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Federal No Surprises Act
Transparency in Health Care
In October 2020, the federal government issued the "transparency in coverage" final rule under the Federal No Surprises Act. The rule provides protection against balance or "surprise" billing under certain circumstances, and phases in new transparency requirements on most group health plans and health insurers. The purpose of the requirements is to enable consumers to make informed health care purchasing decisions.
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.
Nonparticipating describes providers and facilities that haven’t signed a contract with your health plan. Nonparticipating 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, such as when you have an emergency or schedule a visit at a participating facility but are unexpectedly treated by a nonparticipating provider.
Your rights and protections against surprise medical billsWhen you get emergency care or get treated by a nonparticipating provider at a participating hospital or ambulatory surgical center, you are protected from balance or surprise billing.
Services you are protected from balance billing for:
If you have an emergency medical condition and get emergency services from a nonparticipating provider or facility, the most the provider or facility may bill you is your plan’s in-network out-of-pocket amount, such as copays, coinsurance and deductibles. 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.
Michigan law also protects you from balance billing and requires that you pay only your in-network cost sharing amounts for: (i) covered emergency services provided by an out-of-network provider at an in-network facility or out-of-network facility; (ii) covered nonemergency services provided by an out-of-network provider at an in-network facility if you do not have the ability or opportunity to choose an in-network provider; and (iii) any healthcare services you receive at an in-network facility from an out-of-network provider within 72 hours of receiving services from that facility’s emergency room.
Certain services at a participating hospital or ambulatory surgical center
When you get services from a participating hospital or ambulatory surgical center, certain providers there may be nonparticipating. In these cases, the most those providers may bill you is your plan’s in-network out-of-pocket 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 participating facilities, nonparticipating 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 from a nonparticipating provider. You can choose a provider or facility in your plan’s network.
Additionally, Michigan law states if you consent to receive nonemergency care from an out-of-network provider, the balance billing prohibition does not apply. These protections apply to any patient covered by a Michigan health benefit plan and a self-funded plan established or maintained by the state or local unit of government for its employees.
When balance billing isn’t allowed, you also have the following protections:
- You’re only responsible for paying your share of the cost, such as copays, coinsurance and deductibles that you would pay if the provider or facility was in-network. Your health plan will pay nonparticipating providers and facilities directly.
- Your health plan generally must:
- Cover emergency services without requiring you to get approval for services in advance (prior authorization)
- Cover emergency services by nonparticipating providers
- Base what you owe the provider or facility (out-of-pocket costs) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits
- Count any amount you pay for emergency services or services rendered by nonparticipating providers in the circumstances outlined above toward your deductible and out-of-pocket limit
If you believe you’ve been incorrectly billedContact your health insurance carrier. If your carrier is unable to resolve your billing inquiry, contact the No Surprises Help Desk at 1-800-985-3059 or call the Michigan Department of Insurance and Financial Services at 1-833-275-3437.
Visit http://www.cms.gov/nosurprises for more information about your rights under federal law.
Visit http://michigan.gov/difs for more information about your rights under Michigan law.
Health insurance carriers that provide coverage to state employees will begin publicly posting two1 machine-readable files (MRFs) on their websites beginning July 1, 2022. In 2023, federal law will require all health plans to offer price comparison tools to help members estimate what health care services will cost before receiving care. The MRFs are a step toward ensuring health plans and insurers will meet these requirements.
The MRFs include the following:
• In-Network File: All negotiated rates with in-network (INN) providers for all covered items and services.
• Allowed-Amount File: Billed charges and allowed amounts for covered items and services provided by out-of-network (OON) providers.
1The pharmacy file has an enforcement delay until additional federal guidance is released.
To view information specific to a health insurance carrier's MRF,
access the links below:
|Insurance Carrier||MRF Resource Link|
|BCBSM/Blue Care Network (BCN)||https://bcbsm.sapphiremrfhub.com/tocs/current/state_of_michigan2|
|Health Alliance Plan (HAP)||https://www.hap.org/readable
|McLaren Health Plan||https://www.mclarenhealthplan.org/mhp/transparency-in-coverage-and-no-surprises-act|
|Physicans Health Plan||www.phpmichigan.com/Members/PriceTransparencyandInteroperability
Employees may visit their insurance carrier's website or contact their customer service center for specific costs under their plan.