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3 things your plan participants should know about the No Surprises Act

This will be an exciting open enrollment season. For many employers, business will be again conducted in-person, and there are new consumer protections pursuant to the No Surprises Act, part of the Consolidated Appropriations Act, 2021 (Pub. L. 116-260), which will impact your health plan offering when they take effect on January 1st.

While most obligations under the Act fall on health plans and health care providers, health plan participants will be directly impacted by the Act’s slated changes and will notice some significant differences in their health care experience almost immediately.

A little education during open enrollment can prevent a lot of questions from falling on HR later, so the following information may be worth sharing with your employees:

Expect greater transparency around benefits and costs

Participants will have more access to details about their health plan design, and what services cost, than ever before. Mandated transparency tools will be heavily promoted by both providers and carriers, but there is no requirement that participants use them. Beginning Jan. 1, 2022, all health care providers must make information on patients’ rights with respect to balance billing publicly available. Expect health plans to share more information on their websites explaining balance billing (when a patient is responsible for an amount over what a health plan pays). Plus, health plan ID cards will show deductibles and out-of-pocket maximums.

Expect more notices and consents

Participants will receive an electronic or paper notice if the provider they intend to see for non-emergent services is housed within an in-network health care facility but does not participate in the participant’s health plan. Putting participants on notice is intended to prevent surprise bills caused by the participant incorrectly assuming the services will be covered at their in-network benefit level.

The notice must include helpful items like charge estimates and alternative in-network providers available at the facility (if any); plus, a clear statement that consenting to non-network services is optional and that in-network providers may be available. Clear carve-outs exist in situations when no in-network provider is available, or when the provider is related to emergency medicine, anesthesiology, pathology, radiology, and neonatology. In such cases, the health plan in-network cost-sharing will apply.

Expect advanced Explanation of Benefits (EOBs)

Under the Act, providers must reach out to patients with scheduled care in advance of their appointment to solicit the patient’s insurance information. The provider must then send the patient’s carrier a description of items and services they anticipate providing as well as estimated charges. The carrier then delivers, with a very short turnaround time, a newly minted paper or electronic Advanced EOB prior to the appointment.

The Advanced EOB provides a good-faith estimate of the final participant cost based upon things like likely charges and where the participant will be against their deductible and out-of-pocket maximum. Employers can only hope carriers will continue their tradition of marking these documents with the famous watermark, “This Is Not a Bill.” Otherwise there may be questions created by these potentially confusing, albeit ultimately informative, new documents.

With January 1st around the corner, health plans and providers are moving quickly to make these changes as regulations and guidance continue to be published. As with most regulations, these parties will be required to make a good-faith effort to meet the requirements by the deadline and then are obligated to modify their efforts as more direction comes to light. Employees and their covered dependents can expect new types of notifications and other tools that allow them better visibility to their portion of the cost of care, and we can expect these tools to improve over time.

Source: Benefits Pro

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