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First rules to protect patients from unexpected medical bills issued by agencies

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The Biden administration issued rules Thursday to shield Americans from large, unexpected medical bills after patients wind up in emergency rooms or receive other care they did not realize lay outside their insurance networks.

The rules, to begin in January, are the first in a series of coordinated steps that four federal agencies are required to take to set in motion a law Congress adopted last year to protect health-care consumers against a practice known as surprise billing.

Thursday’s rules spell out that, if a health plan provides for any emergency services, those services must be covered without requiring permission from an insurer ahead of time.

And no matter whether the emergency room or its doctors are part of the insurer’s network, patients may not be charged more for emergency care or air ambulances than if those services were given by providers in the insurer’s network. Patients cannot be billed, in other words, for the difference between what the hospital charges and what an insurance company pays for out-of-network care.

Another aspect of the rules bans higher charges in instances in which an anesthesiologist, assistant surgeon or others providing such ancillary care are outside of a network even though the patient’s main surgeon is part of a health plan’s network of allowed medical personnel and facilities.

As the insurance industry has used fixed networks of doctors and hospitals as a way to rein in medical spending, out-of-network bills have emerged in recent years as a big source of patients’ ire. Unlike many ideas for controlling medical expenditures in the United States that are ensnared in partisan wrangling, blocking such big, unexpected bills has united the sympathies of Democrats and Republicans.

Members of Congress sparred for nearly two years over different approaches to protecting patients from surprise bills, but the parties coalesced around the “No Surprises Act” as part of a coronavirus pandemic relief package lawmakers passed days before Christmas last year. Former president Donald Trump signed it into law.

“Congress actually got something good done,” Health and Human Services Secretary Xavier Becerra said in an interview Thursday, calling the provisions “as meaningful as anything we’ve done on health care since the Affordable Care Act.” The ACA was adopted without Republican support 11 years ago.

HHS is the main department that wrote the surprise billing rules. But they are being coordinated with the departments of Labor and Treasury, as well as the Office of Personnel Management because the protections will apply to federal employees’ health benefits.

Vulnerability to large, unexpected medical bills “is a real big fear. It is the bogeyman [nagging at medical consumers’] peace of mind,” Becerra said. “We are now in the process of banishing the bogeyman.”

Recent data makes clear the extent to which experience with unexpected bills — and fear of them — weigh on American consumers.

About two-thirds of U.S. adults said they were very or somewhat worried about being able to afford large bills from a health-care provider outside their insurance network, according to polling earlier this year by the Kaiser Family Foundation, a health-care policy group.

Worry about such bills exceeds concerns about affording prescription drugs or other parts of their health insurance, such as deductibles or monthly premiums, Kaiser’s survey shows.

Other Kaiser data, published last year in the Journal of the American Medical Association, shows that 1 in 5 insured adults had received an unexpectedly high medical bill from an out-of-network provider of care in the previous two years.

A 2019 study by the federal Government Accountability Office found that about 7 in 10 trips by air ambulances — conveying to hospitals seriously ill patients who seldom choose which company to call — were outside the patients’ insurance networks. Typical prices for a trip were $36,000 to $40,000, according to data the study examined.

With the prospect of patients no longer receiving large bills for certain out-of-network care, the law adopted last year calls for outside arbiters to resolve disputes over how much insurers must pay hospitals.

This arbitration method was favored by the hospital industry and opposed by the insurance industry. Arbitration won out over another approach that would have resolved billing disputes through “benchmarks,” consisting of the typical price a given insurer pays for a medical service in that geographic area.

The law, however, does not specify who the arbitrators should be, delegating that decision to HHS before the ban takes effect.

The rules issued Thursday do not address arbitration.

Becerra said “sort of the fine print here — how do you settle disputes” would be covered in other rules the departments will issue before January. He noted the matter of arbitration “is of great interest to a lot of stakeholders.”

Several states have created their own billing protections in recent years, but they are more limited in their reach. The federal rules will pertain to all types of coverage: large group plans obtained through employers, health benefits through self-insured companies, small-group plans, individual insurance such as health plans sold through Affordable Care Act marketplaces and plans for federal employees.

The regulation issued Thursday allows a 60-day public comment period after which it could be changed.

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