NSA and Balance Billing Laws by State

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NSA and Balance Billing Laws by State

No Surprises Act (NSA) established new federal protections against surprise medical bills and balance billing, which took effect on 1st Jan, 2022.

State-regulated insurance plan (such as employer-sponsored commercial plans):

  • If that state already has a balance billing law deemed by the federal government as meeting certain criteria, the state law will govern the OON payment amount and Federal IDR process (if any exists in that state).
  • If a state does not have such a qualifying law, then the federal law’s initial payment and IDR process governs the OON payments.

Federally regulated insurance plans (such as ERISA/employer self-funded or federal Marketplace plans):

For federally regulated insurance plans (such as ERISA/employer self-funded or federal Marketplace plans), the federal law’s initial payment and IDR process governs the OON payment amount.

Note: In some states, ERISA plans are allowed to opt-in to the state law for balance billing.

Balance Billing Laws by State

 

NSA and Balance Billing Laws by State
NSA and Balance Billing Laws by State

The federal government has already released guidance designating some states as having a qualifying law for balance billing.

See below, which will be updated as more guidance comes in on the remaining states.

Federal Government (CMS)

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

3 Alaska Admin. Code § 26.110(a) is a specified state law that will apply for purposes of determining the out-of-network rate with respectto items and supplies furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Alaska by nonparticipating providers, nonparticipating emergency facilities or nonparticipating providers of air ambulance services. Federal IDR process will only apply for services not applicable to the state law.

Federal process applies

Federal Government (CMS)

Federal External Review Process

Federal IDR Process applies

Federal process applies

Arizona will enforce certain provision of the law and the Federal Government will enforce others

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement, with the Federal Government enforcing certain provisions and California others.

Federal External Review Process

Cal. Health and Safety Code §§ 1371.30, 1371.31, and 1371.9, and §§ 10112.8, 10112.81 and 10112.82(a) of the Insurance Code are specified state laws that will determine the out-of-network rate for non-emergency services furnished to individuals in health care service plans and certain health insurance plans in California by noncontracting individual health professionals at contracting health facilities. The Federal IDR process will apply to other out-of-network services that the California law does not cover.

Federal process applies

Collaborative Agreement, with the Federal Government enforcing certain provisions and Colorado others.

Federal External Review Process

CR.S. § 10-16-704(3)(d)(II), § 10-16-704(5.5), and § 10-16-704(15) are specified state laws that will determine the out-of-network rate with respect to items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Colorado by nonparticipating providers or nonparticipating emergency facilities.

Federal process applies

Collaborative Agreement

Federal External Review Process

CGS Sec. 38a-477aa– specified state law that will apply for “purposes of determining the out-of-network rate with respect to certain health care services by out-ofnetwork health care providers at an in-network facility or an out-of-network clinical laboratory upon referral of an in-network provider and emergency services furnished to individuals with coverage from carriers in CT.” Federal IDR process will only apply for services not applicable to the state law.

Federal process applies

Collaborative Agreement

Federal External Review Process

18 Del. Code §§ 3349 and 3565 are specified state laws that will apply for purposes of determining the out-of-network rate with respect to covered emergency services conducted by out-of-network providers.

Federal process applies

Collaborative Agreement

Federal External Review Process (DC does not have the capability)

Federal IDR Process applies

Federal process applies

Florida will enforce most of the provisions of the No Surprises Act, and the Federal Government will enforce some.

Federal External Review Process

Sections 408.7057, 627.42397, 627.64194(4), 627.64194(6), 641.513(5), and 641.514, F.S. and rule 59A-12.030, Florida Administrative Code are specified state laws that will determine the out-of-network rate with respect to items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Florida, as well as claim dispute payment amounts pertaining to HMOs that are above certain claims payment thresholds. These thresholds are described in the letter. The Federal IDR process would apply for out-of-network HMO services below these thresholds.

Federal process applies

Collaborative Agreement

Federal External Review Process

OCGA 33-20E-8 is a specified state law, and Georgia IDR process applies

Federal process applies, but CMS will enter into a collaborative enforcement agreement with Georgia to will enforce the outcome of the federal patient-provider dispute resolution process.

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Idaho Department of Insurance

Idaho External Review Process

Federal IDR Process applies

Federal process applies

Illinois

TBD

TBD

TBD

TBD

Federal Government (CMS)

Federal External Review Process (Indiana does not have the capability)

Federal IDR Process applies

Federal process applies

Iowa Department of Insurance

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Kansas external review process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Kentucky external review process

Federal IDR Process appliesl; Kentucky will enforce the process in some cases and CMS in others

Federal process applies

Federal Government (CMS)

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Maine External Review Process

Title 24-A, Maine Insurance Code, Chapter 56-A, §4303-C is a specified state law that will apply for purposes of determining the out-of-network rate with respect to items and services furnished to individuals in an insured group health plan, or group or individual health insurance coverage in Maine by nonparticipating providers, nonparticipating emergency facilities or nonparticipating providers of air ambulance services. Federal IDR process will NOT apply

Federal process applies

Collaborative Agreement

Federal External Review Process

Maryland has an All-Payer Model Agreement that would determine the out-of-network rate for hospital services . § 19-710.1 of the Health General Article applies as a specified state law for purposes of determining the out-of-network rate with respect to covered services furnished to individuals in HMOs in Maryland by health care providers who are not under contract with the HMO. § 14-205.2 of the Maryland Insurance Article is a specified state law that will determine the out-of-network rate with respect to EPOs or PPOs services delivered by nonpreferred on-call and hospitalbased physicians who accept assignment of benefits.The federal independent dispute resolution process will apply for all other out-of-network services to which Maryland’s All-Payer Model Agreement or specified state laws do not apply.

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Michican will enforce all provisions of No Surprises Act except those which affect air ambulance providers

Not stated in letter.

Not stated in letter.

Not stated in letter.

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Missouri will enforce certain provisions of the No Surprises Act, and the Federal Government will enforce others.

Federal External Review Process

Section 376.690, Missouri Revised Statute (RSMo), is a specified state law that will apply for purposes of determining the out-of-network rate with respect to unanticipated out-of-network care furnished to individuals with coverage from health carriers in Missouri by out-of-network health care professionals at an in-network facility. The federal independent dispute resolution process will apply to other out-of-network services that the state law does not cover.

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Nebraska Revised Statutes 44-6849 and 44-6850 are specified state laws that will apply for purposes of determining the out-of-network rate with respect to emergency services furnished to individuals in health benefit plans in Nebraska by out-of-network health care providers. The Federal IDR Process will apply in cases which the state law does not cover.

Federal process applies

Nevada Division of Insurance will enforce certain sections of the law, and the federal government will enforce others.

Nevada External Review Process

NRS 439B.748, 751 and 754 are specified state laws that will apply for purposes of determining the out-of-network rate with respect to medically necessary emergency services furnished to individuals in health benefit plans, the Public Employees’ Benefits Program and other organizations under NRS 439B.736(1)(c) in Nevada by an out-of-network emergency facility or out-of-network provider. Federal IDR process will apply in cases where state law does not apply.

Federal process applies

Collaborative Agreement

New Hampshire External Review Process

NH RSA Title XXX 329:31- b(III) is a specified state law that will apply for purposes of determining the out-of-network rate with respect to anesthesiology, radiology, emergency medicine, or pathology services furnished to individuals in a managed care plan in New Hampshire by a health care provider in a hospital or ambulatory surgical center that is in-network. Federal IDR process will applie in cases where state law does not apply.

Federal process applies

Collaborative Agreement

Federal External Review Process

N.J.S.A. 26:2SS-1 to -20 includes a specified state law that will apply for purposes of determining the out-of-network rate with respect to out-ofnetwork services rendered on an inadvertent and/or emergency or urgent basis to individuals covered under a health benefits plan issued in New Jersey by a New Jersey licensed or certified health care provider. Federal IDR process will applie in cases where state law does not apply.

Federal process applies

Collaborative Agreement

New Mexico External Review Process

“Section 59A-57A-1, et. seq. NMSA 1978 and 13.10.33 NMAC are specified state laws that will apply for purposes of determining the out-of-network rate with respect to out of network emergency care”

Federal process applies

New York

TBD

TBD

TBD

TBD

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

North Dakota external review process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Ohio External Review Process

ORC 3902.50 – 3902.54 are specified state laws that will apply for purposes of determining the out-of-network rate with respect to emergency services and non-emergency services by nonparticipating providers at in-network facilities. Federal IDR process will apply to other services (air ambulance services) that the state laws do not apply to.

Federal process applies

Federal Government (CMS)

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies; Oregon Division of Financial Regulation will enforce IDR process

Federal process applies

Pennsylvania will enforce certain provisions and the Federal government others.

Federal External Review Process

Federal IDR Process applies

Federal process applies

Puerto Rico will enforce most provisions, but needs to identify specific enforcement agency

Waiting for confirmation from Puerto Rico, but federal external review process may apply

Federal IDR Process applies, but waiting for confirmation from Puerto Rico

Federal process applies, but waiting for confirmation from Puerto Rico

CMS will enforce most provisions, but work in collaboration with Rhode Island on enforcement of other provisions

Federal External Review Process

Federal IDR Process applies

Federal process applies

South Carolina will enforce most provisions, but work in collaboration with CMS on enforcement of other provisions

South Carolina External Review Process

Federal IDR Process applies

Federal process applies

South Dakota will enforce certain provisions, but will enter into a collaborative agreement with the Federal Government (CMS) to enforce others

South Dakota external review process

Federal IDR Process applies

Federal process applies

Tennessee

TBD

TBD

TBD

TBD

Texas will enforce certain provisions, and CMS will directly enforce other provisions

Federal External Review Process

Texas Insurance Code (TIC) Chapter 1467 and rules under 28 TAC Ch. 21, Subchapter PP, are a specified state law that will apply for
purposes of determining the out-of-network rate with respect to emergency care. Federal IDR process will apply to other services (air ambulance services) that the state laws do not apply to.

Federal process applies

U.S. Virgin Islands will enforce most provisions, but needs to identify specific enforcement agency

Waiting for confirmation from U.S. Virgin Islands, but federal external review process may apply

Federal IDR Process applies, but waiting for confirmation from U.S. Virgin Islands

Federal process applies, but waiting for confirmation from U.S. Virgin Islands

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Federal IDR Process applies

Federal process applies

Collaborative Agreement

Federal External Review Process

Sections 38.2- 3445.01 through 38.2-3445.07 and 14 VAC 5-405-10 et seq are specified state laws that will apply for purposes of determining the out-of-network rate with respect to emergency services provided to an enrollee, or nonemergency services provided to an enrollee at an in-network facility if the nonemergency services involve surgical or ancillary services provided by an out-of-network provider furnished to individuals in fully-insured managed care plans issued or delivered in Virginia, including grandfathered plans. Federal IDR process will apply for services not impacted by state law.

Federal process applies

Washington will enforce all major provisions

Washington External Review Process

Washington will enforce Federal IDR Process

Federal process applies

West Virginia State Department will enforce all major provisions

West Virginia external review process

Federal IDR Process applies

Federal process applies

Federal Government (CMS) will enforce most provisions. CMS will also amend its existing collaborative enforcement agreement with Wisconsin to include enforcement of these provisions

Federal External Review Process

Federal IDR Process applies

Federal process applies

Federal Government (CMS)

Federal External Review Process

Federal IDR Process applies

Federal process applies

Note:

Collaborative Enforcement Agreement: State and Federal government will share responsibility of coordinating and enforcing NSA provisions
Federal Government (CMS) Enforcement: CMS will enforce the provisions of the NSA in the state
Federal External Review Process: CMS will intervene on behalf of the state for adverse determinations
Federal IDR Process: CMS will enforce the provisions of the IDR process laid out in the NSA.
Federal Process Applies: CMS will enforce dispute resolution process laid out in the NSA.

Ref: American College of Emergency Physicians

Learn More:

The No Surprises Act (NSA) and What It Means for Emergency Rooms

Surprise Medical Bill: New Protections for Consumers Starting 2022

No Surprises Act (NSA), Federal IDR and how it works?