Overview of rules & fact sheets

Overview of rules & fact sheets

Federal IDR Process update: Certain functions of the Federal IDR Process are temporarily paused in response to the TMA IV and TMA III opinions and orders, which were issued on August 3, 2023, and August 24, 2023, respectively. On September 5, 2023, the Departments directed certified IDR entities to resume making eligibility and conflict of interest determinations for all single and bundled disputes submitted on or before August 3, 2023, and encouraged disputing parties to continue engaging in open negotiations. On September 21, the Departments directed certified IDR entities to resume processing all single and bundled disputes submitted on or before August 3, 2023.

The TMA III order vacated certain provisions of the regulation establishing the methodology for calculating the Qualifying Payment Amount (QPA). For disputes initiated prior to the TMA III order, disputing parties have already supplied a QPA, and certified IDR entities should continue to consider the supplied QPA among other factors, and additional information (other than prohibited categories of information) in light of the TMA III order, when selecting between the offers made by the disputing parties to determine which offer best represents the value of the items or services at issue.

The Departments will provide guidance in the near future about other issues associated with these decisions.

Rules focused on specific protections and provisions

In July, 2021, the U.S. Departments of Health and Human Services, Labor, and the Treasury (the Departments) released the “Requirements Related to Surprise Billing; Part I,” to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers.

In October, 2021, the Departments released the “Requirements Related to Surprise Billing; Part II,” which provides additional protections against surprise medical bills, including:

  • Establishing an independent dispute resolution (IDR) process to determine out-of-network payment amounts between providers (including air ambulance providers) or facilities and health plans.
  • Requiring good-faith estimates of medical items or services for uninsured (or self-paying) individuals.
  • Establishing a patient-provider dispute resolution process for uninsured (or self-paying) individuals to determine payment amounts due to a provider or facility under certain circumstances.
  • Providing a way to appeal certain health plan decisions.

On August 19, 2022, the Departments issued final rules titled “Requirements Related to Surprise Billing: Final Rules.” The rules finalize requirements under the July 2021 interim final rules relating to information that group health plans and health insurance issuers offering group or individual health insurance coverage must share about the qualifying payment amount (QPA). On February 23, 2022, in Texas Medical Association, et al. v. United States Department of Health and Human Services, and July 26, 2022, in LifeNet, Inc. v. United States Department of Health and Human Services, the United States District Court for the Eastern District of Texas (District Court) vacated portions of the October 2021 interim final rules related to payment determinations under the Federal IDR process. In light of the Court’s rulings and comments received, these rules also finalize select requirements under the October 2021 interim final rules related to consideration of information when a certified IDR entity makes a payment determination. Learn more about the status of the IDR system implementation (PDF).

In November, 2021, the “Prescription Drug and Health Care Spending” interim final rule was issued, implementing new requirements for group health plans and issuers to submit certain information about prescription drug and health care spending. This includes, among other things, information on the most frequently dispensed and costliest drugs, and enrollment and premium information, including average monthly premiums paid by employees versus employers.

Together, these lay the groundwork to provide consumers with protection against surprise billing.

How do these rules affect providers, facilities, and air ambulance providers?

Similar to health plans, the rules lay out the IDR process that providers, facilities, and air ambulance providers can follow in the case of certain out-of-network claims when open negotiations don’t result in an agreed-upon payment amount. Providers, facilities and air ambulance providers will be required to meet deadlines, attest to no conflicts of interest, choose a certified IDR entity, submit a payment offer and provide additional information if needed. This could include information like level of training, experience, and severity of condition.

Providers, facilities and air ambulance providers are also required to give uninsured (or self-pay) individuals good-faith estimates of expected charges for scheduled health care services, and may have to participate in a patient-provider payment dispute resolution process if their billed charges are higher than the good-faith estimates.

Request for Information

On September 16, 2022, the Departments issued a Request for Information (RFI) to inform rulemaking on the No Surprises Act requirements related to the advanced explanation of benefits (AEOB) and good faith estimate (GFE) for covered individuals. This RFI seeks information and recommendations on transferring data from providers and facilities to plans, issuers, and carriers; other policy approaches; and the economic impacts of implementing these requirements. Read the Advanced Explanation of Benefits RFI to learn more. Comments can be submitted through November 15, 2022.

Proposed rules

On September 20, 2023, a proposed rule was released outlining the fees established in the No Surprises Act for the Federal IDR process. This proposed rule would amend existing regulations to provide that the administrative fee amount charged by the Departments to participate in the Federal IDR process, and the ranges for certified IDR entity fees for single and batched determinations, will be established by the Departments in notice and comment rulemaking, rather than in guidance published annually. This proposed rule also proposes the amount of the administrative fee and the certified IDR entity fee ranges for disputes initiated on or after January 1, 2024. Read the Federal IDR Process Administrative Fee and Certified IDR Entity Fee Ranges Proposed Rule to learn more about the proposed requirements.

On September 10, 2021, a proposed rule was released on the reporting of air ambulance costs, insurance agent and broker compensation, and enforcement of various requirements as a part of continuing efforts to implement provisions to protect patients from surprise billing. Read the Air Ambulance NPRM – Fact Sheet to learn more about the proposed requirements.

Fact sheets

Fact sheets for consumers can be found on CMS.gov/Medical-Bill-Rights under Get Help.

Guidance & technical resources

Some documents include guidance pertaining to rules that have been vacated by Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:23-cv-59-JDK or Texas Medical Association, et al. v. United States Department of Health and Human Services, Case No. 6:22-cv-450-JDK. These decisions vacated rules related to batching of IDR disputes, the administrative fee amount for IDR disputes, requirements related to the timeframe for sending an initial payment or notice of denial of payment, the methodology for calculating qualifying payment amounts (QPAs), and/or provisions pertaining to air ambulance disputes. Please review the opinions in the cases cited above for further information on which provisions of the regulations and guidance were vacated and the notes on our website about applicable guidance. Disregard those specific sections of these documents to the extent inconsistent with the court’s opinions.

Independent dispute resolution process

Good faith estimates & the patient-provider dispute resolution process

Disclosures, notice & consent

Insurance ID cards

Page Last Modified:
09/21/2023 07:59 AM