second set of regulations has been issued to implement the Consolidated Appropriations Act ‘s (CAA) No Surprises Act, which helps protect health care participants from surprise billing and excessive cost-sharing. Specifically, patients should pay only a rate similar to the in-network coverage for emergency services and certain non-emergency services furnished by out-of-network (OON) providers at in-network facilities.

These regulations provide details about the independent dispute resolution (IDR) process that health care providers and health care plans must use to resolve payment disputes.

See summary below of additional requirements, which generally apply to group health plans for plan years beginning on or after January 1, 2022:

IDR Disputing parties must utilize a 30-day open negotiation period. If the negotiations fail, they may initiate the IDR process. The bulletin below lists the steps and deadlines of the IDR process.

​Expanded External Review Grandfathered health plans are generally exempt from external review requirements. However, they will be subject to the external review of adverse benefit determinations for coverage issues related to these cost-sharing and surprise billing provisions.

Employers with self-insured health plans will want to ensure that their TPA is preparing for timely compliance. And insurers are responsible for compliance of fully-insured health plans.

Our bulletin below and the DOL’s news release contain more information on the interim final rule. 

Read Our Bulletin

If you have questions or need help, please contact one of our benefit consultants.

This blog and its contents are not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.