Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

HHS Addresses Out-of-Network ‘Surprise Bills’ in Marketplace Plans


The Department of Health and Human Services (HHS) is joining the ongoing debate over “surprise bills” or out-of-network balance billing in its Benefit and Payment Parameters for 2017. Released last week, the final rule sets standards for plans on the Health Insurance Marketplace and addresses the issues of network adequacy in at least three different provisions.

First, the parameters create a notification requirement for plans to inform enrollees when a provider they have received care from leaves the plan’s network. Enrollees should receive notification 30 days prior to the effective date of the change, or in instances when the provider’s network status is terminated without cause, enrollees are allowed to continue with that provider at in-network cost-sharing rates for the shorter of 90 days or until treatment is complete.

Second, starting in 2017 Healthcare.gov plans will be rated based on their network coverage. The rating will allow consumers to compare the breadth of network coverage for plans in the same geographic area.

Finally, HHS addressed “surprise bills” specifically in a provision that requires plans to count out-of-network services provided at an in-network facility towards an enrollee’s annual cost-sharing limit. There are exceptions, particularly if the plan provides written notice to the enrollee within 48 of the service that the provider is out-of-network. But this guideline may make a small dent in the balance billing problem many consumers face.

Other provisions of the 2017 Benefit and Payment Parameters include the creation of six standardized plan options across the metal levels that will make comparison shopping easier for consumers and risk adjustment modifications using more recent data. As well, HHS set the open enrollment periods for the next three years. For 2017 and 2018, open enrollment will begin November 1 of the year preceding the benefit year and run through January 31 of the benefit year. For 2019, open enrollment will begin on November 1 and run through December 15 of the year preceding the benefit year.

For more information, review the Final HHS Notice of Benefit and Payment Parameters for 2017 Fact Sheet on the Centers for Medicare and Medicaid Services website.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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