Congressional Research Service Issues a Report on Surprise Billing

On July 26, 2021, the Congressional Research Service (CRS) issued Surprise Billing in Private Health Insurance: Overview of Federal Consumer Protections and Payment for Out-of-Network Services. The report aims to answer questions about the No Surprises Act (the Act), including its requirements and consumer protections.

As background, the Act was initially part of the CAA passed by Congress in late 2020. Recently, federal agencies issued interim final rules implementing the Act’s requirements. For more information on the Act and the interim final rules, see the article published in the July 8th edition of Compliance Corner, "Federal Agencies Issue Interim Final Rules Implementing the No Surprise Billing Act".

The CRS report reiterates that federal requirements address surprise billing in specific scenarios:

• Out-of-network emergency services.
• Out-of-network services provided to a consumer during an outpatient observation stay or an inpatient or outpatient stay during emergency services.
• Out-of-network nonemergency, ancillary and non-ancillary services provided at an in-network facility.
• Out-of-network air ambulance services.
• Services scheduled at least three business days in advance.
• Out-of-network services from a provider that initially was in network but subsequently became out of network during treatment (i.e., continuity of care).
• Out-of-network services from a provider that the consumer assumed was in network based on incorrect information from the plan.

Further, the CRS explains that the consumer protections take one of two forms, financial protection, and informational protection (via consumer notices), and protections will vary depending on the situation. The report elaborates on the specific protections based on the surprise billing scenario, among other related topics such as enforcement of surprise billing requirements and the interaction with state surprise billing laws. While the report does not provide new guidance, it does elaborate on the Act’s requirements which will soon be effective.

Employers should reference this report to better understand the Act, as its requirements and the interim final rules are applicable to group health plans and health insurance issuers for plan and policy years beginning on or after January 1, 2022.

CRS Report »