The Consolidated Appropriations Act (CAA) was signed into law in late December, 2020 under former President Trump. It tackles multiple long-debated healthcare policies. The law stipulates new regulations that will require providers, insurers, and employers to provide consumers with data pertaining to coverage and costs before consumers receive care. This means that Americans will now have access to information that could change the way they shop for healthcare.
No Surprise Billing
Included in the CAA is the No Surprise Act (NSA). The NSA includes requirements for health insurers and group health plans to provide information and tools for consumers to better navigate their healthcare. Surprise billing — also known as balance billing — has long been debated for patients in covered out-of-network situations, such as when receiving emergency services. However, due to the NSA, beginning January 1, 2022, health plans must treat these out-of-network services as if they were in-network when calculating patient cost-sharing. Patients won’t be held accountable to the “surprise” bill, with insurers and providers handling any payment disputes.
A range of consumer protections are also included, such as a mandatory advance cost estimate. Health plans are obligated to implement a price transparency tool and provide accurate, up-to-date directories on public websites. Furthermore, providers will be prohibited from billing patients more than the applicable in-network cost sharing amount, and a penalty of up to $10,000 for each violation can apply.
A New Final-Offer Arbitration Process
The NSA also creates a new final-offer arbitration process to decide how much insurers must pay out-of-pocket network providers. If an out-of-network provider is dissatisfied with a health plan’s payment, it can initiate arbitration. The arbitrator must choose between the final offers submitted by each party after analyzing various factors, including the health plan’s historical median in-network rate for comparable services.
Health Insurer-Related Policies
The Act includes many health insurer-related policies such as forbidding “gag clauses” in contracts between plans and healthcare providers that limit access to cost and quality data. The law calls for reporting on drug costs and similar issues, and contains provisions related to “non-qualitative treatment limitations” for mental health or substance use disorders.
The Future for Healthcare Consumers
The price and quality transparency requirements set forth in the CAA can empower healthcare consumers to make informed decisions, and they’ll now have the ability to shop for high-quality healthcare at a fair price. The overall healthcare system and insurance markets will likely evolve quickly to reflect the demands of a more educated consumer with actionable data at their disposal.
