b' Wordw w w. w m i m u t u a l . c o mThe NO SURPRISES Act .By David Leo, I Congress passed the Consolidated Appropriates Act of 2021. In late 2020, That law amended existing federal health insurance laws and created the new No President of Surprises Act which offers certain billing protections to covered members who WMIMutualInsurance Company receive: (1) emergency care; (2) non-emergency care from out-of-network providers & WMI TPAworking in in-network facilities; and (3) air ambulance services from out-of-network providers. While this law is in its infancy and many details are yet to be ironed out, here is a brief summary of the protections it offers consumers against unexpected medical bills and excessive out-of-pocket costs. It should be noted that the law applies to both fully-insured health insurance policies and self-funded health plans.The No Surprises Act was enacted to protect consumers2.It bans higher out-of-network cost sharing (e.g., from surprise medical bills. The U.S. Centers for Medicarecoinsurance, copayments or deductibles) for all & Medicaid Services (CMS) explains surprise medicalemergency and some non-emergency services. You bills as follows: cant be charged more than in-network cost sharing What are surprise medical bills? If you have healthfor these services.insurance and get care from an out-of-network provider3.It bans out-of-network charges and balance bills or at an out-of-network facility, your health plan mayfor supplemental care (e.g., anesthesiology or not cover the entire out-of-network cost. This can leaveradiology) by out-of-network providers who work you with higher costs than if you got care from an in- at an in-network facility.network provider or facility. In the past, in addition to4.For non-emergency applications of the No any out-of-network cost sharing that you might oweSurprises Act, health care providers and facilities (e.g., deductible, coinsurance and/or out-of-pocketare required to give you an easy-to-understand expenses), the out-of-network provider or facility couldnotice explaining that getting care out-of-network bill you for the difference between the billed charge andcan be more expensive and it must provide options the amount your health plan paid unless banned by stateto avoid balance bills. If, after receiving this notice, law. This is called balance billing. An unexpectedyou decide to waive your billing protections, you balance bill from an out-of-network provider is alsomust offer your informed consent.called a surprise medical bill.If you are the victim of a surprise medical bill, heres At first blush, it may appear that consumers are now freewhat you are entitled to under the law. It should be noted, to go to any provider they want without having to worryhowever, that the law only applies to surprise medical bills about out-of-network exposure or costs, but that would beand not to any and all out-of-network services or expenses an overbroad and incomplete reading of the law. While theso to quote Greg Brady in the 1971 Wheeler-Dealer episode No Surprises Act is intended to protect consumers from largeof the Brady Bunch, caveat emptor. That said, here are the surprise bills or high uncovered medical expenses, thereprotections you are entitled to under the law:are some limitations on its scope and application. CMS sets1.If your bill qualifies as a surprise bill, you are forth several applications of the No Surprises Act: only responsible for paying your share of the cost 1.It bans surprise bills for emergency services,(e.g., copayments, coinsurance, deductibles and even if you get them out-of-network and withoutout-of-pocket expenses) that you would pay if the prior authorization or approval. provider or facility was in-network. Your health 20 www.wpma.com / Spring 2022'