Surprise Billing Changes (No Surprise Act): Effective 1/1/2022
Posted on October 29, 2021
Effective 1/1/2022, and in accordance with the Consolidated Appropriations Act: No Surprise Act and the Massachusetts Chapter 260 of the Acts of 2020, Health New England will apply the following regulatory requirements.
Balance Billing Protection from Out-of-Network Providers:
The federal “No Surprises Act” creates a process which providers must follow in order to balance bill. Balance billing is when the provider bills for the difference between the provider’s charge and the allowed amount. The allowed amount is the maximum amount on which payment is based for covered services.
Providers (including facilities, physicians, and non-physician practitioners) who are not contracted with Health New England, may not balance bill our members for covered emergency services or certain non-emergency services unless the provider has obtained consent from the member. This consent is known as the “Notice and Consent” process.* In this process, the provider, before any services are performed, must inform our member of their out-of-network status and the member’s right not to be balanced-billed. The provider must then obtain our member’s consent in writing.
*Notice and Consent process does not apply to:
- Emergency services
- Certain ancillary services (emergency medicine, anesthesiology, pathology, radiology, neonatology, and diagnostic services including radiology and lab services)
- Items and services due to unforeseen urgent medical need during a procedure for which notice and consent has been previously been obtained
- Any situation where there is no In-Plan provider available at the In-Plan facility to provide the service
Any member who feels there is a violations of this balance billing protection, has the right to report the incident to the Massachusetts Division of Insurance (DOI). They will do this by submitting a formal complaint at this website: https://www.mass.gov/how-to/filing-an-insurance-complaint. They may also call (617) 521-7794.
Continuity of Care:
If our member is receiving any of the following from one of our in-network providers who decides to terminate or does not renew their contract with Health New England, our member can continue to receive services with this provider for up to 90 days after the termination of the contract:
- A course of treatments for a serious or complex condition
- Undergoing institutional or inpatient care
- Scheduled to undergo non-elective surgery (including post-operative care)
- Pregnant and undergoing treatment
- Terminally ill and receiving treatment
This does not apply if the provider’s contract is terminated with Health New England for fraud or failure to meet quality standards.
Emergency Services & Non-Emergency Services:
Health New England covers emergency services in an Emergency Room without prior authorization regardless of when our member seeks care at an in-network facility or out-of-network facility.
Emergency care includes post-stabilization services unless:
- The member is medically able to be transferred to an in-network facility
- The provider has met the “Notice & Consent” requirement of the Consolidated Appropriations Act: No Surprise Act
Emergency care provided out-of-network must be covered as if in-network:
- Utilization Management will be the same for in-network and out-of-network services
- In-network cost sharing will apply whether the services are performed in-network or out-of-network
- Cost sharing will count towards the in-network deductible and out-of-pocket maximum if applicable to the member’s benefit plans
Non-emergency services performed at an in-network facility, by a provider who is not contracted with Health New England:
- Will be covered at in-network cost share (copayment/coinsurance)
- The cost-share will count towards the member’s in-network deductible and out-of-pocket maximum, if applicable to the member’s benefit plan
In order to bill our member any remaining balance, prior to services being performed:
- You must provide in writing to our member a recognized** amount, a list of providers, and received their written consent
- Also, you may not bill our member more than their in-network cost sharing
** Under the federal “No Surprises Act,” a recognized amount is either the amount specified by state law or a qualifying amount based on a historic amount.
Provider Directory Updates:
With the implementation of this Act, it is now more important for our provider directories to contain the most up-to-date information. Based on the requirements of this Act, providers are obligated to verify their provider directory information at least once every 90 days. Failure by providers to confirm current and accurate provider directory information requires the removal of the provider or facility from the Health New England (HNE) directory. HNE has begun utilizing CAQH ProView® to assist us with the initiative of provider directory validation for many of our providers, and will be using it for all published providers by the end of 2021. Providers should validate and update their provider directory data in CAQH for distribution to HNE. As a reminder, please refer to Provider Directory Validation and CAQH Initiative at http://hnetalk.com/provider/ for more information.
For more information or questions, please go to https://healthnewengland.org/Providers/Resources and click on “No Surprises Act.” You may also call Provider Relations at (800) 842-4464 extension 5000 or send an email to providerrelations@hne.com.
