No Surprises Act
As of January 1, 2022, consumers have new billing protections when getting emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Through new rules aimed to protect consumers, excessive out-of-pocket costs are restricted, and emergency services must continue to be covered without any prior authorization, and regardless of whether or not a provider or facility is in-network.
Previously, if consumers had health coverage and got care from an out-of-network provider, their health plan usually wouldn't cover the entire out-of-network cost. This left many with higher costs than if they’d been seen by an in-network provider. This is especially common in an emergency situation, where consumers might not be able to choose the provider. Even if a consumer goes to an in-network hospital, they might get care from out-of-network providers at that facility.
In many cases, the out-of-network provider could bill consumers for the difference between the charges the provider billed, and the amount paid by the consumer’s health plan. This is known as balance billing. An unexpected balance bill is called a surprise bill.
The Consolidated Appropriations Act of 2021 was enacted on December 27, 2020 and contains many provisions to help protect consumers from surprise bills, including the No Surprises Act under title I and Transparency under title II. Learn more about protections for consumers, understanding costs in advance to avoid surprise bills, and what happens when payment disagreements arise after receiving medical care.
For more information about your rights as a consumer, please visit Consumers | CMS
Health Plan Transparency
Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. Beginning July 1, 2022, HealthFirst TPA, Inc. started publishing machine-readable files contraining the following sets of costs for items and services:
- In-Network Rate File: rates for all covered items and services between your plan and in-network providers.
- Allowed Amount File: allowed amounts for, and billed charges from, out-of-network providers.
To access the machine readable files for your plan, please go to our security portal site and login to your account or set up a new account. You can also download our portal app either on iOS or Android.
Phase 2 and Phase 3 go into effect in 2023 and 2024.
For more information about the Health Plan Transparency, please vist Consumers | CMS
Mental Health Parity - Amendments to MHPAEA
The Consolidated Appropriations Act, 2021 was enacted on December 27, 2020.5 Section 203 of Title II of Division BB of the Appropriations Act amended MHPAEA, in part, by expressly requiring group health plans and health insurance issuers offering group or individual health insurance coverage that offer both medical/surgical benefits and MH/SUD benefits and that impose NQTLs on MH/SUD benefits to perform and document their comparative analyses of the design and application of NQTLs. Further, beginning 45 days after the date of enactment of the Appropriations Act, these plans and issuers must make their comparative analyses available to the Departments or applicable State authorities, upon request, including the following information:
- The specific plan or coverage terms or other relevant terms regarding the NQTLs and a description of all MH/SUD and medical or surgical benefits to which each such term applies in each respective benefits classification;
- The factors used to determine that the NQTLs will apply to MH/SUD benefits and medical or surgical benefits;
- The evidentiary standards used for the factors identified, when applicable, provided that every factor shall be defined, and any other source or evidence relied upon to design and apply the NQTLs to MH/SUD benefits and medical or surgical benefits;
- The comparative analyses demonstrating that the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to MH/SUD benefits, as written and in operation, are comparable to, and are applied no more stringently than, the processes, strategies, evidentiary standards, and other factors used to apply the NQTLs to medical/surgical benefits in the benefits classification; and
- The specific findings and conclusions reached by the plan or issuer, including any results of the analyses that indicate that the plan or coverage is or is not in compliance with the MHPAEA requirements.
Read the CMS publsihed FAQs sheet about the new amendments to MHPAEA by visiting FAQs-Part-45 (cms.gov)
HealthFirst TPA remains committed to serving our members, employers, and providers by helping them navigate through these changes as seamlessly as possible. We’ve made it our utmost priority to offer and implement robust solutions that will adhere to the No Surprises Act, Health Plan Transparency, and Mental Health Parity provisions so you can remain educated about your rights as a member, employer, or provider. We continue to closely monitor all legislation with the help of our ERISA attorneys, The Phia Group, around the surprise billing and transparency laws and will communicate updates as they become available.