A surprise medical bill is any unexpected cost incurred by a patient after receiving medical care.
This can include: an out-of-network-charge, unexpected facility fees, balance bills or any bill that’s much higher than you expect.
Under the new law, which applies to plan years beginning on or after January 1, 2022:
- Plans and insurers are limited in cost-sharing and other restrictions they can impose, although different rules apply for emergency and non-emergency care.
- Out of network costs must apply to network deductibles and out-of-pocket maximums in cases of emergency care.
- In the case of non-emergency out-of-network care, providers (and facilities) must give 72 hours’ notice of out-of-network services as well as an estimate of charges. If the patient doesn’t consent to the out-of-network care, the patient is only liable for network cost sharing.
- Plans must update provider directories at least every 90 days.
- Plans and insurers must make initial payments or issue denial notices to providers within specified timeframes.
- An independent dispute resolution (IDR) process will determine how much plans and insurers must pay to nonparticipating providers and facilities when the parties cannot agree on payment. The Act identifies the factors that IDR entities should consider when determining payment.
- Group health plans and insurers must provide external review (in accordance with existing ACA external review requirements) for any adverse determination relating to emergency services or air ambulance services (addressed separately in the Act).
While the new law won’t take effect until 2022, there are steps consumers can take now to protect themselves from surprise bills.