In this post, you'll learn what the No Surprises Act entails, including the Advanced EOB. See the end for a note on GFEs in Massachusetts.
Brief summary of the No Surprises Act
Effective January 1, 2022, the No Surprises Act (NSA) is meant to protect insured, uninsured and self-pay patients from surprise medical bills. Part one of this federal legislation refers to cases where balance billing insured individuals is no longer allowed; as well as when exceptions may apply. Part two of this legislation refers to what is known as the Good Faith Estimate (GFE), which is a patient cost estimate ALL providers must give uninsured and self-pay patients before services are rendered. Though GFEs are not federally required for insured individuals, some states do require GFEs for all patients (e.g., Indiana and Ohio).
Also found in part two of the NSA is what is called an Advanced Explanation of Benefits (Advanced EOB). The Advanced EOB is essentially a version of the GFE—but for insured individuals—and forces providers to send patient cost estimates to health plans/issuers and the health plan/issuer sends an Advanced EOB to the patient to let them know ahead of time what care will likely cost.
What are the requirements around the Advanced EOB?
All health care providers and facilities are required to ask patients when they schedule a visit if they have coverage through a health insurer/group health plan. If the patient has coverage and wishes to utilize their insurance option, the provider/facility is required to provide a notice to the insurer/plan of the estimated cost of the services that are reasonably expected to be provided in connection with the visit.
Once the notice of estimated costs is received, the insurer/plan must provide the patient with an Advanced EOB through mail or electronic means, depending on the preference of the health plan member.
How is the Advanced EOB different from the GFE?
Federally required GFEs are relatively straightforward (pricing-wise) for providers: Providers typically charge a patient either their chargemaster price or a separate, no-insurance cash price. Though every provider needs to meet specific requirements on the paperwork-side of things, creating GFEs can be relatively simple—especially since the Department of Health and Human Services (HHS) updated rules in April 2022 that allow providers to leave diagnostic codes off GFEs if the patient has yet to be diagnosed.
The Advanced EOB is complex. Though many Americans have high deductible health insurance plans that only provide bill coverage when deductibles are met, there are so many nuances to individual plans that can shape how coverage shakes out.
Is the Advanced EOB legislation being enforced right now?
Short answer: no.
The departments that put together the NSA actually stated in the legislation that, “until rulemaking to fully implement this requirement to provide such a good faith estimate to an individual's plan or coverage is adopted and applicable, HHS will defer enforcement of the requirement that providers and facilities provide good faith estimate information for individuals enrolled in a health plan or coverage and seeking to submit a claim for scheduled items or services to their plan or coverage.”
The legislation suggests that HHS may issue new, interim rules as the 2022 year unfolds, though no further piece of legislation has yet to make its way to the general public (as of June 13, 2022). The legislation states that significant infrastructure is needed for compliance from providers and health plans/issuers.
Note on GFEs in Massachusetts
All Massachusetts residents 18 years old+ are required to get and maintain creditable health insurance coverage. Massachusetts law requires insurance companies to offer Good Faith Estimates to their members. The Massachusetts Division of Insurance posts the company contact information to obtain estimates on its website. Effective July 2022, providers will be expected to follow specific requirements to prevent surprise bills.
What is Rivet?
Rivet is a software solution that integrates with your EHR for up-front patient cost estimates (that comply with the No Surprises Act), as well as denied claim and underpaid claim tools.
Download this PDF to see more information about Rivet's products.