The No Surprises Act

New consumer protections and other obligations included in the Consolidated Appropriations Act (CAA) also known as the “No Surprises Act” will bring some changes. We want you to understand the steps we’re taking to protect you and your employees. While there is no action required by our fully-insured employer groups, we have provided the below information for your reference.

Please note that the information below pertains to BlueCross BlueShield of Vermont fully-insured employer groups. For Administrative Services Only (ASO) employer groups, please review our CAA communication that outlines the steps we're taking and the services we can provide to you.

Consumer Protections under the CAA

The CAA includes important consumer protections and we’ve outlined them below.

Effective for plan years starting January 1, 2022, the No Surprises Act protects patients from “surprise” bills in certain situations where a provider bills a member for the difference between what the insurer paid and the amount the provider bills (“balance bill”). The No Surprises Act prevents providers from balance billing patients in two situations—emergency services and services delivered at in-network facilities by out of network providers, including labs.

When a claim is received from an out of network provider, the insurer has 30 days to deny or pay the claim. If the provider is dissatisfied with the payment received, the insurer and the provider must engage in 30 days of “good faith negotiation.” If that is unsuccessful, either the insurer or the provider can initiate the “independent dispute resolution” (IDR) process, which will determine the final payment amount for the claim. This amount is binding on the insurer and the provider, and such awards can only be challenged in court under limited circumstances. Regardless of what happens at the IDR, the member pays no more than the initially calculated cost-share. The member is not involved in the IDR process at all.  

There are limited situations where certain providers can ask patients to waive their rights under the CAA and we anticipate the need for member support to ensure that providers do not seek a waiver when they are prohibited from doing so.

How does this affect your employees?

When the protections are triggered, patients are responsible for no more than in-network cost-sharing amounts, including deductibles, co-insurance and co-pays. 

What is Blue Cross required to do? 

Blue Cross will ensure procedures are in place to timely pay or deny claims and help ensure that your employees are benefitting from the full protection of the new law.  We will handle the IDR process and will advocate for your employees if out of network providers are not following the law. 

Starting January 1, 2022, health plans must identify on insurance cards the amount of the in-network and out-of-network deductibles, the in-network and out-of-network out-of-pocket maximum, and a phone number and website address for consumer assistance information. 

How does this affect your employees? 

Your employees and their dependents will receive new ID cards on or after January 1, 2022. Please let them know they can expect new cards.  

What is Blue Cross required to do? 
We are adding fields to the ID card to help your employees understand their in-network and out-of-network cost-sharing amounts. Our ID cards already display the customer service team’s phone number and our website address. This will remain in place for 2022. We will be reissuing member ID cards, upon renewal, beginning with the January 1, 2022 renewal. 

For plan years starting January 1, 2022, health insurance issuers are required to maintain a “price comparison tool” available via phone and website that allows enrolled individuals to compare cost-sharing for items and services by any participating provider.

How does this affect your employees? 

Please encourage your employees to create an account on our Member Resource Center. Once they have an account, they can log in and use the tool to estimate the cost of upcoming care.

What is Blue Cross required to do? 

We have a price-comparison tool available today on our Member Resource Center. Members can access our price comparison tool by signing into our Member Resource Center or by calling our customer service team at (800) 247-2583. 

Note: The federal government has delayed implementation of this requirement as it seeks to align the CAA mandates with the newly stated “Transparency in Coverage Rule” which becomes effective January 1, 2023. 

For plan years starting January 1, 2022, the CAA requires that health plans establish a verification process to confirm provider directory information at least every 90 days. Health Plans must establish a response protocol to respond to member network questions within one business day and retain communications for at least two years.

How does this affect your employees? 

If a member provides documentation that they received incorrect provider information related to whether or not the provider is in-network, the member will only be responsible for in-network cost-sharing. If this happens, please encourage your employees to contact our customer service team at (800) 247-2583. 

What is Blue Cross required to do? 

We will ensure our provider directory management and processes will be compliant with this requirement. 

What are network providers required to do? 

Network providers are obligated to update Blue Cross provider directory information and protect their patients from harm resulting from incorrect information.

With plan years beginning January 1, 2022, the CAA requires health plans to document comparative analyses of the design and application of nonquantitative treatment limits (NQTLs) applied to medical and mental health benefit. The NQTL analysis must be made available to state and federal authorities upon request.

How does this affect your employees? 

The NQTL analysis will be made available to employees upon request. 

What is Blue Cross required to do? 

Blue Cross is committed to meeting or exceeding mental health and physical health parity standards. We have taken the necessary steps to ensure you remain compliant with federal mental health parity requirements.

Although not part of the CAA, effective for plans issuing on or after July 1, 2022, the Transparency in Coverage (TCR) rule requires that health plans share negotiated prices for services in publicly available “machine-readable files.”

How does this affect your employees? 

This will not affect your employees. 

What is Blue Cross required to do? 

We are prepared to publish these prices on behalf of our groups. Current configuration rules require the posting of many terabytes of data (a trillion bytes), with storage costs ranging in the millions of dollars. As such, this aspect of the TCR rule remains under consideration while work underway at the federal level addresses storage cost concerns. 

While delayed pending formal rulemaking, the Advanced Explanation of Benefits will provide greater price transparency and allow for greater financial planning for health care consumers. 

How does this affect your employees?

Once this process is put in place, your employees will see greater transparency about how much medical services cost and who pays what over the course of time for care. It will help people estimate the cost of care and provide insight into the way the health care system works.

What are network providers required to do? 

The CAA requires providers and facilities to estimate the charge for a scheduled service when an appointment is made or shortly thereafter. Once a provider has produced a cost estimate for a scheduled service, providers must communicate the estimate to Blue Cross. 

What is Blue Cross required to do? 

Once Blue Cross receives an estimate from a provider or request from a member, we must deliver information to the member including: 

  • Our cost estimate (both how much the provider will receive and the member’s cost share)
  • Where the member is in their deducible and out-of-pocket maximum
  • Whether provider is in network
  • Whether the service is subject to prior approval 
  • What the member’s accumulated cost share is currently 

Need More Information?

Please contact your account manager or the consumer and business support services team at (800) 255-4550 with any questions about the steps we are taking and the services we can provide.

Notably, under this federal legislation, states are explicitly given enforcement authority over group health plan compliance of some CAA provisions, even though group health plans are typically primarily regulated by the U.S. Department of Labor.