Billing and Payment Rules Focused on Specific Protections and Provisions

Know your rights…

On July 1, 2021, the “Requirements Related to Surprise Billing; Part I,” interim final rule was issued to restrict surprise billing for patients in job-based and individual health plans who get emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. See the  New York State Disclosure Notice Regarding Patient Protections Against Surprise Billing.

On September 30, 2021, a second interim final rule was issued and is open for public comment. The “Requirements Related to Surprise Billing; Part II” rule provides additional protections against surprise medical bills, including:

• Establishing an independent dispute resolution process to determine out-of-network payment amounts between providers (including air ambulance providers) or facilities and health plans.
• Requiring good-faith estimates of medical items or services for uninsured (or self-paying) individuals.
• Establishing a patient-provider dispute resolution process for uninsured (or self-paying) individuals to determine payment amounts due to a provider or facility under certain circumstances.
• Providing a way to appeal certain health plan decisions.

Together, these lay the groundwork to provide consumers with protection against surprise billing, which began January 1, 2022. Learn more about how these rules help consumers.

On November 17, 2021, a third interim final rule was issued and is open for public comment. The “Prescription Drug and Health Care Spending” rule implements new requirements for group health plans and issuers to submit certain information about prescription drug and health care spending. This includes, among other things, information on the most frequently dispensed and costliest drugs, and enrollment and premium information, including average monthly premiums paid by employees versus employers.