Federal Surprise Billing Rule Takes Effect January 1

December 8, 2021

Changes are coming soon at the federal level to protect patients from surprise bills for medical services. Starting Jan. 1, 2022, out-of-network physicians who provide care at in-network facilities may not bill patients for any amount beyond the patients in-network cost sharing obligation.

Surprise bills happen when a patient seeks care at a hospital or other facility that is in their insurance network, and subsequently receives a bill from an out-of-network physician or clinician who provided services during the patient's visit to the facility. The intent of the federal No Surprises Act, passed in 2020, is to take patients out of the middle of payment disputes between physicians and insurers. The law prevents health insurers and healthcare professionals from charging patients more for these unexpected out-of-network services when patients choose care at an in-network facility, but end up unknowingly receiving some services from nonparticipating health professionals.

Under Illinois law, since 2013 certain types of facility-based physicians (radiologists, anesthesiologists, pathologists, emergency physicians, and neonatologists) have been prohibited from balance billing out-of-network patients who receive care at in-network facilities. The new federal law extends this prohibition to all non-participating facility-based physicians providing services at an in-network hospital or other facility.

Although implementation details of the federal No Surprises Act are still being negotiated, including the interaction between the state and federal law, it is clear that facility-based physicians may not balance bill patients when the facility is in the patient's health care network.

The No Surprises Act applies to employer-sponsored group health plans (those generally regulated by ERISA and exempt from state-level insurance regulations) and individual plans purchased through the health insurance exchanges or on the individual market. The Act does not apply to Medicare and Medicaid, which already have protections against surprise billing.

Access the Centers for Medicare and Medicaid Services resources.

If you have questions, please contact the ISMS Health Policy Research and Advocacy team by email.

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