Beginning on Jan. 1, 2022, the Act, among other things, prohibits balance billing by limiting cost sharing to the in-network amount for:
- Emergency services provided by out-of-network facilities and providers
- Certain situations where a patient receives care from an out-of-network provider at an in-network facility
In general, the interim final rule is relatively narrow in scope. The rule:
- Clarifies the definition of post stabilization services
- Defines the notice and consent process necessary to balance bill for post-stabilization services
- Provides technical details for determining the qualifying payment amount that will be used to determine patient cost sharing in covered, out-of-network situations for California hospitals
The rule also reinforces the “prudent layperson” standard and appears to prohibit health plans from denying coverage for emergency services based on the patient’s final diagnosis. CHA will soon make available a detailed summary of the interim final rule.
An additional interim final rule implementing the No Surprises Act is anticipated in August. This rule will include details on the independent dispute resolution process used to determine the payment amount when providers and health plans cannot agree on reimbursement for out-of-network care covered under the No Surprises Act, and the transparency provisions that include the good faith estimate for providers and the advanced EOB for plans.