Download a helpful, one-page guide to understanding surprise medical bills.
Health plans must negotiate surprise medical bills on behalf of patients who receive emergency services rendered by out-of-network providers/facilities, air ambulance services, and services provided by out-of-network providers at in-network hospitals or facilities. The new law lifts the burden off patients, so they are held harmless and not balance billed for provider charges that exceed the in-network rate.
The law includes prohibitions on balance billing, a settlement process for disputes between health insurers or group health plans and out-of-network providers, and coordination with state surprise billing laws.
The law applies to medical bills related to:
- Out-of-network emergency covered services at a hospital or free-standing facility.
- Covered items and services provided by an out-of-network health care provider at an in-network facility.
- Out-of-network air ambulance items and services.
The law applies to emergency services at out-of-network hospitals and free-standing emergency facilities, out-of-network providers at in-network facilities, and out-of-network air ambulance carriers. Providers are prohibited from balance billing patients for these services. In addition, out-of-network providers of ancillary services at an in-network facility are also prohibited from balance billing patients. Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory and diagnostic services, and where there is not an in-network provider available.
The No Surprises Act establishes an Independent Dispute Resolution (IDR) process, also referred to as arbitration, to resolve disputes between out-of-network providers and insurers/health plans and prohibits balance billing by out-of-network providers with certain exceptions. The law does not apply if the member chooses to receive items and services from an out-of-network provider.
How does this new rule affect me?
While BCBSKS contracts with most hospitals and providers in our state, there could be occasions where you go seek emergency care at an in-network facility but are seen and treated by a provider who is out-of-network. In those cases, BCBSKS will now cover the care received by that provider at in-network rates.
BCBSKS cannot impose out-of-network member cost-sharing (co-pays, deductibles) requirements that are greater than those applied to in-network services (e.g., if your BCBSKS plan has a 10% co-insurance for in-network services, the co-insurance for out-of-network services cannot exceed 10%). Also, out-of-network cost-sharing must be applied to in-network deductibles and cost-sharing limits.
How does the No Surprises Act require coverage for out-of-network services including air ambulance?
BCBSKS will cover the same out-of-network items/services as it does in-network items/services regardless of whether they are provided by a non-participating provider/facility, subject to the requirements for cost-sharing (co-pays and deductibles), payment amounts, and dispute resolution. This includes all covered items/services in connection with the visit to the facility even if that care is provided outside of the facility (e.g., laboratory and telemedicine services).
If BCBSKS has a network of participating providers and covers any air ambulance benefits, BCBSKS must cover services provided by an out-of-network air ambulance carrier, even if BCBSKS does not have any in-network air ambulance carriers, subject to the requirements for cost-sharing, payment amounts, and dispute resolution.
Are there any restrictions or plan terms that change what out-of-network services are covered?
Coverage for emergency services must be provided without any prior authorization requirements or with administrative requirements or coverage limits that are more restrictive than those applicable to in-network emergency services.
Coverage for emergency services must be provided without regard to any other term or condition of the plan or coverage except for: (a) the exclusion or coordination of benefits when it’s not consistent with any benefits for emergency services); (b) any affiliation or waiting period or (c) any applicable cost-sharing requirements.
BCBSKS cannot deny benefits for a member with an emergency medical condition that receives emergency services, based on a general plan exclusion that applies to non-emergency items/services (e.g., denying emergency treatment for a dependent pregnant woman based on a general exclusion for dependent maternity care).
How is cost sharing handled for out-of-network emergency, out-of-network air ambulance or out-of-network service at an in-network facility when member has no choice?
In cases of extreme emergency, there will be times when you are unable to tell emergency providers where you would like to receive treatment. For situations like these, where the patient has no control over where they receive care, BCBSKS will not make a member pay out-of-network cost-sharing if it is a higher amount than what would be typical for their cost-sharing on in-network services. For example, if a member’s plan requires 10% co-insurance for in-network services, the co-insurance for out-of-network services cannot exceed 10%. In addition, out-of-network cost-sharing must be applied to in-network deductibles and cost-sharing limits.
When can a provider balance bill an individual?
Patients may be balanced billed for out-of-network non-ancillary services at an in-network facility if the provider:
- informs the patient in advanced that they are out-of-network ,
- provides an estimate of the charges, and
- secures a written acknowledgement from the patient that they received the notice and understand any cost-sharing will be applied to their out-of-network limits.
Ancillary services are those for emergency medicine, anesthesiology, pathology, radiology, neonatology, and laboratory.
What are my rights and protections against surprise medical bills?
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing, or balance billing.
What is balance billing (sometimes called surprise billing)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. Out-of-network describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called balance billing. This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. Surprise billing is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services - If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center - When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
- You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization).
- Cover emergency services by out-of-network providers.
- Base what you owe the provider or facility (cost-sharing) on what it would pay an in‑network provider or facility and show that amount in your explanation of benefits.
- Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the Kansas Insurance Department at https://insurance.kansas.gov/ . You can also visit https://www.cms.gov/nosurprises for more information about your rights under federal law.
What is the process if BCBSKS and the out-of-network provider/facility do not agree on the rates the provider/facility bills?
BCBSKS negotiates and agrees upon rates in advance with in-network facilities and providers. It is what we do to help protect our members from paying more for their care than they should. These negotiations do not take place with out-of-network facilities and providers until after a service is provided.
Included in the ACA is an independent dispute resolution (IDR) process, sometimes called a arbitration, which was established to determine the provider reimbursement amount if the health insurer or group health plan and the out-of-network provider are unable to negotiate a reimbursement rate (and if there is not a state law methodology to establish the reimbursement amount). The most important thing for our members to know about this is that once the IDR process concludes, the provider cannot balance bill, or send a bill to the patient for the remainder that was not covered by BCBSKS.