A new Federal regulation aims at preventing unpleasant “surprise” health care billings for insurance participants for plan years starting on or after January 1, 2022.
According to CMS, a “surprise” bill “is an unexpected bill from a health care provider or facility. This can happen when a person with health insurance unknowingly gets medical care from a provider or facility outside their health plan’s network. Surprise billing happens in both emergency and non-emergency care.” This CMS Fact Sheet provides more details:
Also called “balance billing,” these bills can come from providers of medical services, like a lab, anesthesiologist, assistant surgeon, or others, even including air ambulance companies. The bills can happen even if the participant used an in-network hospital to provide their services.
The new way “surprise” bills must be processed and paid by insurers is complex and outside the scope of this article. Suffice to say, this new regulation’s purpose is to ensure these services are covered as in-network services.
Employers must let plan participants know about this new protection. This DOL website provides a sample participant notice, along with a list of what information must be provided. The notice must be “publicly available, posted on a public website of the plan or issuer, and included on each explanation of benefits.”
Check with your broker, insurance company, or third-party administrator to see if they have notices available for your use and can provide you with the required state law balance billing language for each state in which you have employees.
Once you have the notices ready, make a downloadable copy available to each plan participant (ex. all employees in the plan, plus any COBRA or retiree participants, etc.), post the notice in your offices and on your website, and make sure your claims processor is including the language on Explanations of Benefits sent to participants indicating how a claim was processed.
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