The Centers for Medicare and Medicaid Service in late June released a series of new regulations targeted at banning surprise billing in most instances, taking aim at a scourge that ends up costing many covered individuals thousands of dollars even when they are treated in-network.
The goal of the rule, slated to take effect Jan. 1, 2022, is to ensure that health plan enrollees are not gouged for out-of-network billing and balance billing for most services unless divulged to the beneficiary and approved by them in advance.
Balance billing ― when a medical provider bills a covered individual for the difference between the charge and the amount the insurer will pay ― is already prohibited by Medicare and Medicaid.
The interim rule will cover people who are insured by employer-sponsored health plans and plans purchased through publicly operated marketplaces. The new regulations are being implemented as required by the No Surprises Act of 2021, which passed through Congress with bipartisan support.
Surprise billing happens when people unknowingly get care from providers that are outside of their health plan’s network, which can happen for both emergency and non-emergency care. Examples of surprise billing include:
Two-thirds of bankruptcies are caused by outstanding medical debt, and out-of-network billing is partly to blame for that.
Studies have shown that more than 39% of emergency department visits to in-network hospitals resulted in an out-of-network bill in 2010, increasing to 42.8% in 2016. During the same period, the average amount of a surprise medical bill also increased, from $220 to $628.
The new regulations:
This is an interim final rule that is still out for public comment. It may be changed after the CMS receives comments.
More than likely it will take effect at the start of 2022, mostly intact.