Overview of rules & fact sheets
Overview of rules & fact sheets
Rules focused on specific protections and provisions
On July 1, 2021, the “Requirements Related to Surprise Billing; Part I,” interim final rule was issued 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.
On September 30, 2021, a second interim final rule was issued and is open for public comment. The “Requirements Related to Surprise Billing; Part II” rule provides additional protections against surprise medical bills, including:
- Establishing an independent dispute resolution 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.
Together, these lay the groundwork to provide consumers with protection against surprise billing, starting in 2022. Learn more about how these rules help consumers.
On November 17, 2021, a third interim final rule was issued and is open for public comment. The “Prescription Drug and Health Care Spending” rule implements 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.
How do these rules affect providers, facilities, and air ambulance providers?
Similar to health plans, the rules lay out the independent dispute resolution 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 independent dispute resolution 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.
- July 1 Fact Sheet: What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing
- July 1 Fact Sheet: Requirements Related to Surprise Billing; Part I Interim Final Rule with Comment Period
- September 30 Fact Sheet: Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period
- September 30 Fact Sheet: What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing – September Update
- November 17 Fact Sheet: Prescription Drug and Health Care Spending Interim Final Rule with Comment Period
Guidance & technical resources
- Calendar Year 2022 Fee Guidance for the Federal Independent Dispute Resolution Process Under No Surprises (Download Fee Information) (PDF)
- Health plans and insurers: preliminary information about insurance ID card criteria is available in the Frequently Asked Questions about the Consolidated Appropriations Act, 2021 Implementation Part 49. (PDF)
- Standard notice & consent forms for nonparticipating providers & emergency facilities regarding consumer consent on balance billing protections (Download Surprise Billing Protection Form) (PDF)
- Model disclosure notice on patient protections against surprise billing for providers, facilities, health plans and insurers (Download Patient Rights & Protections Against Surprise Medical Bills) (PDF)
- Paperwork Reduction Act (PRA) model notices and information collection requirements for the Federal Independent Dispute Resolution Process (Download Model Notices and Information Requirements)
- Paperwork Reduction Act (PRA) model notices and information collection requirements for the good-faith estimate and patient-provider payment dispute resolution (Download Model Notices and Information Requirements)
- Requirements for including federal agency contact information and website URL on certain documents (Download Memo of Requirements for Plans, Providers and Facilities) (PDF)
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. Comments on the proposed rule are open until October 18, 2021. Read the Air Ambulance NPRM – Fact Sheet to learn more about the proposed requirements.