No Surprises Act: Federal law provides patient billing protection

On Dec. 27, 2020, as a part of the appropriations bill, Congress passed the No Surprises Act. This law – not guidance – will go into effect for plan/policy years beginning on/after Jan. 1, 2022.  

The No Surprises Act establishes federal standards to protect patients from balance billing for defined items and services provided by specified doctors, hospitals and air ambulance carriers on an out-of-network (OON) basis. This federal law applies to individual, small- and large-group fully insured markets, and self-funded group plans including grandfathered plans.

The legislation caps patient cost-sharing for OON items and services at network levels and requires providers to work with insurers and health plans to negotiate remaining bills. If the insurer/health plan and the provider are unable to reach agreement, an Independent Dispute Resolution (IDR) process, sometimes called “arbitration,” will help determine the reimbursement amount.

This act may not pre-empt state surprise billing laws that establish a process for determining OON reimbursement for covered items and services for insurers subject to the state’s law.

There are federal rules and processes yet to be developed, and questions about scope and applicability as it relates to state laws have yet to be answered. UnitedHealthcare will continue to provide updates as details are released. 

To learn more, please refer to the No Surprises Act FAQs and contact your broker or UnitedHealthcare representative.

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