En español | Consumers would be protected from getting hit with surprise out-of-pocket charges for medical care, even though they have health insurance, under provisions included in year-end congressional legislation that also provides COVID-19 relief and measures to fund the federal government through most of 2021. These provisions will take effect in 2022.
Many Americans learn that having health insurance doesn't protect them from huge medical bills after they have gotten the care they need. These surprise fees usually stem from “balance billing,” a practice that happens when someone gets health care from a doctor, hospital or other medical provider that doesn't belong to the patient's health insurance network. While most insurance pays some out-of-network charges, consumers are often asked to pay the difference between what the provider billed for and how much was reimbursed by the insurance company. Most often, the consumers didn't even know that they were receiving care from an out-of-network provider, especially when they need medical care in an emergency and are rushed to a hospital that's not part of their insurance plan's network.
Under a bipartisan agreement included in the larger COVID-19 relief and federal spending bill, patients who get care in an emergency room will be billed the in-network rate for that care, whether or not they are treated at an in-network facility.
Patients would also be “held harmless” in certain non-emergency situations in which they get care from an out-of-network provider. For example, if someone goes to a hospital and doesn't have a choice of who gives them anesthesia, the pathologist who processes their lab work or the radiologist who reads their X-ray or other diagnostic test, patients cannot be balanced billed because someone turns out to be an out-of-network provider. One exception to this provision would be if the provider lets a patient know 72 hours before providing the care that the provider is out of the patient's network and the patient consents to such care — and the extra charges that go with it.
The legislation also provides for an independent arbiter to settle payment disputes between providers and insurers if the two cannot settle the issue through negotiation. But it explicitly says the patient won't be a party to that dispute.
It's not uncommon for doctors and other provider to drop their participation in an insurance company's network. Under this legislation, if a patient's provider leaves the insurance network, the patient can continue to see that doctor and pay in-network rates for 90 days while looking for another provider.
"While not perfect, the legislation preventing surprise billing offers strong protections for consumers," says Andrew Scholnick, an AARP senior legislative representative. “Americans will no longer be stuck with expensive out-of-network bills from providers they didn't choose or had no control over."
Medicare and Medicaid already ban balance billing, but people with private insurance have no such protection. AARP has been pushing for such legislation for several years.
AARP has also called for insurance companies to maintain up-to-date directories of their providers so patients don't unwittingly go to out-of-network doctors or facilities. Under this legislation, insurers have to update their directories every 90 days and must provide consumers with accessible online tools and phone numbers.