As of January 1st you are protected from certain Surprise Bills thanks to the No Surprises Act. The good news is that the less-talked about Consolidated Appropriations Act (CAA) gives you protection from surprise bills in two other ways.
Consolidated Appropriations Act
First, let’s understand a few important things about the CAA. The Act applies to many types of plans including individual, group, non-federal government and church plans. It does not cover Medicare plans. The changes I describe below went into effective January 1, 2022.
Accurate Provider Directories
If you’re like me, you’ve called your insurer to ask if a doctor is in network. You were told to look it up on the insurer’s website. There was all kinds of language on the website that basically said if the information is wrong, it’s not the insurance company’s fault.
You found that out if you got a surprise bill from an out-of-network doctor who used to be in-network. You called the insurance company for help. The insurance company said it was your fault for not calling the doctor before receiving treatment to make sure he was still in network.
The burden was never on the insurer to make sure their network information was current and accurate. Not anymore.
How the Protection Works
As of January 1st insurers have to update their provider directories every 90 days. If you call to ask a provider’s network status, the insurance company must get back to you within one business day. You only pay the in-network cost share if the insurer incorrectly tells you an out-of-network provider is in-network.
If you have already paid out-of-network fees to your provider, she must reimburse you the overpayment.
Continuity of Care
Prior to the CAA, if a patient was in the middle of treatment when their in-network doctor dropped out of network, they usually didn’t find out until long after the fact. And then they only found out when they received huge out-of-network surprise bills.
I had one client who received out-of-network bills for three months of treatment. When she called her doctor to find out what happened, the doctor claimed she didn’t know she was no longer in-network. Neither the insurance company nor the provider was under any obligation to notify her of the change in network status.
The Continuity of Care provision of the CAA is intended to stop those situations. Certain patients can now temporarily receive on-going care at in-network cost-sharing rates.
Who is Protected
Patients receiving “continuing care” are entitled to protection under the CAA. To qualify, the patient must be:
- Undergoing a course of treatment for a serious and complex condition; or
- Receiving institutional or inpatient care; or
- Scheduled for non-elective surgery; or
- Pregnant; or
- Terminally ill
In addition, the patient must already be receiving care or treatment from the provider or facility.
Temporary Protection
If the patient qualifies for continuing care, she can continue to receive treatment from her current provider or facility at in-network cost-share rates for up to 90 days or until she no longer qualifies. Whichever comes first.
Insurer’s Requirements
The insurer must notify the patient of the provider’s change in status. The insurer also has to inform the patient of her right to receive transitional care.
It’s important to remember the transitional period won’t last more than 90 days. Use that period of transition to find an in-network doctor or decide if out-of-network costs are a viable option.
Words of Caution
As well intended as these laws are, that doesn’t mean they will work smoothly. You still need to advocate for yourself. In fact, the government has said there will be further regulations (that means clarifications) in the future. For now, insurers have to implement these regulations using a “good faith, reasonable interpretation.” That means you need to be prepared for mistakes, uninformed providers and insurance reps, and less than accurate interpretations of the regulations.
While these new laws are being sorted out, here are the things you need to do protect yourself:
- Call your insurer to find out if your provider is still in network. Document the call (who you spoke with, when, and what you were told). Remember, if you are incorrectly told your provider is in-network, you aren’t responsible for out-of-network costs.
- If you have already erroneously paid your previously in-network provider out-of-network fees, the provider must reimburse you the overpayment.
- Do you think you qualify for continuity of care? Call your insurer and ask. If they say no, ask why. Again, document the conversation in case you need to appeal an out-of-network bill.
Regulations that protect patients are good. But don’t assume they take care of the problem. People still administer insurance plans. They make mistakes. Don’t you make a mistake by not understanding what you are due. You must be informed and persistent when correcting mistakes – whether they are intentional or accidental.