The Departments of Labor, Health and Human Services and Treasury issued a notice of clarification to explain the Department’s position on the coverage of emergency services by non-grandfathered group health plans under the Affordable Care Act.
The ACA requires non-grandfathered group health plans that cover emergency services to do so even if a provider is not a plan “participating provider.” ACA also requires plans to apply the same cost-sharing requirement for emergency services provided out-of-network as emergency services in-network. The amount a provider can charge for such services is not set forth in the statute. Rulemaking requires the charges to be reasonable, considering one of the following three options: the in-network negotiated rate, the out of network determination for other services, or the Medicare rate.
In 2016, a lawsuit was filed against the Departments asserting that the final regulations on charges for emergency services should be invalidated because they do not ensure a reasonable payment. The court remanded the matter back to the Departments so they could address the issue in future rulemaking. That rulemaking was issued this week in the form of a “Clarification of Final rules.”
The Clarification holds that the November 2015 final rule provides a reasonable methodology to determine appropriate payments by group health plans and health insurance issuers for out-of-network emergency services. The rulemaking can be found by clicking here.
