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What Medicare Agents Need to Know about the No Surprises Act

Posted by Jean A. Lentsch on 2/8/22 12:40 PM

No Surprises Act

Don’t be surprised if you get a lot of questions about the No Surprises Act. Surprise medical bills have been a serious concern for people receiving hospital care for a while now. The No Surprises Act aims to ease these concerns. Here’s what your Medicare clients should know about the new patient protection.

The Problem of Surprise Bills

If you’re scheduling a doctor’s appointment or procedure, it’s smart to check your health plan’s network. Overwise, you might get hit with large out-of-network fees or have your claim rejected. Unfortunately, this can be easier said than done.

When you need emergency care, you don’t have time to check your plan’s networks. Even when care is scheduled ahead of time, it can be hard to verify current network status, especially when many providers are involved, and their network status keeps changing.

Take the story of the North Carolina man described by Spectrum News. After receiving cochlear implant surgery, he received something else: a bill from the Providence Anesthesiologist Associates. Their contract with the health plan had been terminated, so his care wasn’t covered, even though he says he was not notified of this change before his surgery.

According to an infographic from JAMA, 18% of emergency department visits result in at least one surprise bill. The No Surprises Act aims to change this.

According to CMS, starting in 2022, the new law provides protection against surprise bills in the following situations:

  • Emergency services
  • Non-emergency services from out-of-network providers at in-network facilities
  • Services from out-of-network air ambulance service providers

But the Changes Don’t Apply to Medicare

The No Surprise Act applies to private health insurance plans, such as those obtained through an employer or the Health Insurance Marketplace. CMS says, “People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.”

In Original Medicare, providers can choose to opt out of Medicare. These providers can treat Medicare patients, but they’ll need to enter into a private contract first. The good news is that most providers accept Original Medicare.

Many Medicare Advantage plans use networks. However, there are special rules in place to provide coverage for emergency care regardless of the network. For example, with PPO plans, emergency and urgent care are always covered. Likewise, Medicare Advantage plans that operate as Private Fee-for-Service (PFFS) plans must also cover emergency care.

What Should Clients Do to Control Costs?

When comparing plan options, Medicare enrollees should consider the networks and covered services. When planning care, enrollees should try to stick to network providers whenever possible to avoid additional costs.

Despite the rules put in place to protect Medicare patients from surprise bills, your clients may find that their plan is refusing to pay for a service. If this happens, HHS says it’s possible to appeal the decision. The first level appeal, called a “request for reconsideration,” should be made within 60 days of learning that the Medicare Advantage plan has decided not to pay for, not to allow, or to stop a service.

New laws like the No Surprises Act can elicit questions and confusion. If you need assistance, contact Western Asset Protection at 800-955-5390 or reach out through our agent portal. We’re here to help!

Topics: No Surprises Act

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