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September 02, 2021 (Cleveland, OH )

Federal, State ‘Surprise Billing’ Regulations Effective in Early 2022

In January 2022, Ohio hospitals will have two new sets of regulations to follow regarding out-of-network billing and reimbursement: one set at the federal level and the other at the state level.

Federal Rules

The federal requirements follow the No Surprises Act, which is effective Jan. 1 and under which an interim final rule was published July 1, 2021, on Part 1 of these regulations. The rules:

• Ban balance billing in certain out-of-network scenarios, including emergency and post-stabilization services.

• Establish requirements regarding health plans’ initial payment – or notice of denial – to providers.

• Require providers to make publicly available – including on their websites – information on patients’ rights regarding balance billing.

• Permit patients to waive balance billing protections if the out-of-network provider provides notice and obtains the patient’s consent.

• State that some of the policies implemented recently by commercial health plans restricting coverage for emergency services are inconsistent with the prudent layperson standard under the Affordable Care Act as well as requirements of the No Surprises Act.

Some provisions of the No Surprises Act are not covered by these rules and will be addressed in future regulations. These include the independent dispute resolution process, good faith estimates and advanced explanation of benefits, provider directories, and continuity of care.

State Rules
At the state level, a set of rules has been proposed by the Ohio Department of Insurance pursuant to Ohio H.B. 388, which was passed by the Ohio General Assembly in late 2020 and addresses reimbursement for unanticipated out-of-network care. This state legislation:

• Bans balance billing for unanticipated or emergency care.

• Requires insurers to cover emergency or unanticipated out-of-network care.

• Limits a covered person’s cost-sharing for those services to what they would pay for in-network services.

• Establishes a default reimbursement rate for these services.

• Outlines an arbitration process.

The bill calls for an effective date of Jan. 12, 2022. However, in comments submitted on the proposed rule the Ohio Hospital Association has urged the state to delay that effective date.

Hospitals strongly support protecting patients from gaps in their health care coverage that may result in unanticipated medical bills and want to ensure this shared goal is accomplished in a way that does not place excessive regulatory burdens on providers.

For more on billing and reimbursement issues, contact us.