What Providers Need to Know About the No Surprises Act
Frequently Asked Questions
Q. What is the No Surprises Act?
The No Surprises Act, (part of the Consolidated Appropriations Act, 2021 (CAA-21)), effective for claims with a date of service Jan. 1, 2022, and forward, includes:
- Protections for individuals from getting surprise medical bills after receiving emergency medical care and certain related services.
- Provisions for non-participating providers to negotiate and/or dispute certain reimbursements they receive from insurance companies.
Q. When did this act start?
Jan. 1, 2022.
Q. What types of services are covered by the No Surprises Act?
Under the No Surprises Act, out-of-network providers are prohibited from billing patients more than their in-network cost-sharing amounts for:
- All out-of-network emergency facility and professional services.
- Post-stabilization care at out-of-network facilities (until the patient can be safely transferred to an in-network facility).
- Air ambulance services (transports) in emergency and non-emergency situations.
- Out-of-network services delivered at, or ordered from, an in-network facility.
Q. Does the No Surprises Act cover regular ground ambulance services?
No.
Q. How will the No Surprises Act change how payer organizations, such as EmblemHealth and ConnectiCare, collect and pay our providers for services?
Surprise out-of-network services can no longer be billed directly to the patient. Payer organizations have 30 days to make an initial payment or send a notice of denial to the provider.
Q. How is the initial payment of a claim determined?
The initial payment is based on the “qualifying payment amount,” which is the median rate in each geographical area and insurance market for a particular service. If the provider feels the amount the payer organization paid is too low based on their existing rates and their usual medical billing amounts, the No Surprises Act allows for a new process, beginning with an open negotiation process.
Q. How do providers initiate the open negotiation period with the health plan?
Providers have the option to begin a 30-day “open negotiation,” during which the provider and the payer can negotiate on a mutually agreeable payment amount. The open negotiation request must be sent within 30 business days of receipt of the initial payment or notice of denial. The surprise billing open negotiation form must be used to initiate the process and can be found here: Open Negotiation Notice (dol.gov).
Providers can submit the official request form for negotiation by, fax, mail, or email at the contacts below:
FAX:
- HMO Provider Contact Center: 212-510-4981
- PPO Provider Contact Center: 212-510-3184
- ConnectiCare Provider Contact Center: 860-674-2232
MAIL:
- HMO (HIP) PO Box 2845, New York NY 10116
- PPO (GHI) PO Box 2832, New York NY 10116
- ConnectiCare Commercial PO Box 546, Farmington, CT 06034-0546
EMAIL:
- hmo_oon_negotiations@emblemhealth.com
- ppo_oon_negotiations@emblemhealth.com
- cci_oon_negotiations@emblemhealth.com
In the event you file a federal independent dispute resolution (IDR) after the open negotiation period ends, a copy of your federal Notice of IDR Initiation and all related inquiries should be sent to nsa_idrsubmission@emblemhealth.com for both EmblemHealth and ConnectiCare.
Note: A copy of your federal Notice of IDR initiation should be sent to us the same day you file it. More IDR information can be found below.
Q. What if an agreement cannot be reached on the reimbursement amount?
At the end of the negotiation period, if the health plan and provider or facility haven’t agreed on a payment amount, either party can begin the independent dispute resolution (IDR) process.
Q. What standards must be met to start an independent dispute resolution (IDR)?
A dispute can’t be started until the required 30-business-day open negotiation period has ended. Then, the dispute must be started within four business days after the open negotiation period has ended, except in the circumstance described in this memorandum (PDF).
Q. How does the independent dispute work?
Implementation and enforcement of the No Surprises Act involves both federal and state governments. Generally, the law assigns enforcement to the states but calls for federal enforcement where states are unwilling or unable to take it on. Many states are sharing enforcement responsibility with the federal government, sometimes with a collaborative enforcement agreement. In addition, almost half of all states have specified state laws that will be used to determine payments from insurers (generally state-regulated insurers) to out-of-network providers in lieu of the federal independent dispute resolution (IDR) system. These states generally use either a standard payment rule, a state-specific dispute resolution process, or a hybrid of the two to determine the out-of-network payment rate.
State |
What is state's overall strategy for No Surprises Act enforcement? |
Notes |
Connecticut |
Shared |
Federal enforcement for some surprise billing provisions. State enforcement for some surprise billing provisions. |
Massachusetts |
Shared (collaborative) |
Federal enforcement for some surprise billing provisions. State enforcement for some surprise billing provisions, with use of a collaborative enforcement agreement. |
New Jersey |
Shared (collaborative) |
Federal enforcement for some surprise billing provisions. State enforcement for some surprise billing provisions, with use of a collaborative enforcement agreement. |
New York |
Shared |
Federal enforcement for some surprise billing provisions.
|
Q. What is the definition of shared (collaborative enforcement) and shared enforcement?
Shared (collaborative enforcement) is when enforcement is shared and a collaborative enforcement agreement between the state and the federal government will be used to allocate responsibilities for at least some designated provisions. For example, for enforcement against providers, the state might investigate and issue voluntary enforcement letters, and the federal government would impose civil monetary penalties as needed.
Shared enforcement is when some provisions are enforced by the state and some by the federal government.
This map shows more information on how the No Surprises Act is enforced by each state.
Q. How are the state bureaus contacted?
Most states are responsible for enforcing Affordable Care Act (ACA) standards that apply to fully insured health plans, including those sold to individuals and small employers. These standards include the requirement that plans cover Essential Health Benefits and the prohibition on plan designs that discourage enrollment from people with significant health needs. In states that fail to enforce the ACA standards, the U.S. Department of Health and Human Services is responsible for enforcement. See the table below for contact information for state departments of insurance.
State |
Department of Insurance Website |
Connecticut |
|
Massachusetts |
|
New Jersey |
|
New York |
Q. For the states with a shared/collaborative strategy to enforce the No Surprises Act, how do you determine whether the state or federal independent dispute resolution (IDR) process should be used?
If your state is in the “Bifurcated Process” column, you should review the state law or All-Payer Model Agreement and, if necessary, consult with the proper state authorities on whether the state or the federal IDR process applies to the particular payment dispute at issue.
Q. How does the federal independent dispute resolution (IDR) process work?
The IDR process is outlined here:
- Ending Surprise Medical Bills (Centers for Medicare & Medicaid Services (CMS))
- Start a Dispute (U.S. Dept. of Health and Human Services)
Q. What types of services are covered by the federal IDR process?
Use federal IDR for:
- Self-insured plans sponsored by private employers, private employee organizations, or both in all states, except in cases in which a self-insured plan has opted into a specified state law, in a state that permits these plans to opt in, or when an All-Payer Model Agreement applies.
- Health benefits plans offered under 5 U.S.C. 8902 in all states, except in cases where an Office of Personnel Management (OPM) contract with a Federal Employee Health Benefits (FEHB Carrier includes terms that adopt the state process.
- Where the plan or issuer and provider or facility are in different states, the federal IDR process will apply.
- Air ambulance and out-of-area (outside NY, CT, MA, NJ) regardless of line of business.
Go to the Centers for Medicare & Medicaid Services (CMS) website for more information.
Q. What types of services are NOT covered by the federal IDR process?
- The federal IDR process does not apply to items and services payable by Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or TRICARE.
- The federal IDR process also does not apply in cases where a specified state law or All-Payer Model Agreement under Section 1115A of the Social Security Act provides a method for determining the total amount payable under a group health plan or group or individual health insurance coverage with respect to the out-of-network items and services furnished by the provider or facility.
Q. Do I need to notify the health plan when I file a federal IDR?
Yes. Send a copy of your federal Notice of IDR Initiation to us the same day you file it. Please send all IDR actions to nsa_idrsubmission@emblemhealth.com.
Q. Where can I find more information on this topic?
General Information:
You can learn more about the Federal No Surprises Act process on the Centers for Medicare & Medicaid Services (CMS) website.
Member Information
EmblemHealth: Consumer Protections (emblemhealth.com)
ConnectiCare: Important Legal Notices for ConnectiCare Members (connecticare.com)
This information was compiled December 2022 and is subject to change, as there may be amendments to this language and/or the Act itself. We will make every effort to update this language as necessary.
