Under the rule, patients would be responsible only for their in-network cost-sharing for both emergencies and certain non-emergencies where they are unable to choose in-network providers.
The regulation, which applies to those with job-based and individual market insurance plans, also covers non-emergency care from out-of-network providers at in-network facilities — such as an out-of-network anesthesiologist working with an in-network surgeon or an out-of-network radiologist reading an X-ray ordered by an in-network doctor.
It applies to air ambulance services from out-of-network providers, but ground ambulance services are not covered.
If a patient chooses to see out-of-network providers, they would be prohibited from billing the patient the balance unless they provided notice of their network status and an estimate of charges, generally 72 hours in advance. The patient would also have to consent to receiving out-of-network care that could cost them more. The rule provides a template that providers can use.
Who pays the rest of the bill
To resolve the balance of the bill, the No Surprises Act calls for insurers and providers to go through negotiation or an independent dispute resolution process. The arbiter would be required to consider the median in-network rate, previous contracts, the complexity of services, training of the provider and other factors. There would be no minimum payment threshold to enter arbitration.
Insurers advocated basing payments on locally negotiated rates, not arbitration. Hospitals voiced concerns about a number of provisions, including holding hospitals responsible for physician billing and payments, among others. Doctors said the act would hurt physician practices and that smaller offices may not have the resources to participate in arbitration.
The Biden administration will tackle arbitration and other provisions in subsequent rules. The arbitration process was a controversial and less defined part of the law, and industry representatives are expected to seek to influence the rule.