Federal No Surprises Act and WA Patient Balance Billing Protections

  • 2022 Federal No Surprises Act

    The federal No Surprises Act is a new law taking effect January 1, 2022, that 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.

    Washington Balance Billing Protection Act

    The Washington state Balance Billing Protection Act has been effective since January 1, 2020, protecting patients from surprise or balance billing if they receive emergency care at any medical facility or when treated at an in-network hospital or outpatient surgical facility by an out-of-network provider. It applies only to our members residing in Washington state and covered under fully-insured plans and self-funded plans that chose to participate. Self-funded plans that did not opt into the state act are covered under the Federal No Surprises Act.

    Starting January 1, 2022, it will work in partnership with the federal No Surprises Act to protect patients from balance billing. The federal law will not pre-empt state balance billing laws except where the federal protections are broader or more favorable to consumers.