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HHS Shares New FAQ on Surprise Billing

The Department of Health and Human Services (HHS) on July 7 published new FAQ regarding the No Surprises Act and Affordable Care Act that respond to concerns about cost sharing and facility fees.

The guidance clarifies cost sharing as it relates to nonparticipating providers for the maximum out-of-pocket (MOOP) limit. Cost sharing for services provided by participating providers is considered in-network cost sharing for purposes of the MOOP limit, and cost sharing for services provided by nonparticipating providers is considered out-of-network cost sharing for purposes of the MOOP limit.

Further, HHS states that if a plan or issuer has a direct or indirect contractual relationship with a provider or facility that provides services to a participant, beneficiary, or enrollee under the plan or coverage, the provider or facility is considered a participating provider for purposes of the No Surprises Act and is also considered in-network for purposes of the MOOP limit. The service cannot be considered in-network for the MOOP limit but out-of-network under the No Surprises Act.

Finally, HHS confirms that facility fees are included in the definition of items and services for both the Transparency in Coverage final rule and the good faith estimate requirements of the No Surprises Act. Plans and issuers are required to include facility fees in good faith estimates.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Julie Kozminski is a senior policy analyst at America's Essential Hospitals.

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