning the network status of a provider with the insurance company and is billed in excess of the in-network amount, the health care provider or facility is responsible for reimbursing the patient for the excess amount.
Continuation of Care Requirements
If a provider or a facility ceases to be an in-network provider and an individual meets the definition of a continuing care patient, the health care provider or facility must:
- continue to accept the previously agreed upon amount for up to 90 days after the patient is notified of the change in network status, and
- continue to treat the patient within the provisions of the previous contract.
Additional information regarding the CMS Continuation of Care requirements: CMS No Surprises Act Provider & Facility Information.
Out-of-Network Balance Billing Exceptions
In certain situations, non-participating providers and facilities may balance bill; however, the following are some of the conditions that must apply:
- based on the patient’s medical condition, the patient is able to travel to an available participating provider facility using non-medical/non-emergency medical transportation
- the patient is in a condition to receive notice and provide informed consent
- the non-participating provider adheres to notices and timeframes as described in the No Surprises Act
- the health care provider or facility satisfies any additional state law requirements
Providers and facilities need to be aware of certain conditions where balance billing is prohibited, even if a patient has signed a consent notice.