Surprise Billing: Know Your Benefits

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Understand Your Rights Against Surprise Medical Bills

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

Starting in 2022, there are new protections that prevent surprise medical bills. If you have private health insurance, these new protections ban the most common types of surprise bills. If you’re uninsured or you decide not to use your health insurance for a service, under these protections, you can often get a good faith estimate of the cost of your care up front before your visit. If you disagree with your bill, you may be able to dispute the charges. Here’s what you need to know about your new rights.

What Are Surprise Medical Bills?

Before the No Surprises Act, if you had health insurance and received care from an out-of-network provider or an out-of-network facility, even unknowingly, your health plan may not have covered the entire out-of-network cost. This could have left you with higher costs than if you got care from an in-network provider or facility. In addition to any out-of-network cost-sharing you might have owed, the out-of-network provider or facility could bill you for the difference between the billed charge and the amount your health plan paid, unless banned by state law. This is called “balance billing.” An unexpected balance bill from an out-of-network provider is also called a surprise medical bill.

People with Medicare and Medicaid already enjoy these protections and are not at risk for surprise billing.

What Are the New Protections if I Have Health Insurance?

If you get health coverage through your employer, a Health Insurance Marketplace or an individual health insurance plan you purchase directly from an insurance company, these new rules will:

  • Ban surprise bills for most emergency services, even if you get them out-of-network and without approval beforehand (prior authorization).
  • Ban out-of-network cost-sharing (such as out-of-network coinsurance or copayments) for most emergency and some non-emergency services. You can’t be charged more than in-network cost-sharing for these services.
  • Ban out-of-network charges and balance bills for certain additional services (such as anesthesiology or radiology) furnished by out-of-network providers as part of a patient’s visit to an in-network facility.
  • Require that health care providers and facilities give you an easy-to-understand notice explaining the applicable billing protections, who to contact if you have concerns that a provider or facility has violated the protections and that patient consent is required to waive billing protections (i.e., you must receive notice of and consent to being balance billed by an out-of-network provider).

What if I Don’t Have Health Insurance or Choose to Pay for Care on My Own Without Using My Health Insurance (Also Known as “Self-Paying”)?

If you don’t have insurance or you self-pay for care, in most cases, these new rules make sure you can get a good faith estimate of how much your care will cost before you receive it.

What if I’m Charged More Than My Good Faith Estimate?

For services provided in 2022, you can dispute a medical bill if your final charges are at least $400 higher than your good faith estimate and you file your dispute claim within 120 days of the date on your bill.

What if I Don’t Have Insurance From an Employer, a Marketplace or an Individual Plan? Do These New Protections Apply to Me?

Some health insurance coverage programs already have protections against surprise medical bills. If you have coverage through Medicare, Medicaid or TRICARE, or receive care through the Indian Health Services or Veterans Health Administration, you don’t need to worry because you’re already protected against surprise medical bills from providers and facilities that participate in these programs.

What if My State Has a Surprise Billing Law?

The No Surprises Act supplements state surprise billing laws; it does not supplant them. The No Surprises Act instead creates a “floor” for consumer protections against surprise bills from out-of-network providers and related higher cost-sharing responsibility for patients. So as a general matter, as long as a state’s surprise billing law provides at least the same level of consumer protections against surprise bills and higher cost-sharing as does the No Surprises Act and its implementing regulations, the state law generally will apply.

For example, if your state operates its own patient-provider dispute resolution process that determines appropriate payment rates for self-pay consumers, and Health and Human Services (HHS) has determined that the state’s process meets or exceeds the minimum requirements under the federal patient-provider dispute resolution process, then HHS will defer to the state process and would not accept such disputes into the federal process.

As another example, if your state has an All-Payer Model Agreement or another state law that determines payment amounts to out-of-network providers and facilities for a service, the All-Payer Model Agreement or other state law will generally determine your cost-sharing amount and the out-of-network payment rate.

Where Can I Learn More?

Still have questions? Visit CMS.gov/nosurprises or reach out to human resources.

 

Source: Centers for Medicare and Medicaid Services

What Happens If I Miss Open Enrollment?

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An open enrollment period is a short period of time when you can enroll in or make changes to your employee benefits elections. Possible changes include adding or dropping coverage, adding or removing dependents, or enrolling in benefits for the first time.

Open enrollment is your opportunity to take advantage of important benefits, such as health, vision, dental and life insurance, a health savings account (HSA), and a retirement plan.

The decisions you make during the open enrollment period can have a significant impact on your life and your finances, so it is important to weigh your options carefully and to make your decisions during the open enrollment period.

Failure to comply with your employer’s open enrollment deadline could result in a loss of coverage for you and your loved ones. Missing this deadline also means that you could be unable to make changes or enroll in benefits until the next open enrollment period.

One exception to this rule is if you experience a life-changing qualifying event that would trigger a special enrollment period (SEP). Events such as getting married or divorced, having or adopting children, or losing eligibility for other health coverage can trigger special enrollment rights. In some cases, you can also qualify for special enrollment if you become eligible for a premium assistance subsidy under Medicaid or a state Children’s Health Insurance Program (CHIP).

If you think you might qualify for a SEP, contact your HR manager. If you have not recently experienced a life event, but have missed the open enrollment deadline, you should also contact your HR manager to find out whether you have any other options.

Options for Obtaining Health Coverage

If you miss your employer’s open enrollment deadline, there are a number of ways in which you can try to obtain health insurance; however, the availability of some options will depend on their enrollment deadlines.

  • Spousal Benefits—If your spouse receives benefits from his or her employer and the open enrollment period is still open (or coming up), you may be able to enroll in coverage through your spouse’s plan.
  • Young Adult Benefits Under a Parent’s Plan—If you are younger than 26 years old, you may be able to be added as a dependent on your parent’s plan. If your parent’s plan offers dependent coverage, this option should be available to all children under 26, regardless of whether or not you are employed, married, have children or are a student. However, this option is likely available only if your parent’s work-based plan offers coverage for family members and if the open enrollment period for that plan has not yet closed.
  • State Insurance Marketplace—Depending on the timing, you can consider buying health insurance from the Health Insurance Exchange Marketplace. Marketplace coverage is only available for purchase during an annual open enrollment period, unless you qualify for a SEP. (See the SEP section of www.healthcare.gov to check). Similar to employer-based plans, a SEP can be triggered if you experience a qualifying life event.

Regulations Issued to Implement Ban on Surprise Billing

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On July 1, 2021, the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments) jointly released interim final rules outlining certain requirements related to surprise billing. These rules implement certain provisions of the No Surprises Act, which is a ban on surprise medical bills effective in 2022 that was enacted as part of the Consolidated Appropriations Act, 2021, signed into law in late 2020.

Surprise Medical Bills
Surprise medical bills occur when patients unexpectedly receive care from out-of-network health care providers. For example, a patient may go to an in-network hospital for treatment, such as surgery or emergency care, but an out-of-network doctor may be involved in the patient’s care. Patients often cannot determine the network status of these providers during treatment in order to avoid the additional charges. In many cases, the patient is not involved in the choice of provider at all.

Overview of the Interim Final Rules
These interim final rules protect participants, beneficiaries and enrollees in group health plans and group and individual health insurance coverage from surprise medical bills when they receive emergency services, non-emergency services from nonparticipating providers at participating facilities, and air ambulance services from nonparticipating providers of air ambulance services, under certain circumstances. Under these provisions, providers will have to work with the group health plan or health insurance issuer to determine the appropriate amount to be paid by the plan or issuer. Hospitals and healthcare facilities could turn towards outsourcing their medical billing processes to firms such as Gryphon Healthcare to ensure compliance to these new regulations, as external agencies can often focus solely on the billing processes thereby eliminating any human errors or inaccurate billing.

The interim final rules generally apply to group health plans and health insurance issuers offering group or individual health insurance coverage. However, certain provisions apply to emergency departments, health care providers and facilities, and providers of air ambulance services related to the protections against surprise billing.

Allergies: Seasonal Relief

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Days are growing longer, warmer weather is creeping in and as the seasons change, so will your allergy symptoms. You can combat your allergic reactions with these seasonal tips.

Spring

Mold growth blooms indoors and outdoors with spring rains. As flowers, trees, weeds and grasses begin to blossom, allergies will follow. Spring-cleaning activities can stir up dust mites, so be sure to:

  • Wash your bedding every week in hot water to help keep pollen under control.
  • Wash your hair before going to bed, since pollen can accumulate in your hair.
  • Wear an inexpensive painter’s mask and gloves when cleaning, vacuuming or painting to limit dust and chemical inhalation and skin exposure
  • Vacuum twice a week.
  • Limit the number of throw rugs in your home to reduce dust and mold.
  • Make sure the rugs you do have are washable.
  • Change air conditioning and heating air filters often.

Summer

Warm temperatures and high humidity can put a strain on seasonal allergy and asthma sufferers. Summer is the peak time for some types of pollen, smog and even mold:

  • Stay indoors between 5 a.m. and 10 a.m., when outdoor pollen counts tend to be highest.
  • Be careful when going from extreme outdoor heat to air conditioning. The temperature change can trigger an asthma attack.
  • Wear a mask when you mow the lawn or when around freshly cut grass. Afterward, take a shower, wash your hair and change clothes.
  • Dry laundry inside instead of on an outside clothesline. Check your yard for allergens, as well as other irritants such as oak, birch, cedar and cottonwood trees; weeds such as nettle or ragweed can also trigger allergies.
  • Wear shoes, long pants and long sleeves if allergic to bee stings.
  • Do not wear scented deodorants, hair products or perfumes when outdoors.

If you are unsure your symptoms are allergy related or your symptoms are getting worse please consult a doctor.

Taking Care of Your Mental Health

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2020 has been a long year. COVID has changed our family & social landscape, Old man winter is settling in, days are shorter, nights are longer and this time of year carries its own stresses for many. Mental health and wellness should be a top priority and many people may not realize the signs and maybe uncertain where to get help.
What is mental health?
Your mental well-being includes how you think, act and feel. It also helps you cope with stress, relate to others and make decisions. Mental well-being includes mental health, but goes far beyond treating mental illness. For example, you could go through a period of poor mental health but not necessarily have a diagnosable mental illness. And your mental health can change over time, depending on factors such as your workload, stress, and work-life balance. Therefore, it might be essential to visit your nearest direct primary care facility and consult with a physician about your current mental state. This can help the doctor to diagnose your condition better.
What is mental illness?
Mental illness refers to a variety of conditions that affect your mood or behavior, feelings or thinking. Mental illnesses can occur occasionally, while others are chronic and long-lasting. Common mental illnesses include anxiety, depression, schizophrenia and bipolar disorder. 1 in 5 U.S. adults will experience a mental illness in any given year, and more than 50% will experience mental illness at some point in their life.
Why is mental well-being important?
Mental health is extremely important and doesn’t just affect the mind but can also have effects on your physical well-being, causing weight gain, heart attack, or stroke. Because it’s such a crucial component of your health, it’s important to focus on maintaining or improving your mental health. While it’s not always easy, there are ways to help improve your mental health. Some people may take the assistance of a professional through online therapy in New York City or elsewhere, and some may adopt a few self-care measures to deal with mental health issues. It is essential to take every possible course of action to support the mental wellness of yourself and your family. While some might go down the medicinal or supplement (from https://mykratomclub.com and the likes) path, others could follow meditation and yoga to help with their mental health problems. Here are three simple ways to do so every day:
  1. Express gratitude. Taking five minutes a day to write down the things that you are grateful for has been proven to lower stress levels and can help you change your mindset from negative to positive.
  2. Seek help. . If you suffering from the symptoms of mental illness, be it anxiety or irritability at the slightest inconvenience, then it would be a good idea to seek the help of experts. Talking to a therapist and opting for counselling sessions could be of immense help. However, for that, you might need to look for platforms developed by BetterHelp (you can get a 15% discount upon availing of their services), where patients can meet the most experienced therapists.
  3. Get exercise. You probably hear all the time how beneficial exercise is to your overall health, but it’s true. Exercising can improve brain function, reduce anxiety and improve your self-image.
  4. Get a good night’s sleep. Strive for seven to eight hours of sleep a night to improve your mental health.
If you or someone you know is feeling off, not like yourself/themself or sad please know that you are not alone. There are resources available to you. You should contact your primary care physician for guidance or the National Suicide Prevention Lifeline which is available 24/7/365.
National Suicide Prevention Lifeline at 800-273-8255
website: https://suicidepreventionlifeline.org

5 Summer Wellness Tips

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Summer is an exciting time of the year that is typically filled with cookouts, outdoor activities, and other events. To promote a happy, healthy summer, try following these five wellness tips:

  1. Drink plenty of water. Dehydration in the summer months can make you more susceptible to heat exhaustion and heatstroke. To avoid symptoms of dehydration such as dizziness, weakness, and fatigue, try to drink at least eight to ten glasses of water throughout the day.
  2. Watch what you eat at summer cookouts. Common cookout foods like burgers and hot dogs are full of fats that can make you feel lethargic. Sticking to lighter more refreshing foods like fish, pasta salads and watermelon can give you more energy while still satisfying your appetite.
  3. Protect yourself from the sun. Protect yourself from the harmfulness of UV rays by wearing protective clothing, staying in shaded areas during the sun’s highest points (from 10 a.m. to 4 p.m.) and using a sunscreen with an SPF of at least 15. It may also be a good idea to install an air conditioner (get in touch with professionals from brookshvac.com/ac-installation/) so that you don’t have to worry about sweating at all times.
  4. Exercise safely outside. Exerting high amounts of energy in the heat raises your body temperature, making you more at risk for heat exhaustion and stroke. Make sure to drink lots of water, wear breathable clothing and have healthy snacks to fuel your body.
  5. Take a vacation to prevent burnout. Reduced productivity, exhaustion and decreased engagement are all symptoms of burnout. Taking time away from your work responsibilities to get your mind and body in check is essential to keep up work performance and overall health.

Simple Ways to Improve Your Health

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Get Active:

Did you know that exercising regularly could help you fight off chronic conditions and diseases? Exercise can help control your blood pressure, blood sugar and weight, raise your “good” cholesterol, and prevent diseases such as colorectal cancer, heart disease and Type 2 diabetes. If you’re ready to get active, keep the following tips in mind:
  • Get at least 150 minutes of moderate-intensity aerobic activity (e.g., briskly walking) or 75 minutes of vigorous-intensity aerobic activity (e.g., running) every week.
  • Incorporate muscle-strengthening exercises at least two days a week.
  • Avoid injuries by doing the following three steps each workout:
    • Warm up: Warming up allows your body time to adjust from rest to activity. Always remember to gradually increase the intensity of your warmup to reduce stress to your bones, muscles and heart.
    • Cool down: As with warming up, cooling down should include movements similar to those in your workout, but at a gradually decreasing level of intensity.
    • Stretch: After cooling down, stretching helps to build flexibility and range of motion. When stretching, remember to use gentle, fluid movements and to breathe normally.

    After an active and aggressive workout, however, it is equally necessary to take shower in order to feel fresh again. You can also elevate your bathing experience and the relaxation it gives by including CBD based bath salt or soap (click here to by some) in your shower routine.

Getting a Good Night’s Sleep

Getting enough sleep isn’t always possible, but inadequate sleep is a bigger problem than you may think. Getting an adequate amount of sleep is vital to staying healthy and avoiding fatigue, which is why those who often suffer from insomnia consider ingesting CBD capsules or pills (perhaps bought from Blessed CBD and its likes) to ease their mind and get a good night’s sleep. Remember that fatigue causes drowsiness, moodiness, loss of energy, inability to focus, and lack of motivation and alertness, which can, in turn, cause decreased productivity and even be a safety hazard. Hence, aim for seven to eight hours of sleep each night. Even if it means rearranging your schedule, make sleep a priority.
If you are struggling to fall asleep or have a delayed sleep wake disorder or something similar, try the following tips:
  • Maintain healthy habits, such as eating nutritiously, exercising regularly, managing your stress levels and not smoking-all of which will help you sleep better at night and give you more energy throughout the day.
  • Create and stick to a sleep routine. Go to bed and wake up around the same time each day, including on weekends. Make sure your bedroom is at a comfortable temperature and is quiet. Engage in a relaxing activity prior to bedtime such as listening to soft music or smoking cannabis (head to mmj express or like websites to find some premium strains).
  • Limit caffeine, alcohol, nicotine, large meals and rigorous exercise within a few hours of bedtime.

Eating 101

Eating a well-balanced diet is key to maintaining your health. In fact, improving your diet could help you live longer and reduce the chances of developing costly chronic diseases. Keep the following tips in mind when you’re getting started on your healthy eating journey:
  • Get a personalized eating plan. Speak with your doctor to develop a plan that will give you the amounts of each food group you need daily. Your doctor may recommend you seek out a registered dietician or nutritionist to create the best plan for you.
  • Set realistic goals. You are more likely to succeed in reaching realistic goals when you make changes gradually. Start with small changes.
  • Balance your plate with a variety of foods. Fifty percent of your plate should be filled with fruits and vegetables, 25 percent with lean meat, poultry or fish, and 25 percent with grains.
  • Eat slowly. It takes between 15-20 minutes for your brain to get the message that your body is getting food. When your brain gets this message, you may stop feeling hungry.
  • Practice portion control. A portion is the amount of food you choose to eat. Talk with your doctor or visit the United States Department of Agriculture’s website to learn more about proper portion sizes and daily food intake customized to your age, gender and activity level.
Please speak with your doctor if you have questions about fitness programs and/or healthy eating or how you can get started. If these tips do not help you sleep better, or you suspect you have a sleep disorder such as sleep apnea or insomnia, see your doctor.

HR Compliance Bulletin: IRS Issues Guidance on Tax Credits for Coronavirus Paid Leave

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Small and midsize employers may begin using two new refundable payroll tax credits to obtain reimbursement for the costs of providing coronavirus-related leave to their employees, the U.S. Department of Labor (DOL) and Internal Revenue Service (IRS) announced on March 20, 2020.

This relief is provided under the Families First Coronavirus Response Act (the Act), which was enacted on March 18, 2020. The Act provides funds for employers with fewer than 500 employees to provide paid leave, either for their employees’ own health needs or to care for their family members. The Act aims to help employers keep workers on their payrolls while ensuring that workers are not forced to choose between their paychecks and the public health measures needed to combat the coronavirus (COVID-19).

This Compliance Bulletin provides the DOL and IRS’ guidance.

HR Compliance Bulletin: Guidance on Tax Credits for Coronavirus Paid Leave

If you have any questions or would like additional information please contact our office at 617-723-0700.

HR Compliance Bulletin: Coronavirus Relief Laws

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New Coronavirus Relief Laws Require Paid Employee Leave Highlights:

  • Coronavirus relief legislation requires employers with fewer than 500 employees to provide 12 weeks of FMLA leave for child care reasons related to COVID19. 
  • The new FMLA leave must be compensated after the first 10 days, at two-thirds of an employee’s wage, up to $200 per day. 
  • Employers must also provide 80 hours of paid sick time for specified reasons related to COVID-19.

 

New Coronavirus Relief Law Requires Paid Employee Leave

 

If you have any questions or would like additional information please contact our office at 617-723-0700.