Overview of rules & fact sheets

Overview of rules & fact sheets

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. Learn more about how these rules help consumers.

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 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 in other languages

Guidance & technical resources

Independent dispute resolution process

Good faith estimates & the patient-provider dispute resolution process

Disclosures, notice & consent

Insurance ID cards

 

Page Last Modified:
11/28/2022 04:34 PM