Article 16: Nine Federal Laws You Should Know About >>

16.9 Consolidated Appropriations Act of 2021

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. 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.
These new rules will:

• Ban surprise bills for emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
• Ban out-of-network cost-sharing (like out-of-network coinsurance or copayments) for all emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
• Ban out-of-network charges and balance bills for supplemental care (like anesthesiology or radiology) by out-of-network providers who work at an in-network facility.
• Require that health care providers and facilities give you an easy-to-understand notice explaining that getting care out-of-network could be more expensive and options to avoid balance bills. You’re not required to sign this notice or get care out-of-network.

The No Surprises Act gives you important 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:
  1. Cover emergency services without requiring you to get approval for services in advance (prior authorization).
  2. Cover emergency services by out-of-network providers.
  3. 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.
  4. Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.”

The Southern California IBEW-NECA Health Trust Fund provides fully insured medical and prescription benefits through Blue Shield PPO Plan, Kaiser Permanente and UnitedHealthcare HMO. The carriers will provide participants with all necessary reporting. If you believe you’ve been wrongly billed, or if you have questions, claims or disputes, please contact your health carrier.

Blue Shield: (855) 599-2650
Kaiser Permanente: (800) 464-4000
UnitedHealthcare: (800) 624-8822