The Biden administration has issued an interim rule carrying out a late-2020 change in law applying to the FEHB and other employer-sponsored health insurance plans targeting “surprise billing” in which enrollees can be hit with unexpected charges for unknowingly getting care from providers outside of their plan’s network.
Such billing can occur, for example, in emergency and other urgent care settings when enrollees don’t have time to check whether facilities are in-network, or when they receive care at an in-network facility from providers who are out of network. A 2019 survey by the Kaiser Family Foundation—not affiliated with the Kaiser medical provider—found that 39 percent of respondents had received an unexpected medical bill in the past 12 months; in 13 percent of those cases the bill was for $2,000 or more.
According to a fact sheet, the rule:
• Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
• Bans high out-of-network cost-sharing for emergency and non-emergency services. Patient cost-sharing, such as co-insurance or a deductible, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on in-network provider rates.
• Bans out-of-network charges for ancillary care (like an anesthesiologist or assistant surgeon) at an in-network facility in all circumstances.
• Bans other out-of-network charges without advance notice. Health care providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.
The policies are to be effective in the FEHB as of the start of the 2022 plan year.
OPM said in a statement that “Facing a difficult medical situation is challenging enough – no one should then face a surprise medical bill when they get home. This interim rule helps to protect Americans from financial ruin and honors federal employees, retirees, their covered family members and other enrollees who receive healthcare through the FEHB program, the largest employer-sponsored plan, by giving them new protections from unexpected medical bills.”