Agencies Release First Rule on the No Surprises Act
On July 13, 2021, the DOL, HHS, and IRS released a joint Interim Final Rule implementing specified provisions of the No Surprises Act, a new law included within the Consolidated Appropriations Act, 2021. The No Surprises Act addresses, among other things, a prohibition on surprise billing, which impacts emergency room parity rules previously implemented under the Affordable Care Act (“ACA”) and ACA provisions related to provider choice.
The Interim Final Rules will be finalized on September 13, 2021 and apply for plan years beginning on or after January 1, 2022.
Background
ACA Provider Choice and Emergency Services Requirements
Under §2719A of the ACA, most group health plans that require designation of a participating primary care provider must permit the participant or beneficiary to designate an available, participating primary care provider of their choice, and must inform participants of their ability to make a designation or, if they don’t, a primary care provider will be designated for them. A participant can designate a pediatric primary care provider for children, and the notice must inform participants and beneficiaries that they do not need prior authorization from the plan to access participating Ob-Gyn providers, though prior authorization may be required for certain services and providers may have to comply with any referral processes. The ACA did not extend these requirements to “excepted benefits” such as stand-alone dental or vision plans, and grandfathered health plans were exempt from complying.
Additionally, §2719A of the PHSA requires emergency services to be provided:
- Without prior authorization (whether they are provided by an in-network or out-of-network provider);
- Without regard to whether the health care provider furnishing the emergency services is a participating network provider with respect to the services; and
- Without imposing administrative requirements or limitations on …
