Spotlight Mandate: Update member cost-sharing calculation for No Surprises Act items and services

Under this regulation:

• Services administered in an out-of-network emergency department will now apply in-network cost-sharing
• Non-emergency services performed by an out-of-network provider at an in-network facility (except if the notice and consent requirements are fulfilled) will now apply in-network cost-sharing
• Out-of-network air ambulance services that would have been covered if the air ambulance provider was in-network will now apply in-network cost-sharing

The regulation also requires in-network cost-sharing to be calculated using payment amounts that would have applied to an in-network provider based on a “recognized amount” for non-air ambulance services (which will be the “qualifying payment amount” (QPA) in most cases) and the lesser of billed charges or QPA for air ambulance services. The out-of-network cost-sharing will apply toward the member’s in-network deductible and annual out-of-pocket maximum.

Who it applies to: Fully insured group health plans, self-funded group health plans and individual policies – including all grandfathered plans.

Effective date: Plan years beginning on or after Jan. 1, 2022

Action required: No member or employer group action is needed at this time; changes will be made within BCBSND systems.