​The No Surprises Act: AT LAST!

By Sadie Tuescher
 
As of January 1st, 2022 an incredibly important piece of legislation went into effect that is long overdue. The No Surprises Act has many components, and while we are disappointed in some that create extra reporting without pay to agents like ourselves, we are also very happy about the main provision: the end to emergency services balance billing for patients who have an ACA-compliant plan.
 
Before this rule went into effect, patients who had an ACA-compliant plan--that’s most insurance, commercial, employer, individual, with the exception of short term plans—had guaranteed coverage for emergency services out of network. However, almost all insurance companies found a loophole in how the ACA worded this provision: the insurers determined that while they had to cover emergency care out of network, they only had to pick up the portion of the bill that they would have paid if the person went in network. That led to gigantic balance bills for patients.
 
In a real case, a client of mine sought emergency care out of state while travelling. The ER bill totaled more than $30,000. His insurer, a prominent health insurance marketplace carrier in Wisconsin, applied $7,000 toward his deductible saying the amount was what they would have allowed had he stayed in network, and they paid $0 of that bill. At the time, I helped negotiate that bill in half—something that none of our major hospital systems will do anymore. Insurance paid nothing. Under the No Surprises Act, his insurer in 2022 would still be allowed to apply his $7,000 deductible, but they would have to pay the remaining amount to the hospital.
 
And while we are thrilled, this act is merely another bandage to our already bleeding health care system. Rather than checking the amount hospitals can charge for services, the act merely passes the cost on to insurance companies—which then passes the cost on to consumers through higher premiums and bigger deductibles. There is no check whatsoever on what hospitals are allowed to charge for services, and how much they can balance bill individuals when they are out of network with the patient’s insurance. I worry this will only intensify the perverse incentives hospitals have to keep costs high. See our prior blog post for more information. 
 
In the immediate sense, we are happy for patients. We’ve been calling for federal balance billing rules for nearly a decade and are glad to see this change.
 
If you seek emergency care out of network, your insurance company will now have a specific appeal process to follow. Do not pay the balance bill, contact your agent and/or insurance company immediately. Wisconsin Health Insurance Advocate brokers provide assistance at no cost to clients, and can provide assistance for a fee to non-clients.