Health Insurance Industry Issues and Legislation

The No Surprise Act ("Act"), part of the stimulus bill, was signed into law on December 28. The Act applies to the 135 million Americans with self-funded coverage, as well as those in fully -insured plans. Patients are the major beneficiaries of the Act. It extends them balance billing protection when they utilize federally regulated providers including Air Ambulance services, but not ground ambulances. Patients will be responsible for only the cost-sharing amounts that they would pay to in-network providers in either an emergency or non-emergency setting when they utilize an out-of-network provider. The impact on providers and payors is yet to be determined, as providers will be paid on the amount they negotiate or an amount determined in binding arbitration. The law goes into effect on January 1, 2022.

With 80% of U.S. workers experiencing mental health issues in 2020, employers are moving to destigmatize mental health issues and address employee mental health needs. Many are going further, embracing benefits and policies beyond mental health care by offering employees more flexible schedules, additional leave, and parenting and family-specific benefits. All are designed to improve employees' mental health by reducing stress and anxiety. Employers are also focusing on implementing new strategies to address workplace mental health in the coming year.

The Department of Labor, Health and Human Services, and Treasury (tri-agencies) have issued a new final rule with adjustments to current requirements that group plans and insurers must follow to continue their status as grandfathered plans under the Affordable Care Act. Under the new rules, grandfathered plans will be able to impose higher cost-sharing requirements without losing their grandfathered status. There is also a new "special rule' for high-deductible health plans (HDHPs) and an alternative method for grandfathered plans to calculate the maximum percentage increase for fixed-amount cost-sharing has been added.

30 states already have their own partial or comprehensive laws to deal with surprise medical bills. While self-funded plans are not covered by state laws, some states' surprise bill laws include a provision allowing self-funded plans to opt-in for coverage. Regardless, surprise and nonsurprise out-network bills will continue to be a fact of life for the foreseeable future. Fortunately, HHC Group has attorney negotiators with a 25-year track record of getting providers to accept an appropriate amount as payment in full for services they provide. Our negotiators always get signed agreements from the providers to avoid patient balance billing.