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This interim final rule with comment would implement certain protections against surprise medical bills under the No Surprises Act, including requirements on group health plans, issuers offering group or individual health insurance coverage, providers, facilities, and providers of air ambulance services.

Statement of Need:

Surprise bills can cause significant financial hardship and cause individuals to forgo care.  The No Surprises Act provides federal protections against surprise billing and limits out-of-network cost sharing under many of the circumstances in which surprise medical bills arise most frequently. These interim final rules fulfill a rulemaking requirement under the No Surprises Act and protect individuals from surprise medical bills for emergency services, air ambulance services furnished by nonparticipating providers, and non-emergency services furnished by nonparticipating providers at participating facilities in certain circumstances.

Summary of the Legal Basis:

The Department of Labor regulations are adopted pursuant to the authority contained in 29 U.S.C. 1002, 1135, 1182, 1185d, 1191a, 1191b, and 1191c; Secretary of Labor's Order 1-2011, 77 FR 1088 (Jan. 9, 2012).

Alternatives:

In developing the interim final rules, the Departments considered various alternative approaches, including whether cost-sharing should be based on the recognized amount in circumstances where the billed charge is lower, whether plans and issuer should take into account the number of claims paid at the contracted rate when calculating the qualifying payment amount, and many others.

Anticipated Costs and Benefits:

The provisions in these interim final rules will ensure that participants, beneficiaries, and enrollees with health coverage are protected from surprise medical bills. Individuals with health coverage will gain peace of mind, experience a reduction in out-of-pocket expenses, be able to meet their deductible and out-of-pocket maximum limits sooner, and may experience increased access to care. Plans, issuers, health care providers, facilities, and providers of air ambulance services will incur costs to comply with the requirements in these interim final rules.

Risks:

The risk of not pursuing this rulemaking is that the Department would fail to meet its statutory obligations to issue regulations, group health plans would lack guidance needed to comply with the statutory requirements, and individuals would continue to be burdened by surprise medical bills.