Issued on July 1, 2021, the “Requirements Related to Surprise Billing; Part I” interim final rule (IFR) clarifies patient protections and defines a qualifying payment amount (QPA) to limit patient cost-sharing.

Signed into law on December 27, 2020, the Consolidated Appropriations Act (CAA) of 2021 requires the most comprehensive changes to active employee health plans since the Patient Protection and Affordable Care Act (ACA). The CAA protects consumers from certain balance-bills for out-of-network (OON) medical services and establishes the first federal procedure to handle eligible disputed OON medical claims. The CAA also includes several provisions to increase health plan transparency around medical costs and coverage. Additional price and quality transparency measures, including new disclosure requirements, took effect when the U.S. Departments of Labor, Treasury, and Health and Human Services issued the Transparency in Coverage final rule (TiC Rules) on January 11, 2021.

The No Surprises Act is a key component of the CAA. This legislation prohibits plan sponsors and providers from billing participants for more than the in-network (INN) cost-sharing amount due under their plans in most cases of out-of-network surprise billing for emergency services, for services at INN facilities, and for air ambulance services (covered settings). The most notable exclusion is ground ambulance transport. All amounts paid by a participant must count toward the participant’s INN annual deductible and INN annual out-of-pocket maximum. The first No Surprises Act Interim Final Rule¹ clarifies these provisions and provides detailed instructions for determining cost-sharing and payment amounts in covered settings. This paper is designed to help plan sponsors understand the IFR provisions and how they will impact their specific plans.

Additional CAA provisions address independent dispute resolution (IDR), ID card requirements, continuity of care, updating of provider directories and explanation of benefits, pricing comparisons, gag clause removal, and requirements for mental health parity and addiction. Compliance with the new legislation places major administrative burdens and potentially higher costs for compliance on plan sponsors.

On August 20, 2021, the U.S. Departments of Labor, Health and Human Services, and Treasury released an FAQ on the CAA and TiC Rules, delaying the enforcement date of certain provisions. They will issue more guidance for many CAA provisions and updated TiC Rules after January 1, 2022. However, the enforcement date for the balance-billing provisions of the No Surprises Act was not deferred in the FAQ. For a detailed explanation of CAA regulations and how they will impact plan sponsors, see Milliman’s April 2021 white paper "CAA and other transparency measures: Timing and implication of surprise billing for plan sponsors."

NO SURPRISES ACT

Interim final rule: Overview

• TAKES EFFECT FOR HEALTHCARE PROVIDERS AND FACILITIES ON JANUARY 1, 2022. TAKES EFFECT FOR GROUP HEALTH PLANS, HEALTH INSURANCE ISSUERS, AND FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM CARRIERS FOR CONTRACT YEARS BEGINNING ON OR AFTER JANUARY 1, 2022.
• INTERPRETED TO APPLY TO GRANDFATHERED AND NON-GRANDFATHERED PLANS FOR APPLICABLE SERVICES, INCLUDING ANY PLANS SUBJECT TO ERISA AND FEDERAL NONGOVERNMENT PLANS.
• DOES NOT APPLY TO RETIREE-ONLY PLANS, HEALTH REIMBURSEMENT ARRANGEMENT (HRA) PLANS, EXCEPTED BENEFITS, OR SHORT-TERM, LIMITED-DURATON INSURANCE PLANS.

The U.S. Departments of Health and Human Services (HHS), Labor, and Treasury, as well as the Office of Personnel Management, issued an interim final rule implementing one of the key provisions of the No Surprises Act, which seeks to protect patients against surprise billing at the federal level. Surprise billing happens when people unknowingly get care from providers that are outside of their health plans' networks. Surprise bills can happen with both emergency and nonemergency care. Surprise bills have two primary components—higher cost-sharing amounts due to less generous OON benefits, and balance-bills, which are provider bills for the cost of the service in excess of a plan’s OON-allowed amount. Federal health programs such as Medicare and Medicaid provide strong surprise billing protections to enrollees. The No Surprise Act extends similar protections to Americans insured through employer-sponsored and commercial health plans, with key elements of these protections outlined in the interim final rule (IFR).

Among other provisions, the IFR:

• Bans surprise billing for emergency services. Emergency services, regardless of where they are provided, must be treated on an in-network basis without requirements for prior authorization.
• Bans high out-of-network cost-sharing amounts in covered settings. Patient cost sharing, such as deductibles and coinsurance, cannot be higher than if such services were provided by an in-network doctor, and any coinsurance or deductible must be based on an amount determined under federal regulations.
• Bans out-of-network balance-bills for ancillary care in covered settings, as from an anesthesiologist or assistant surgeon at an in-network facility, in all circumstances.
• Bans other out-of-network balance-bills in covered settings without advance notice. Healthcare providers and facilities must provide patients with a plain-language consumer notice explaining that patient consent is required to receive care on an out-of-network basis before that provider can bill at the higher out-of-network rate.

HHS views tackling balance-billing as critically important, and cited several supporting data points in the IFR. Two-thirds of all bankruptcies filed in the United States are tied to medical expenses. Researchers estimate that one of every six emergency room visits and inpatient hospital stays involves care from at least one out-of-network provider, resulting in surprise medical bills. And a 2019 study by the Government Accountability Office (GAO) found that the median price charged by air ambulance providers ranged from $36,400 to more than $40,000, and over 70% of these transports were furnished out-of-network, meaning most or all costs fell to the insured individual alone.²

Balance-billing protections: Overview

Balance-billing can occur when a participant intentionally or unintentionally receives care from an OON provider. Most OON care is planned for, but in certain situations consumers may not be aware that they are seeing an OON provider, such as when receiving emergency care at an out-of-network (OON) facility or nonemergency care at an in-network (INN) facility from an OON provider. In these cases, participants can be responsible for the difference between what the group plan sponsor reimburses OON providers and what the OON provider charges. OON charges are high—typically two to three times INN payment rates.³ Because there is no limit to the amount that OON providers or facilities may charge, balance-billing can result in significant financial obligation to the participant. Balance-billing also frequently occurs with ground and air ambulance providers. Specifically, the IFR provides balance-billing protection to participants for the following medical services:

• Emergency services received from out-of-network (OON) providers or facilities
• Nonemergency services received from OON providers working at in-network (INN) facilities, except for nonancillary services when notice is provided to and consent is received from the participant.
• Air ambulance services provided by OON providers.
• Consistent with the statute, the IFR does not include any protections for ground ambulance billing.

The notice and consent provision outlined in the IFR will be used to determine whether nonemergency services delivered by OON providers at INN facilities are protected from balance-billing. For a participant to relinquish balance-billing protections, the provider must obtain written consent from the participant after written notice. The IFR includes guidance for the application of the notice and consent provision, and notes that plans must proceed as if protections still apply until notice and consent documentation is received.

Balance-billing protections: Emergency services

Definition of emergency services

The IFR states that balance-billing protections apply to all emergency services as defined under the Emergency Medical Treatment and Labor Act (EMTALA), section 1867 of the Social Security Act, with the following modifications:

• The IFR expands the definition of emergency services to include all services rendered at independent freestanding emergency departments, defined as any emergency department that is geographically separate from a hospital and licensed by the state to provide emergency services. This includes Urgent Care centers that are permitted to provide emergency services, even if they are not licensed as independent freestanding emergency departments. Urgent care centers are only included in this definition in certain states where they are permitted to provide emergency services.
• The IFR further expands the definition of emergency services to include any pre-stabilization services provided to a patient after being admitted to the hospital, regardless of which department of the hospital administers the services. If a patient comes to the emergency room and is subsequently admitted to another department of the hospital, all pre-stabilization services provided in that department are subject to the balance-billing protections in the No Surprises Act.

Post-stabilization services

The definition of emergency services also includes post-stabilization services rendered after a participant is moved out of the emergency department and admitted to the hospital, unless both of the following criteria are met:

• The emergency physician determines the participant can travel to an INN facility within a reasonable distance using nonemergency transport.
• The provider or facility providing the post-stabilization services to the participant satisfies the notice and consent provisions of the No Surprises Act and the participant is in such a state of mind that they can understand the notice and consent criteria and adequately provide consent. The participant’s state of mind is determined by the emergency physician.

If state laws prohibit consent to balance-billing, those laws supersede the criteria outlined above, and all post-stabilization services are protected.

Denial of emergency medical claims

Currently the ACA defines an emergency medical condition as a medical condition such that a prudent layperson would reasonably think bodily harm or death could occur if medical attention were not sought immediately. Plan sponsors can deny emergency claims if the prudent layperson criteria are not met, and frequently use only final diagnosis codes to make the initial determination.

The IFR specifies that when denying an emergency claim, plan sponsors:

• Must review all supporting documentation, including procedure codes and symptoms, when making an initial claim determination.
• Cannot rely solely on final diagnosis.
• Cannot impose a time limitation between when symptoms begin and when the patient seeks emergency care.
• Cannot deny emergency claims because the symptoms did not have a sudden onset.
• Cannot make claim determinations using other benefit provisions when covering emergency services. For example, if a plan sponsor covers emergency services but not general maternity services, and a participant seeks emergency medical care for a prenatal issue, the claim would not be eligible for denial and would be subject to the protections of the No Surprises Act.

Plan sponsors should review their emergency claim adjudication process to ensure compliance with this provision, as the plan sponsor is liable for noncompliance even if an outside entity is responsible for claim adjudication and review.

Balance-billing protections: Nonemergency services

The No Surprises Act prohibits balance-billing for surprise medical bills for nonemergency services provided by OON providers at INN facilities. The IFR clarifies this provision by defining a healthcare facility as a facility that has a contractual relationship either directly or indirectly with a plan sponsor, including a hospital, outpatient department of a hospital, critical access hospital, ambulatory surgical center, and potentially urgent care centers. The IFR further expands this definition to include single-case agreements for specific participants at OON facilities.

The IFR defines a visit to include telemedicine, imaging, lab work, and preoperative and postoperative services regardless of whether an offsite vendor is used.

This provision applies to all air ambulance claims if the plan sponsor covers any benefits related to air ambulance services, even if there is not an established network of providers of air ambulance benefits.

Balance-billing protections: Disclosure requirements

The No Surprises Act protects against balance-billing by requiring notice and disclosure requirements for providers, facilities, and plan sponsors. Plan sponsors must post an explanation of plan benefits related to the No Surprises Act on the plan’s website including:

• The requirement and prohibitions on balance-billing applicable to the provider as detailed in the No Surprises Act
• Any applicable state laws related to balance-billing
• Instructions for contacting state and federal agencies to file a complaint in the event a provider or facility has violated balance-billing rules

The IFR includes a model notice for plan sponsors to customize and post on their websites. Similar disclosure requirements are mandated for providers and facilities.

Balance-billing protections: Notice and consent process

Under the No Surprises Act, participants can consent to be balance-billed by certain OON providers if they are notified of the provider or facility network status in a timely manner and sign a consent form. The No Surprises Act details the timeline of this consent process as follows:

• For appointments made prior to 72 hours before the date of service, notice and consent must be completed at least 72 hours before the service
• For appointments made within 72 hours of the date of service, notice and consent must be completed on the same day the appointment is made
• For same-day appointments, notice and consent must be completed at least three hours before service

The IFR further specifies that OON providers and facilities must notify plan sponsors that the notice and consent criteria were satisfied prior to any given service and provide supporting documentation. Further, the OON provider, or INN facility on behalf of the OON provider, must indicate whether the services are subject to the protection in the No Surprises Act. In situations where the participant provides consent and is billed directly, the bill can include this notice.

The CAA requires out-of-network providers and facilities to inquire whether a participant has health insurance at the time an appointment is scheduled, and subsequently provide the group plan sponsor a good faith estimate of out-of-pocket participant costs for all scheduled services. The group plan sponsor must then provide an advanced explanation of benefits to the participant. This provision was deferred in the FAQ released August 21, 2021, and an enforcement date will be specified in future guidance released after January 1, 2022. The notice and consent provisions described above were not deferred in the FAQ and are effective for plan years beginning on or after January 1, 2022.

Determination of the cost-sharing amount and payment amount to providers and facilities

Definitions

The IFR defines the rates and amounts applicable to participant cost sharing and OON provider payments for services protected by the No Surprises Act:

• Recognized amount: The rate used to determine the participant cost sharing.
• Qualifying payment amount (QPA): The rate used to determine the recognized amount. The QPA can be considered by the independent dispute resolution (IDR) entity during the IDR process.
• Out-of-network rate: The actual amount paid to the OON provider by the plan sponsor.

The IFR provides guidance on how to calculate each of these rates and amounts. Service providers, third-party administrators (TPAs), preferred provider organization (PPO) networks and pharmacy benefit managers (PBMs) should perform the calculations for plan sponsors according to their roles in the claim negotiation and payment process, and this service should be specified in all relevant 2022 contracts. Plan sponsors may need to facilitate communications between relevant entities when claims are administered by several different vendors.

How to determine the cost-sharing amount

For services protected under the No Surprises Act, participants cannot pay more than they would have paid for services at INN facilities or providers. Additionally, the cost-sharing amount must be counted toward each participant’s INN deductible and INN out-of-pocket maximum.

The amount used to determine cost sharing for services other than air ambulance services is the recognized amount, which the IFR defines as:

1. An amount determined by an applicable all-payer model agreement. Initially, the recognized amount should be equal to the rate specified in the all-payer model agreement, if such an agreement exists. For this methodology to be used, the all-payer agreement must apply to both the OON provider and to the item or service. If an opt-in clause exists, both the plan sponsor and OON provider must have opted into the all-payer agreement.
2. If there is no applicable all-payer model agreement, an amount determined by a specified state law. If a state law is used, the law must apply to the plan, the OON provider, and to the item or service. A state law that permits self-funded plans to opt in will be considered to apply to the plan if the plan opts in.
3. If there is no applicable all-payer model agreement or specified state law, the lesser of the amount billed by the provider or facility or the qualifying payment amount (QPA), which is generally defined as the median of the plan’s contracted rates for the service in the geographic region. This paper provides detailed instructions for calculating the QPA in Appendix A.

Total cost sharing for air ambulance claims is based on the lesser of the QPA and the billed amount.

QPA disclosure requirements

When the QPA is used as the recognized amount, the plan sponsor needs to disclose the following information with the initial payment or declination of payment to the provider:

• The QPA for each item or service
• A statement certifying that the QPA applies as the recognized amount, and that each QPA was calculated using the methodology specified in the IFR
• A statement that the provider or facility may initiate the 30-day open negotiation period by contacting the appropriate office, and that the IDR process may begin four days after the open negotiation period ends if no payment determination is made
• The contact information for the office or person to begin the open negotiation process

If requested by the OON provider, the plan sponsor must also provide the following information:

• Whether the QPA was calculated using contracted rates on a non-fee-for-service basis and, if so, whether an underlying fee schedule or derived amount was used for the rates
• The related service code used to calculate the QPA for new service codes, as applicable
• The database used to determine the QPA, as applicable
• A statement indicating whether the contracted rates include any incentive-based payments, retrospective payments, or payment adjustments that were excluded for the QPA calculation

How to determine the out-of-network rate

The OON rate is defined as the total amount paid to the OON provider by the plan sponsor. This amount is determined as follows:

• If an all-payer model agreement exists, the amount defined in the model
• If no all-payer model agreement exists or applies, the amount determined by state law
• If no all-payer model agreement and no state laws exist or apply, the amount agreed upon by the OON provider and the plan sponsor
• If none of the above apply, the amount determined through the IDR process

The application of the all-payer model agreement and state laws are subject to the same provisions as the recognized amount. To be applicable, each must apply to the plan, to the OON provider, and to the item or service.

If a state law has a connection with ERISA plans, such as a law that governs the payment of benefits or the timing and methodology for determining an OON rate, the state law preempts the IDR process, and the IDR process is not applicable. Plan sponsors not subject to ERISA, such as nonfederal governmental plans, can opt in to the state laws for determining rates, but cannot selectively opt in, and must opt in for all items and services for which the state laws apply. If a plan sponsor opts in, it must indicate so on all materials it distributes.

State laws may not be applicable in determining the OON rate for an air ambulance claim, due to the Airline Deregulation Act of 1978.

There may be situations where the recognized amount is less than the OON rate. In these situations, the plan sponsor will be responsible for paying the total amount owed on the OON rate, less the cost sharing based on the recognized amount.

Initial payment criteria

The No Surprises Act specifies that the plan sponsor must make an initial payment or send a notice of declination of payment within 30 days of receiving a bill. The IFR clarifies that the plan sponsor does not need to make an initial payment until 30 days after the provider provides a “clean” bill, defined as a bill with sufficient detail to determine whether No Surprises Act provisions apply. The IFR does not specify how the initial payment amount should be determined but does specify that the initial payment plus member cost sharing calculated based upon the recognized amount should equal the full payment from the plan sponsor’s point of view.

Conclusion

The No Surprises Act requires plan sponsors to comply with some of the most burdensome tasks since the ACA. The "Requirements Related to Surprise Billing: Part I" IFR clarifies surprise billing provisions and provides detailed instructions for determining cost-sharing and payment amounts for OON emergency services, OON nonemergency services at INN facilities, and OON air ambulance services. With most provisions taking effect on January 1, 2022, the timeline for compliance is tight and plan sponsors are advised to move forward as quickly as possible. Specifically:

• All plan sponsors should immediately review all relevant 2022 service provider, PPO network, and PBM contracts to confirm that the contractors will comply with and provide all surprise and balance-billing determinations specified in the IFR.
• All plan sponsors should prepare to update their websites by January 1, 2022, to meet the new disclosure requirements. The IFR provides a model notice for plans to customize.

While it seems evident that the No Surprises Act will lower out-of-pocket costs for participants, the cost impact to plan sponsors is still unknown. Carriers and plan administrators could potentially raise their prices to pay for the extra work required to manage and implement the new processes. Additionally, this legislation can increase costs for self-funded plans by making plan sponsors responsible for amounts not covered by participant cost sharing. Prior to balance-billing protections, plan sponsor liability was typically capped at the defined OON-allowed amount minus participant cost sharing for OON benefits.

Plan sponsors should also note that additional regulations are forthcoming. The IFR states that the Part I IFR described in this white paper is the first of several regulations that the federal agencies will be issuing to implement the No Surprises Act. Regulations on the independent dispute resolution (IDR) process are expected later in 2021. Several provisions of the CAA and TiC Rules were recently deferred, including the price comparison tool, advanced explanation of benefits, and certain data disclosures. Rules on other Consolidated Appropriations Act provisions, including insurance card requirements, continuity of care, provider network directions, and prohibition on gag clauses, will likely not be provided until after January 1, 2022, but plan sponsors are expected to implement the provisions using a good faith interpretation of the law.

Appendix: How to determine the qualifying payment amount

The No Surprises Act defines the QPA as:

1. In calendar year (CY) 2022, the median contracted rate for similar procedures performed in similar geographic areas as of January 31, 2019, increased using the Consumer Price Index for Urban Consumers (CPI)
2. In all future years, the median contracted rate for similar procedures performed in similar geographic areas in the previous year, trended using the CPI

How to determine the median contracted rate

The first step in determining the QPA is to calculate the median contracted rate (MCR) as of January 31, 2019, with respect to all coverage offered in the same insurance market. To calculate the MCR, arrange the contracted rates of all plans of a specific plan sponsor or administrating entity from least to greatest. The MCR is the middle value, or in the case of an even number of contracts, the average of the two middle values. Rate observations are determined at a contract level—each distinct rate is counted once, regardless of the number of providers or facilities receiving that same rate or the number of claims paid at that rate. Contracted rates include any rented networks, but exclude single case agreements.

The IFR defines the contracted rate as the total amount that a plan has agreed to pay an INN provider or facility, either directly or through a third-party administrator or PBM, including any participant cost-sharing amounts. Each contracted rate represents an individual rate in the MCR calculation. The IFR requires that there must be at least three rates included in the MCR calculation in order for a specific service to have sufficient information.

The IFR further specified the level at which the MCR is to be calculated. The MCR for a given service is only determined based on contracted rates:

• In the same market
  The MCR is determined separately for individual, small group, and large group health insurance coverage, as well as for all self-funded coverage. It includes only major medical insurance coverage. Contracted rates exclude those groups for more limited forms of coverage, such as excepted benefits, short-term limited duration insurance, and account-based plans. Self-funded group health plan contracted rates may, as the plan sponsor’s option, represent only rates for that plan sponsor or rates for all plan sponsors administered by the same entity.
• For the same or similar services
  Services can be grouped according to service codes, such as the Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), and diagnosis-related group (DRG), and may include services under different coding systems. Service code modifiers, which may be used to further describe elements of the case such the provider specialty, place of service, or complexity of the case, can be used to further limit the contracted rates included in the MCR when these modifiers result in changes to contracted rates. The MCR must specifically distinguish between CPT modifier 26 (the professional component) and CPT modifier TC (the technical component) when present, which typically apply for laboratory and imaging services.
• Provided by a provider in the same or similar specialty
  To the extent that a plan varies contracted rates by professional specialty or facility type in the course of normal business practices, the MCR should reflect only contracted rates for professionals or facilities within the same business practice classification. One example noted by the IFR was emergency services—if a plan varies contracted rates based on whether an emergency department is on hospital grounds or is freestanding, then contracted rates used to determine the MCR for freestanding emergency departments should be limited to contracts with freestanding emergency departments. Also of note, all air ambulance providers are considered to be of the same specialty, regardless of whether the provider operates fixed wing or rotary wing ambulances.
• Provided in the same geographic region
  For services other than air ambulance services, provider contracts are grouped by metropolitan statistical area (MSA) within a state. If a plan does not have the required three contracted rate threshold to determine a median at the MSA level, then the plan should look at contracts across all MSAs in the state. If the plan still cannot meet the required three contracted rate threshold, then the plan should combine contracted rates across all MSAs in the same census division. If services are rendered in a non-MSA in a state, the MCR is calculated using all contracted rates in non-MSAs in the state. Should there fail to be three contracted rates at the state level, then the MCR may be calculated using all non-MSAs in the census division. For air ambulance services, the MCR calculation proceeds immediately to the statewide MSA/non-MSA step, proceeding to a census division level calculation if the state-level calculation fails to result in sufficient data, with location based on point of pickup.

Services provided on a basis other than fee-for-service (FFS), such as bundled payments and capitated arrangements, must be included in the MCR. These contracted rates should be determined using an underlying fee schedule used to calculate member cost sharing if one exists. Otherwise, a derived amount consistent with the cost of providing coverage should be used.

Some services, such as anesthesia services and air ambulance mileage, are calculated by multiplying a base cost by a number of units. For these unit-based services, the “same or similar service” is based on all services using that same basis. The MCR is calculated as the median base cost, so all contracted rates should be divided by the number of units prior to the MCR calculation.

What to do if there is insufficient data to calculate the MCR

To calculate a specific MCR, there must be at least three applicable contracted rates. If sufficient data is not available, the MCR should be determined using an All-Payer Claims Database or an eligible third-party database. Allowed amounts reported in the selected database are then used to determine the MCR.

Third-party databases are eligible if they:

• Are not controlled by a health insurance issuer or provider
• Have sufficient information on INN payment amounts
• Distinguish the amounts paid to INN providers and facilities from claims paid to OON providers

Plan sponsors must use a consistent methodology when relying on a database. Plan sponsors are permitted to change databases at the end of the calendar year and may use different databases for different services as long as the choice of database is based on business factors such as the sufficiency of data in each database, and not on the rates in each database. Once a QPA has been determined for a specific service, future same or similar services in the same insurance market offered by a provider in the same or similar specialty in the same region must be calculated using this QPA.

Initially, if there is not sufficient data to calculate the MCR, but there is enough data in a subsequent year, calculate the QPA using the MCR from that year. There must be at least three contracted rates as of January 31 of the preceding year, and the rates must account for at least 25% of the total number of claims for that service and year for all the plans provided by the plan sponsor.

How to calculate the QPA from the MCR

Once the MCR is determined, calculate the QPA by indexing the MCR by the CPI for each year. The CPI for each year is defined as the average for the 12-month period ending August 31 of that calendar year, rounded to 10 decimal places. For unit-based service, the MCR is indexed using the CPI and then multiplied by the number of units associated with the specific service to determine the QPA. For services with insufficient information for which a QPA was determined in a prior year, the prior year’s QPA is indexed using the CPI.

¹ U.S. Departments of Health and Human Services (HHS), Labor, and Treasury. Interim Final Rule: Requirements Related to Surprise Billing; Part I. Federal Register. Retrieved November 30, 2021, from https://www.federalregister.gov/documents/2021/07/13/2021-14379/requirements-related-to-surprise-billing-part-i.

² U.S. Department of Health and Human Services (July 1, 2021). HHS Announces Rule to Protect Consumers From Surprise Medical Bills. Press release. Retrieved November 30, 2021, from https://www.hhs.gov/about/news/2021/07/01/hhs-announces-rule-to-protect-consumers-from-surprise-medical-bills.html.

³ David Lewis (September 2018). The Changing Landscape of Out-of-Network Reimbursement. Milliman White Paper. Retrieved November 30, 2021, from https://www.milliman.com/-/media/milliman/importedfiles/uploadedfiles/insight/2018/changing-landscape-oon-reimbursement.ashx.

This update is intended to provide information and analysis of a general nature and should not be interpreted as legal or other professional advice. Milliman recommends that readers of this update be aided by their own qualified professional for guidance on their specific circumstances.