Overview of Public Health
Service (PHS) Act Provider
and Facility Requirements
Center for Consumer Information & Insurance Oversight (CCIIO)
Legal Disclaimers
• The information provided in this presentation is intended only to be a
general informal summary of technical legal standards. It is not intended
to take the place of the statutes, regulations, or formal policy guidance
upon which it is based. This presentation summarizes current policy and
operations as of the date it was presented. We encourage readers to
refer to the applicable statutes, regulations, and appropriate interpretive
materials for complete and current information.
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Legal Disclaimers (continued)
• The contents of this document do not have the force and effect of law
and are not meant to bind the public in any way, unless specifically
incorporated into a contract. This document is intended only to provide
clarity to the public regarding existing requirements under the law.
• This communication was published, produced and disseminated at U.S.
taxpayer expense.
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Agenda
• Background & Purpose
• Requirements for Providers, Facilities and Providers of Air
Ambulance Services That Apply Starting January 1, 2022
• Information about Requirements for Providers, Facilities and
Providers of Air Ambulance Services
• Enforcement
• Resources
• Definitions
• Questions
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Background & Purpose
• Title I (No Surprises Act) of Division BB of the Consolidated
Appropriations Act, 2021 (CAA) amended title XXVII of the Public Health
Service Act (PHS Act) to add a new Part E.
• Generally, providers, facilities, and providers of air ambulance services
must comply with these new requirements starting January 1, 2022.
• The provisions in Part E create requirements that apply to providers,
facilities, and providers of air ambulance services, such as cost sharing
rules, prohibitions on balance billing for certain items and services, notice
and consent requirements, and requirements related to disclosures about
balance billing protections.
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Background & Purpose (continued)
• These provider, facility, and provider of air ambulance services
requirements generally apply to items and services provided to
individuals enrolled in group health plans or group or individual health
insurance coverage, and Federal Employees Health Benefit plans. The
good faith estimate requirement and the requirements related to the
patient-provider dispute resolution process also apply to the uninsured.
• These requirements do not apply to beneficiaries or enrollees in federal
programs such as Medicare, Medicaid, Indian Health Services, Veterans
Affairs Health Care, or TRICARE. These programs have other
protections against high medical bills.
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Provider and facility requirements that
apply starting January 1, 2022
• No balance billing for out-of-network emergency services (PHSA 2799B-1; 45
CFR 149.410)
• No balance billing for non-emergency services by nonparticipating providers at
certain participating health care facilities, unless notice and consent was given in
some circumstances (PHSA 2799B-2; 45 CFR 149.420)
• Disclose patient protections against balance billing (PHSA 2799B-3; 45 CFR
149.430)
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Provider and facility requirements that
apply starting January 1, 2022
(continued)
• No balance billing for air ambulance services by nonparticipating air ambulance
providers (PHSA 2799B-5; 45 CFR 149.440)
• Provide good faith estimate in advance of scheduled services, or upon request
(PHSA 2799B-6; 45 CFR 149.610 (for uninsured or self-pay individuals)
• Ensure continuity of care when a provider’s network status changes (PHSA
2799B-8)
• Improve provider directories and reimburse enrollees for errors (PHSA 2799B-9)
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No balance billing for out-of-network
emergency services – summary
Nonparticipating providers and nonparticipating emergency
facilities:
• Cannot bill or hold liable beneficiaries, enrollees or participants in group
health plans or group or individual health insurance coverage who
received emergency services at a hospital or an independent freestanding
emergency department for a payment amount greater than the in-network
cost-sharing requirement for such services.
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No balance billing for out-of-network
emergency services – summary
(continued)
• Cost-sharing is calculated as if the total amount that would have been
charged by a participating provider or participating facility were equal to
the recognized amount.
• Certain post-stabilization services are considered emergency services,
and are therefore subject to this prohibition, unless notice and consent
requirements are met.
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Exceptions to no balance billing for out-
of-network emergency services – notice
& consent
Nonparticipating providers and facilities may balance bill for post-
stabilization services only if all of the following conditions have been met:
• The attending emergency physician or treating provider determines that
the beneficiary, enrollee or participant:
1. Can travel using non-medical or non-emergency medical transportation to an
available participating provider or facility located within a reasonable travel
distance, taking into account the individual’s medical condition; and
2. Is in a condition to receive notice and provide informed consent.
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Exceptions to no balance billing for out-
of-network emergency services – notice
& consent (continued)
3. The nonparticipating provider or facility provides the beneficiary, enrollee or
participant with a written notice and obtains consent that includes certain content
and within a specific timeframe and format outlined in regulation and guidance.
See resource slide for link to the regulation and required forms for the notice and
consent documents.
4. The provider or facility satisfies any additional state law requirements.
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Exceptions to no balance billing for out-
of-network emergency services – notice
& consent (continued)
• A provider or facility cannot balance bill for items or services furnished as
a result of unforeseen, urgent medical needs that arise at the time an
item or service is furnished, regardless of whether the nonparticipating
provider or facility previously satisfied the notice and consent criteria.
• Note that this applies to both emergency and non-emergency services.
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No balance billing for non-emergency
services by nonparticipating providers at
certain participating health care facilities
Nonparticipating providers of non-emergency services at a participating
health care facility:
• Cannot bill or hold liable beneficiaries, enrollees or participants in group health
plans or group or individual health insurance coverage who received covered
non-emergency services with respect to a visit at a participating health care
facility by a nonparticipating provider for a payment amount greater than the in-
network cost-sharing requirement for such services, unless notice and consent
requirements are met.
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No balance billing for non-emergency
services by nonparticipating providers at
certain participating health care facilities
(continued)
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• Cost-sharing is calculated as if the total amount that would have been
charged by a participating provider or participating facility were equal to
the recognized amount.
• Health care facilities include: hospitals, hospital outpatient departments,
critical access hospitals, and ambulatory surgical centers.
No balance billing for non-emergency
services by nonparticipating providers at
certain participating health care facilities
(continued)
• Note that notice and consent requirements do not apply to the following list of ancillary
services, for which the prohibition against balance billing remains applicable:
• Items and services related to emergency medicine, anesthesiology, pathology, radiology and
neonatology;
• Items and services provided by assistant surgeons, hospitalists, and intensivists;
• Diagnostic services, including radiology and laboratory services; and
• Items and services provided by a nonparticipating provider if there is no participating provider
who can provide such item or service at such facility.
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Disclose patient protections against
balance billing
• A provider or facility must disclose to any participant, beneficiary, or
enrollee in a group health plan or group or individual health insurance
coverage to whom the provider or facility furnishes items and services
information regarding federal and state (if applicable) balance billing
protections and how to report violations. Providers or facilities must post
this information prominently at the location of the facility, post it on a
public website (if applicable) and provide it to the participant, beneficiary
or enrollee in a timeframe and manner outlined in regulation.
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No balance billing for air ambulance
services by nonparticipating air
ambulance providers
• Providers of air ambulance services cannot bill or hold liable beneficiaries,
enrollees or participants in group health plans or group or individual health
insurance coverage who received covered air ambulance services from a
nonparticipating air ambulance provider for a payment amount greater than the
in-network cost-sharing requirement for such services.
• The cost-sharing requirement must be calculated as if the total amount that
would have been charged for the services by a participating provider of air
ambulance services were equal to the lesser of the qualifying payment amount
or the billed amount for the services.
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Provide a good faith estimate of the expected
charges in advance of scheduled services, or upon
request, to uninsured (or self-pay) individuals
• A health care provider or facility must inquire within a specific timeframe outlined in
regulation and guidance if an individual who schedules an item or service is enrolled in
a group health plan, group or individual health insurance coverage offered by a health
insurance issuer, a Federal health care program or a Federal Employees Health Benefit
plan. If so, inquire if an individual enrolled in a group health plan, group or individual
health insurance coverage offered by a health insurance issuer, or a Federal Employees
Health Benefit plan is seeking to have their claims for such item or service submitted to
plan. The provider or facility must provide notification (in clear and understandable
language) of the good faith estimate of the expected charges, expected service, and
diagnostic codes of scheduled services.
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Provide a good faith estimate of the expected
charges in advance of scheduled services, or upon
request, to uninsured (or self-pay) individuals
(continued)
• The good faith estimate must include expected charges for the items or
services that are reasonably expected to be provided in conjunction with the
primary item or service, including items or services that may be provided by
other providers and facilities.
• From January 1, 2022 through December 31, 2022, HHS will exercise its
enforcement discretion in situations where a good faith estimate provided to an
uninsured (or self-pay) individual does not include expected charges from other
providers and facilities that are involved in the individual’s care.
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Ensure continuity of care when a
provider’s network status changes
A health care provider or facility that ends a contractual relationship with a
plan or issuer and has a continuing care patient:
• Must, generally, in cases where the contractual relationship between a plan or
issuer and a provider or facility ends, resulting in a change in the provider or
facility’s network status with the plan:
A. Accept payment from the plan or issuer (and cost-sharing payments) for a
continuing care patient at the previously agreed to payment amount for up to 90
days after the date on which the patient was notified of the change in the
provider’s network status.
B. Continue to adhere to all policies, procedures and quality standards imposed by
the plan or issuer for such items or services as if the contract were still in place.
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Improve provider directories and
reimburse enrollees for errors
Any health care provider or health care facility that has or has had a contractual
relationship with a plan or issuer to provide items or services under such plan or
insurance coverage:
• Must submit provider directory information to a plan or issuer, at a minimum:
• At the beginning of the network agreement with a plan or issuer,
• At the time of termination of a network agreement with a plan or issuer,
• When there are material changes to the content of the provider directory information of
the provider or facility,
• Upon request by the plan or issuer, and
• At any other time determined appropriate by the provider, facility, or HHS.
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Improve provider directories and
reimburse enrollees for errors
(continued)
Any health care provider or health care facility that has or has had a
contractual relationship with a plan or issuer to provide items or services
under such plan or insurance coverage must:
• Also, reimburse enrollees who relied on an incorrect provider directory and paid
a provider bill in excess of the in-network cost-sharing amount.
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Enforcement
• Under the statute, CMS will only enforce a provision with respect to the
applicable regulated parties if CMS determines that a state is not
substantially enforcing that provision. This can occur, for example, when
a state lacks authority to enforce, or requests that CMS enforce, one or
more provisions.
• Prior to January 1, 2022, CMS will publish a list, by state, of provisions
CMS will enforce.
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Resources
• CMS-9909-IFC: Requirements Related to Surprise Billing; Part I
• CMS-9909-IFC Fact Sheet: What You Need to Know about the Biden-Harris Administration’s
Actions to Prevent Surprise Billing
• Model Notice & Consent Templates
• FAQ for CAA implementation, August 20, 2021
• Requirements Related to Air Ambulance Services, Agent and Broker Disclosures, and Provider
Enforcement NPRM
• Air Ambulance NPRM – Fact Sheet
• CMS-9908-IFC: Requirements Related to Surprise Billing; Part II
• CMS-9908-IFC Fact Sheet: What You Need to Know about the Biden-Harris Administration’s
Actions to Prevent Surprise Billing (September 2021)
• Additional trainings will be forthcoming on a variety of provider enforcement topics, including
deeper dives into the notice and consent rules, provider disclosure requirements, and other
provisions discussed in these slides.
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No balance billing for out-of-network
emergency services – definitions
• Emergency services – with respect to an emergency medical condition, appropriate
medical screening including ancillary services, medical examination and treatment
required to stabilize the patient, and certain post-stabilization services associated with
the emergency medical condition that are covered under the plan or coverage, unless
certain notice and consent and other criteria are met.
• Emergency medical condition – a medical condition, including a mental health
condition or substance use disorder, manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in a condition that places the health of the
individual in serious jeopardy, serious impairment to bodily functions, or serious
dysfunction of any bodily organ.
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No balance billing for out-of-network
emergency services – definitions (continued)
• Nonparticipating emergency facility – an emergency department of a hospital or an
independent freestanding emergency department (or a hospital with respect to post-
stabilization services) that does not have a contractual relationship directly or indirectly
with a group health plan or group or individual health insurance coverage, with respect
to the furnishing of an item or service under the plan or coverage.
• Nonparticipating provider – any physician or other health care provider who does not
have a contractual relationship directly or indirectly with a group health plan or group or
individual health insurance coverage, with respect to the furnishing of an item or service
under the plan or coverage.
• Participating health care facility - any health care facility that has a contractual
relationship directly or indirectly with a group health plan or health insurance issuer
offering group or individual health insurance coverage, with respect to the furnishing of
an item or service under the plan or coverage.
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Ensure continuity of care when a provider’s
network status changes – definitions
Continuing care patient – an individual who:
1. is undergoing a course of treatment for a serious and complex condition from the
provider or facility;
2. is undergoing a course of institutional or inpatient care from the provider or facility;
3. is scheduled to undergo non-elective surgery from the provider, including receipt of
postoperative care with respect to such surgery;
4. is pregnant and undergoing a course of treatment for the pregnancy from the provider
or facility; or
5. was determined to be terminally ill and is receiving treatment for such illness from the
provider or facility.
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Ensure continuity of care when a provider’s
network status changes – definitions
(continued)
Serious and complex condition –
1) in the case of an acute illness, a condition that is serious enough to
require specialized medical treatment to avoid the reasonable possibility of
death or permanent harm; or
2) in the case of a chronic illness or condition, a condition that
a) is life-threatening, degenerative, potentially disabling or congenital; and
b) requires specialized medical treatment over a prolonged period of time.
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Questions
• Send any questions about the provider requirements and
provider enforcement to [email protected].
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