The No Surprises Act (NSA) and subsequent regulations launched on January 1, 2022 have established federal protections that mitigate the financial burden on consumers when health plans deny care provided by providers that have not contracted (i.e., “non- participating”, “out of network”) to accept discounted payment rates from the health plan. Many members and dental stakeholders have reached out to the AAE, and here is some additional information.
In a recent webinar, the Center for Medicare and Medicaid Services (CMS) confirmed that the NSA only applies to major medical coverage plans, not dental insurance. However, the Agency also reminded attendees that:
- Dental offices COULD be impacted by a new regulation that requires a good faith estimate be provided to self-pay and/or uninsured patients prior to care. The estimate must be provided via paper or printable electronic copy prior to care.
- Should the final bill exceed the estimate by greater than $400, the patient could initiate a dispute resolution process if the patient was not told of the additional costs and did not agree to proceed with care.
- Dentists who work/have privileges at hospitals or ambulatory care centers that are in-network with insurance companies may get caught up in the “notice and consent” policies now in place. Specifically, the patient must be provided with an estimate of costs and informed about care provided by any out-of-network provider.
- Emergency services can only be billed at the in-network rate, regardless of the provider of facility’s participation status with the insurance plan the patient might have. Notice and consent is not required in these situations.
- Nonparticipating providers of non-emergency services at participating facilities cannot bill the patient for a payment amount greater than the in-network cost-sharing requirements unless that notice and consent process was followed.
- Dentists should check insurance carrier listings of “in-network” providers and work with payers to update those immediately if information is incorrect, and understand the following:
- The NSA does require all providers to continue care for patients up to 90 days post initial contact, for “long-term” services, at the contracted rate, regardless of when the provider dropped out of any contract.
- NSA regulations do require payers to update their in-network lists & reposting every 90 days; however, if the provider is on the in-network list, the patient can only be held responsible for any cost-sharing amounts, nothing more, for services provided as part of emergency care or non-emergent care at an in-network facility where the notice and consent process was not completed.
AAE staff have asked CMS to provide a definition of “long term services”, as well as a clarification on how pediatric patients, who may have dental coverage via major medical plans, are impacted by the NSA. Members will be alerted of any new policies that may impact their practice. For more information, please contact email@example.com.