Federal agencies have posted a new explanation of how they will regulate the amounts health insurance carriers pay for out-of-network emergency room (ER) care.
The “tri-agencies” — the U.S. Department of Health and Human Services (HHS), the Internal Revenue Service (IRS) and the Employee Benefits Security Administration (EBSA) — included a discussion of their out-of-network ER care payment standards in the new batch of answers to health coverage questions that came out Wednesday.
The Patient Protection and Affordable Care Act of 2010 (PPACA) prohibits non-grandfathered group health plans or individual coverage issuers from imposing higher deductibles, co-payments or other cost-sharing requirements on enrollees who get emergency care from out-of-network providers, rather than in-network providers.
PPACA says nothing about “balance billing” — situations in which a health care provider wants to charge a patient for any billed amounts that the insurance carrier has failed to pay.
Carriers with provider networks usually use network contracts to keep the providers in the networks from balance billing patients for in-network care.
Some states ban any balance billing for out-of-network emergency care, and some states impose strict limits. Other states have no limits.
In states such as New Jersey with strict ER care balance-billing limits, some hospitals have been encouraging patients to consider getting emergency care at out-of-network hospitals.
In the new batch of guidance, the tri-agencies say regulations they released in November require plans in states with no balance-billing restrictions to pay a “reasonable amount” for out-of-network emergency care.
The agencies give three benchmarks for coming up with a “reasonable amount”:
The amount Medicare would pay for the care.
The median amount negotiated with in-network providers for the emergency services provided.
An amount calculated using whatever method a plan normally uses to calculate payments for routine out-of-network care.
If a state bans balance-billing, or an insurance carrier has a contractual obligation to pay the balance-billed amount, the carrier can ignore the instructions on how to calculate reasonable amounts, the agencies say.
The agencies warn, however, that, in that kind of situation, the coinsurance and co-payment requirements for the out-of-network ER care must be the same as the coinsurance and co-payment requirements for in-network ER care.
A carrier can provide out-of-network ER benefits that are better than the benefits required by the minimum standards described in the regulations, the agencies add.
Have you followed us on Facebook?