Under the rule, patients would only be responsible for their network cost sharing for emergencies and certain non-emergency situations when they cannot choose networked providers.
The regulation, which applies to those with insurance plans based on employment and individual market, also covers non-urgent care provided by non-network providers in network facilities, such as an anesthesiologist. off-network working with a network surgeon or an off-network radiologist reading an x-ray ordered by a network doctor.
It applies to air ambulance services provided by non-network providers, but ground ambulance services are not covered.
If a patient chooses to see off-network providers, they will be prohibited from billing the patient the balance unless they provide notice of their network status and an estimate of charges, usually 72 hours in advance. . The patient should also consent to receive out-of-network care which may cost them more. The rule provides a template that providers can use.
Who pays the rest of the bill
To deal with the rest of the bill, the No Surprises Act requires insurers and providers to go through negotiation or an independent dispute resolution process. The arbitrator would be required to take into account the network median rate, past contracts, complexity of services, provider training and other factors. There would be no minimum payment threshold to enter arbitration.
Insurers have advocated basing payments on locally negotiated rates, not arbitration. Hospitals have raised concerns about a number of provisions, including holding hospitals accountable for physician billing and payments, among others. Doctors said the law would interfere with the practices of doctors and small offices might not have the resources to participate in arbitration.
The Biden administration will address arbitration and other provisions in subsequent rules. The arbitration process was a controversial and less defined part of the law, and industry representatives are believed to seek to influence the rule.