NEW RULES:Bans on balance billing and out-of-network cost-sharing

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:

Bans surprise billing for emergency services

If a member receives emergency services, they will be covered at the in-network rate, and the services do not require prior authorization from Health Plan. This is true even if the services are received at a facility or from a provider that does not participate in their network. Additionally, members will be protected from balance billing when receiving post-stabilization services at a nonparticipating facility.

Bans balance billing and out-of-network cost-sharing for emergency services as well as certain nonemergency services performed by a nonparticipating provider (or facility on behalf of the provider) at participating health care facilities including out-of-network ancillary providers such as pathologists, anesthesiologists, and radiologists at in-network facilities: 

In these situations, the member’s cost share cannot be higher than the cost share would have been if the services were provided by an in-network provider or an in-network facility. The member’s cost share must be based on the in-network rates.

Bans balance billing for out-of-network air ambulance service

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