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CMS Issues Letter Detailing California’s Role in No Surprises Act Enforcement

For CEOs, CFOs, government relations executives, finance & reimbursement staff, legal counsel

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The Centers for Medicare & Medicaid Services (CMS) has issued a letter detailing the No Surprises Act (NSA) provisions that it will solely enforce and those that California and CMS will enforce collaboratively.  

The law intends for states to be the primary enforcement agent for the NSA’s provisions. However, recognizing that not all states have the legal authority or resources to enforce each provision of the NSA, the law also allows for CMS to either enforce provisions that a state chooses not to or enter into a collaborative enforcement arrangement. CHA has created a overview that identifies the provisions CMS will enforce and those on which the state will collaborate with the agency to enforce. 

Under a collaborative enforcement agreement, the state will perform the compliance functions of policy form review, investigations, market conduct examinations, and consumer assistance, as applicable. Only if California is unable to obtain voluntary compliance will CMS consider undertaking formal enforcement action as warranted. 

Under this arrangement, the federal independent dispute resolution (IDR) process will apply for purposes of determining the out-of-network rate for items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in California by nonparticipating providers and nonparticipating emergency facilities to which California Health and Safety Code §§ 1371.30, 1371.31, and 1371.9, and §§ 10112.8, 10112.81 and 10112.82(a) of the Insurance Code do not apply. The California Department of Insurance and the Department of Managed Health Care will enforce the outcome of the federal IDR process for such cases in California. 

Additionally, the federal patient-provider dispute resolution process will apply for purposes of determining the amount an uninsured patient must pay a provider, facility, or provider of air ambulance services for an item or service if billed charges substantially exceed the good faith estimate of the expected charges provided prior to furnishing such item or service. CMS will enforce the outcome of the federal patient-provider dispute resolution process in California. 

Additional resources to help CHA members implement the law’s provisions are available on the NSA resource page.