What the No Surprises Act means to you

Unexpected bills can be stressful. Even more so when they are emergency medical bills. Now, if you are on an individual medical plan or on most group health plans, the federal No Surprises Act (NSA) protects you from these unexpected costs by reducing the amount you are billed.

Here’s how it works

Starting Jan. 1, 2022, out-of-network providers caring for you at in-network facilities, air ambulance providers and providers of emergency services may only charge you the cost-sharing, such as your deductible and coinsurance, that you would have paid for in-network services. These providers cannot charge you more than this — this is called balance billing is prohibited under the NSA.

This applies to most insured and self-funded group health plans and individual medical plans. It applies in all states, which for Moda, includes Alaska, Oregon and Texas. It does not apply to short-term medical plans, dental only, vision only, Medicaid, Medicare Supplemental or Medicare Advantage plans.

If you have an Oregon Moda Health plan

The NSA is broader than existing Oregon surprise billing protections. It applies to all emergency services and any services performed by non-participating providers included in a visit to a participating facility. This could include:

• A lab test or durable medical equipment (DME) device provided by an out-of-network provider while you’re being treated at a participating facility (even if the lab or equipment provider is not located at the facility)
• Post-stabilization services following an emergency until you can be safely transferred to an in-network facility
• Air ambulance providers

For help with surprise billing or more information about NSA, contact us at 888-217-2363, or the Oregon Department of Financial Regulation (DFR) at DFR.InsuranceHelp@dcbs.oregon.gov or 888-877-4894.

If you have a Texas Moda Health plan

Texas law also protects members from surprise billing of emergency services and certain services provided by out-of-network providers practicing at in-network facilities. Your Explanation of Benefits (EOB) will show any amounts billed by the provider that are not covered by us. Providers are not allowed to charge you more for:

• Emergency services
• Out-of-network facility-based providers at in-network facilities
• Services from out-of-network laboratory and diagnostic imaging providers in relation to services provided by an in-network provider

If you receive a bill from an out-of-network provider that is charging you more than your in-network cost sharing, contact us at 844-931-1779 for assistance. You may also contact the Texas Department of Insurance at 800-252-3439 if you have a concern about how much a provider charged you for the care you received.

If you are a provider

Reimbursement to providers and facilities for services subject to the NSA will be based on a calculation called the Qualifying Payment Amount (QPA), made in compliance with the NSA. Moda Health certifies that when the QPA is used it will comply with the NSA and will serve as the recognized amount, which forms the basis for member cost sharing. If a provider is not in agreement with the amount Moda Health pays, the provider may request a 30-day open negotiation of the amount. If the 30-day negotiation period does not result in a determination, in general the provider or facility may initiate the independent dispute resolution process within four (4) days after the end of the open negotiation period. An independent arbitrator will review the dispute and make a binding determination as to what the provider should be paid.

To initiate open negotiation for purposes of determining an amount of payment (including cost sharing) for a service subject to the NSA, contact Moda Health at NoSurprisesActIDR@modahealth.com.

For service provided under Texas-based member agreements, if a provider or facility disagrees with our payment amount, you can request mediation or arbitration. To learn more and submit a request, go to www.tdi.texas.gov. After you submit a complete request, you must notify Moda Health at NoSurprisesActIDR@modahealth.com

Last updated Dec 27, 2021