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| Graphic from Centers for Medicare and Medicaid Services |
Kentucky Health News
As of Jan. 1, Americans who get surprise medical bills have new federal consumer protections.
"This new law will help make sure our people have protection against unexpected medical bills in an emergency," Gov. Andy Beshear said in a news release. Congress passed the law more than a year ago but delayed its effective date.
In 2018, the Altarum Healthcare Value Hub found that nearly a third of privately-insured Kentucky adults received an unexpected medical bill either in an amount that was higher than expected, from a doctor they didn't expect or from a doctor that they thought would be in-network, but wasn't.
Surprise medical bills happen when an insured person inadvertently receives care from an out-of-network hospital, doctor or other provider that they did not choose and are then required to pay out-of-pocket for that out-of-network care.
For example, before the new law, even if you used an in-network hospital for an elective procedure, you would be responsible for the balance of any medical bills that were charged by an out-of-network provider, which often showed up in services like anesthesia, imaging and laboratory work.
The new law says patients cannot be asked to pay more than the in-network rate their insurer would typically charge them.
It also addresses "balance billing," the practice of allowing an out-of-network provider or facility to bill you for the difference between the billed charge and the amount your health plan paid.
The new rules ban four key things: surprise billing for emergency services; balance billing and out-of-network cost-sharing; out-of-network charges and balance billing for ancillary care; and certain out-of-network charges and balance billing without advance notice, says a Kentucky Voices for Health blog post.
There is at least one gap in the law. It applies to air ambulances, both emergency and non-emergency, but not to ground transportation.
The legislation covers people covered under employee-sponsored and individual/family health plans for plan years beginning on or after Jan. 1, 2022. If you have coverage through Medicare, Medicaid, Tricare, Veterans Affairs health care or Indian Health Services, you’re already protected against surprise medical billing, Kentucky Voices for Health says.
The federal government estimates that the law will apply to about 10 million out-of-network surprise medical bills each year.
Kaiser Family Foundation research found that about one out of five emergency room visits and between 9% and 16% of in-network hospitalizations involve a surprise medical bill. Another study, published in JAMA Network, found it happens to about one of five insured people, adding an average of $2,011 more to the bill.
Examples of how the new protections apply can be found on the DOI website at https://insurance.ky.gov/ppc/Documents/nsa%20-%20consumer%20bulletin%2012-2021.pdf.
In addition, the Kaiser Family Foundation offers a short video to describe how these new protections work for patients. It also offers a detailed summary of the Act.
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