Federal No Surprises Act

  • What you need to know

    The federal No Surprises Act took effect January 1, 2022, and aims to reduce unexpected medical bills for patients.

    Group health plans, group and individual health insurers, carriers under the Federal Employees Health Benefits (FEHB) Program, health care providers and facilities, and providers of air ambulance services must comply with several requirements.

    The law:

    • Prohibits balance billing of patients when out-of-network (OON)/non-contracted emergency care is received
    • Includes certain ancillary services provided by OON providers at an in-network facility
    • Requires a patient’s informed consent when services are provided by an OON provider
    • Requires that health plans verify the accuracy of provider information included in the plan’s directory at least every 90 days
    • Requires providers to respond every 90 days with updated directory information
    • Includes a dispute resolution clause in the event an OON provider and the health insurer can’t agree on payment
    • Only upon a patient’s request, requires providers to submit a good faith estimate to the health plan prior to any scheduled patient visit

    Premera members with individual plans (state and federal exchanges) and group plans including the School Employees Benefits Board (SEBB) Program and the Federal Employee Program (FEP) are covered by this legislation. Medicare Advantage members aren’t included as they’re already covered by a clause through the Centers for Medicaid and Medicare Services.

    Note: All group plans, including self-funded plans, are covered by the Federal No Surprises Act. Some self-funded plans may have opted into the Washington state Balance Billing Protection Act and may be covered by those guidelines as well.