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Health & Welfare Plans Newsletter

July 1, 2021


[Official Guidance]

Text of Agencies' Interim Final Rule and Request for Comments: Requirements Related to Surprise Billing, Part 1 (PDF)

411 pages. "These interim final rules implement provisions of the No Surprises Act that: [1] apply to group health plans, health insurance issuers offering group or individual health insurance coverage, and carriers in the FEHB Program to provide protections against balance billing and out-of-network cost sharing with respect to emergency services, non-emergency services furnished by nonparticipating providers at certain participating health care facilities, and air ambulance services furnished by nonparticipating providers of air ambulance services; [2] prohibit nonparticipating providers, health care facilities, and providers of air ambulance services from balance billing participants, beneficiaries, and enrollees in certain situations, and permit these providers and facilities to balance bill individuals if certain notice and consent requirements in the No Surprises Act are satisfied; [3] require certain health care facilities and providers to provide disclosures of federal and state patient protections against balance billing; [4] recodify certain patient protections that initially appeared in the ACA and that the No Surprises Act applies to grandfathered plans; and [5] set forth complaints processes with respect to violations of the protections against balance billing and out-of-network cost sharing under the No Surprises Act ...

"Among other requirements, these interim final rules require emergency services to be covered without any prior authorization, without regard to whether the health care provider furnishing the emergency services is a participating provider or a participating emergency facility with respect to the services, and without regard to any other term or condition of the plan or coverage other than the exclusion or coordination of benefits or a permitted affiliation or waiting period....

"These interim final rules specify that cost-sharing amounts for such services furnished by nonparticipating emergency facilities and nonparticipating providers at participating facilities must be calculated based on one of the following amounts: [1] an amount determined by an applicable All-Payer Model Agreement under section 1115A of the Social Security Act; [2] if there is no such applicable All-Payer Model Agreement, an amount determined by a specified state law; or [3] if there is no such applicable All-Payer Model Agreement or specified state law, the lesser of the billed charge or the plan's or issuer's median contracted rate, referred to as the qualifying payment amount (QPA)."

Also released:


U.S. Office of Personnel Management [OPM]; U.S. Department of Health and Human Services [HHS]; U.S. Department of Labor [DOL]; and U.S. Treasury Department

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BenefitsLink Retirement Plans Newsletter, ISSN no. 1536-9587.

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