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
- July 1, 2021 Fact Sheet: What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing
- July 1, 2021 Fact Sheet: Requirements Related to Surprise Billing; Part I Interim Final Rule with Comment Period
- September 30, 2021 Fact Sheet: What You Need to Know about the Biden-Harris Administration’s Actions to Prevent Surprise Billing – September Update
- November 17, 2021 Fact Sheet: Prescription Drug and Health Care Spending Interim Final Rule with Comment Period
- January 3, 2022 Fact Sheet: No Surprises: Understand your rights against surprise medical bills (for consumers) (PDF)
- April 15, 2022 Fact Sheet: Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period
- June 24, 2022 Fact Sheet: Health insurance terms you should know (for consumers) (PDF)
- June 24, 2022 Fact Sheet: What’s a good faith estimate? (for consumers) (PDF)
- June 24, 2022 Fact Sheet: How do I read my medical bill? (for consumers) (PDF)
- June 24, 2022 Fact Sheet: Health care notice & consent form – what to know before you sign (for consumers) (PDF)
- August 19, 2022: Fact Sheet: Requirements Related to Surprise Billing: Final Rules
Fact sheets in other languages
Guidance & technical resources
Independent dispute resolution process
- IDR YouTube playlist: Webinars and system demonstrations
- February 28, 2022: Memorandum regarding continuing surprise billing protections for consumers (PDF)
- Paperwork Reduction Act (PRA) model notices and information collection requirements for the Federal Independent Dispute Resolution Process
- Amendment to the Calendar Year 2023 Fee Guidance for the Federal Independent Dispute Resolution Process Under the No Surprises Act: Change in Administrative Fee (PDF)
- This guidance document was amended by the Amendment to the Calendar Year 2023 Fee Guidance for the Federal Independent Dispute Resolution Process Under the No Surprises Act: Change in Administrative Fee.
- Frequently Asked Questions (FAQs) Regarding the Federal Independent Dispute Resolution Process (Set 1) (PDF)
- Independent Dispute Resolution (IDR) Notice of Initiation Web Form Job Aid (Updated November 28, 2022) (PDF)
- Certified Independent Dispute Resolution (IDR) Entity Selection Response Form Job Aid (PDF)
- Independent Dispute Resolution (IDR) Notice of Offer Web Form Job Aid (PDF)
- Technical Assistance for Certified Independent Dispute Resolution Entities-August 2022 Edition (PDF)
- Frequently Asked Questions (FAQs) about Affordable Care Act and Consolidated Appropriations Act, 2021 Implementation (Set 55) (PDF)
- Chart for Determining the Applicability for the Federal Independent Dispute Resolution (IDR) Process (Updated January 13, 2023) (PDF)
- Chart Regarding Applicability of the Federal Independent Dispute Resolution (IDR) Process in Bifurcated States (Updated January 13, 2023) (PDF)
- These guidance documents are effective as of July 26, 2022, and applicable to all items and services furnished before October 25, 2022, for plan years (in the individual market, policy years) beginning on or after January 1, 2022, by an out-of-network provider subject to the Requirements Related to Surprise Billing; Part II, 86 FR 55980.
- These guidance documents are applicable to all items and services that are furnished on or after October 25, 2022, for plan years (in the individual market, policy years) beginning on or after January 1, 2022, by an out-of-network provider subject to the Requirements Related to Surprise Billing; Part II Interim Final Rules, 86 FR 55980 and Requirements Related to Surprise Billing Final Rules; 87 FR 52618.
- Independent Dispute Resolution (IDR) Timeline for Claims (PDF)
- Initial Report on the Independent Dispute Resolution (IDR) Process: April 15 - September 30, 2022 (PDF)
- Partial Report on the Independent Dispute Resolution (IDR) Process: October 1 - December 31, 2022 (PDF)
- Federal Independent Dispute Resolution Process – Status Update (PDF) (August 19, 2022)
- Federal Independent Dispute Resolution Process – Status Update (PDF) (April 27, 2023)
Good faith estimates & the patient-provider dispute resolution process
- Model Notice: Good Faith Estimate for Health Care Items and Services and Abbreviated GFE for No-Cost Health Care Items or Services
- Paperwork Reduction Act (PRA) model notices and information collection requirements for the good-faith estimate and patient-provider payment dispute resolution
- Guidance on good faith estimates and the Patient-Provider Dispute Resolution (PPDR) process for people without insurance or who plan to pay for the costs themselves (PDF)
- Guidance on good faith estimates and the Patient-Provider Dispute Resolution (PPDR) Process for providers and facilities as established in Surprise Billing, Part II; Interim Final Rule with Comment Period (PDF)
- Guidance for Selected Dispute Resolution (SDR) Entities: Required steps to making a payment determination under the Patient-Provider Dispute Resolution (PPDR) process (PDF)
- Calendar Year 2023 fee guidance for the Federal Patient-Provider Dispute Resolution (PPDR) process established in Surprise Billing, Part II; Interim Final Rule with Comment Period (PDF)
- Frequently Asked Questions (FAQs) about Consolidated Appropriations Act, 2021 Implementation – Good Faith Estimates (GFE) for Uninsured (or Self-Pay) Individuals – Part 1 (PDF)
- Frequently Asked Questions (FAQs) about Consolidated Appropriations Act, 2021 Implementation - Good Faith Estimates (GFE) for Uninsured (or Self-Pay) Individuals – Part 2 (PDF)
- Frequently Asked Questions (FAQs) about Consolidated Appropriations Act, 2021 Implementation - Good Faith Estimates (GFE) for Uninsured (or Self-Pay) Individuals – Part 3 (PDF)
- Frequently Asked Questions (FAQs) about Consolidated Appropriations Act, 2021 Implementation - Good Faith Estimates (GFE) for Uninsured (or Self-Pay) Individuals – Part 4 (PDF)
Disclosures, notice & consent
- Standard notice & consent forms for nonparticipating providers & emergency facilities regarding consumer consent on balance billing protections (PDF)
- Model disclosure notice on patient protections against surprise billing for providers, facilities, health plans and insurers (PDF)
- Requirements for including federal agency contact information and website URL on certain documents (PDF)
Insurance ID cards
- 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)