Have you ever had this happen to you? You’re in an accident and in need of emergency care but you are unable to use an in-network provider. Or, since it was an emergency, you have to use an out-of-network provider. Have you ever received elective non-emergency care at an in-network facility but were inadvertently treated by an out-of-network health care provider? These all have the potential of happening and can be very unsettling.
Although the ACA guidelines state that “true” emergency care is paid as an in-network benefit, you can still run into “surprise billings”. As an example, you receive emergency care at an out-of-network facility feeling confident it will be covered by your insurance. But then you receive a bill from the Emergency Room physician and think, “What is this all about?” This is additional billing that is coming from that particular out-of-network provider.
If this has happened to you, here’s some good news! In July 202O, Nebraska joined with other Midwestern states to regulate “surprise billings” by passing LB997 (the Out-of-Network Emergency Medical Care Act) that went into effect on January 1, 2021. This now means you have protection from the out-of-network providers billing you over what the in-network charge was determined to be.
LB997 applies specifically to:
- Emergency medical care provided at:
- A General Acute Hospital.
- A Satellite Emergency Department.
- An Ambulatory Surgical Center.
- Professional services provided at the facility, including:
- Emergency room physicians.
- Surgeon, assistant surgeon, anesthesiologist.
- Ancillary medical professionals that provide laboratory, pathology or radiology interpretations.
Other benefits of LB997:
- Insurers are required to hold enrollees harmless for amounts beyond the in-network level of cost sharing.
- It prohibits out-of-network professionals and facilities from billing enrollees for any amount above the in-network level of cost sharing.
LB997 also does not cover:
- Ground or Air Ambulance service.
- Non-emergency services, Home Medical Equipment/Durable Medical Equipment, and services tied to emergency care.
- Enrollees of self-funded plans. (Some insurance companies are paying this benefit the same as a fully-insured plan.)
How does LB997 impact non-emergency procedures? It is important to note that this law applies only to emergency services using a fully-insured plan. If you have a procedure done at an in-network facility and, unbeknownst to you, an out-of-network provider is used, they are allowed to balance bill you for this procedure.
With all the scenarios you can encounter regarding your health care, it is wise to know the benefits and coverage of your health insurance plan and to keep up-to-date on how medical claims will be paid. You can always find help with this by talking with the customer service department at your insurance company. Or, reach out to one of the agents at ComPro Insurance and they will be glad to help you!
Note: A federal law was passed in December 2020 approving additional changes to “balance billing.” These will become effective in 2022. We will provide more details on this in a Strictly Business article later this year.
By Kayla Northup, Employee Benefits Sales Manager/Agent, ComPro.