What Is the No Surprises Act?

What Is the No Surprises Act? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance explains what surprise billing is and discusses how the No Surprises Act can affect different patients.  

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Transcript

Mary Leer:  

In terms of fighting surprise billing or the No Surprise Act. What is surprise billing? 

Ashira Vantrees:  

Yeah, so surprise billing occurs when a patient visits a hospital or a doctor’s office that is in network, but then once there, they’re treated by an out-of-network provider. So, often the patient doesn’t know that when they’re in a network facility, they’re being treated by an out-of-network provider, and so then after the fact, after they received care from this out-of-network provider, they are sent a bill to the out-of-network costs for the care that they received. So, this is called Surprise billing, ’cause often patients are unaware that they even receive care from an out-of-network provider, and are expected to pay the full out-of-network costs for that care. So that’s one way we see surprise billing. Another way that we see surprise billing often occur is during surgical procedures, so if the patient is going to get a surgery and then they’re at in-network surgeon in-network hospital, but then during their surgery an out-of-network anesthesiologist used that out of network anesthesiologist they get a whole bill for that. So, it’s not even within the patient’s control, and they don’t even know, so, those are the two kind of big ways we see surprise billing occur. 

Mary Leer:  

Very important to know. Can you briefly describe the No Surprises Act and what does it impact, or how might it impact the insured or the uninsured? 

Ashira Vantrees:  

Yeah, absolutely. So, in December 2021, the Department of Health and Human Services also called HHS. They issued an interim final rule called the No Surprises Act, that would prohibit surprise billing for emergency services, prohibit out-of-network charges for ancillary services like the anesthesiologist during the surgery, and it would prohibit non-emergency services from charging out-of-network rates without obtaining notice and consent from patients. So, this rule became effective on January 1, 2022, and it applies to individuals who have group health insurance plans or individual health insurance plans, but it’s not going to apply to individuals who have Medicare, Medicaid, received care through the Indian Health Services or through the Veteran Affairs Administration because surprise billing has already been banned in those programs. It also does not provide any protection for individuals who are uninsured, but for individuals who are uninsured, it does require that when they’re out of doctor’s office or hospital, that the hospital or doctor’s office gives them a good base estimate of what the cost of that care is going to be before they receive the care. 

Mary Leer:  

Does the No Surprises Act supersede state laws? Could you explain that? 

Ashira Vantrees: 

Yeah, so sometimes that’s kind of the always lawyer answer maybe. So, the No Surprises Act supersedes state laws that provide less protection. So, the No Surprises Act is intended to act like a floor for protection, so if a state has a state law on surprise billing that provides greater protection than the No Surprise Act, that the law will prevail over the No Surprises Act, but any law that provides less protection, the No Surprises Act is going to supersede that law, but what’s also really important to note about the No Surprises Act is that it doesn’t limit state legislators’ ability, so if they have a law that is currently providing less protection than the No Surprises Act, it doesn’t limit their ability to create laws that provide greater protection than the No Surprises Act.

What Are the Differences between Health Care Reform, Patient Protection, ACA, and ObamaCare?

What Are the Differences between Health Care Reform, Patient Protection, ACA, and ObamaCare? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance discusses the differences between Healthcare Reform, ObamaCare, Patient Protection and the ACA and how each impact patients differently.

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Transcript

Mary Leer:  

What is the difference between the following things that most of us have heard about, the healthcare reform, the Affordable Care Act, Patient Protection and the ACA and ObamaCare? 

Ashira Vantrees:  

Yeah, so I think there’s a lot of terms that are used at the moment, when we’re talking about health care reform, our current health care system, so I think it’s important that we can break this down so we really understand exactly what we’re talking about. So first, the ACA. So the ACA stands for, the full bill name is the Patient Protection and Affordable Care Act, but it’s also been referred to as other names, so the Patient Protection and the ACA or ObamaCare, regardless of which name is used, when we use those words that we’re talking about, is that 2010 bill that was passed that created really important programs and protection for patients. And then when we talk about healthcare reform, what we’re talking about is really this larger issue of how we can really change and revise our healthcare system to address things like the increasing cost of healthcare, the number of people who are uninsured, or really the quality of care that we’re receiving and healthcare reform. I think it’s important to note that it can occur in a number of ways. So I think one of the biggest pieces of healthcare reform that we have in the last decade is the ACA, the Patient Protection, Affordable Care Act, and that came in the form of federal legislation, but we can also see health care reform come in through state legislation, so one way that we’re seeing healthcare reform now at a state level is through states passing laws to provide greater protection against burdensome prior authorization step therapy protocols, and requiring copay assistance to count towards meeting patients’ deductible and annual out of pocket limit.

What Is the Affordable Care Act?

What Is the Affordable Care Act? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance explains what the Affordable Care Act entails and also what it does not cover.  

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Transcript

Mary Leer:  

Okay, thinking of the Affordable Care Act, can you briefly describe what the Affordable Care Act or ACA is, and what are the goals of this law? And what does it cover? 

Ashira Vantrees:  

Absolutely. So, the ACA formal name is the Patient Protection and Affordable Care Act, and it was passed in 2010, and what it’s intended to do is to expand access to healthcare from many Americans. And so, the ACA has been able to do this in a number of ways. So for example, the ACA created tax credit for individuals living between 100% to 400%, below the federal poverty line to help provide them some financial assistance to ensure they could be able to get healthcare coverage, and it also created really important protections that require health plans cover the cost of preventative services like cancer screenings for free, and it also requires health plans, or it also prohibits health plans from charging a higher cost for healthcare coverage if they have a pre-existing condition like cancer.  

Mary Leer:  

Wow. Is there anything the Affordable Care Act does not cover? 

Ashira Vantrees:  

Yeah. So, there are limits to what the affordable care act does cover. I should mention that the Affordable Care Act does have what it calls the 10 essential health benefits, and so these 10 essential health benefits are things that health plans that are on with a federal exchange are required to include. That includes coverage for things like prescription drugs, maternity and newborn care, hospitalization costs and other really important things that are really just at the core of our healthcare, but those do have limits. So, the ACA does not cover the cost of long-term care such as living in an assisted living facility or home health care, and it also doesn’t cover the cost of things like cosmetic surgery, weight loss surgery, infertility treatments, or dental and vision for adults.

Which States Have Oral Parity Laws?

Which States Have Oral Parity Laws? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance discuss which states have oral parity laws and how to learn more.  

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Transcript

Mary Leer:  

What states have laws that cover something like oral parity? 

 Ashira Vantrees:  

Yeah, there’s actually quite a few. There’s currently over 40 states that have passed oral parity legislation, and also the District of Columbia has passed oral parity legislation. Aimed Alliance also has an oral parity fact sheet on his website, that’s a really good resource for individuals trying to learn more about this issue, and the fact sheet covers oral parity like we just discussed it, and really why there is a need for federal legislation and in the coming months we’re also creating oral parity mapping on our website, so we’ll have updated maps that are going to be a great resource for patients, that are going to show you where oral parity laws have been enacted and in what state legislators there is currently oral per legislation. 

 Mary Leer:

Wow, I can’t wait to tell people about this because I didn’t have oral chemo, and I think about during covid, like how that would have been a choice of preference, and then not realizing you get hit with that extra expense.

What Is the Cancer Drug Parity Act?

What Is the Cancer Drug Parity Act? from Patient Empowerment Network on Vimeo.

Ashira Vantrees, JD of Aimed Alliance discuss what the Cancer Drug Parity Act is and how it impacts various issues in oncology.

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Transcript

Mary Leer:  

Could you briefly describe what the Cancer Drug Parity Act is? 

 Ashira Vantrees:  

Absolutely. So, the Cancer Drug Parity Act has been introduced in the Senate by Senator Tina Smith, and it’s been introduced in the House of Representatives by Representative Brian Higgins, and it’s federal legislation that if passed, would require health plans to have the same cost sharing requirements, that’s your co-pay, or your co-insurance, for oral chemotherapy treatments, IV chemotherapy treatments. 

Mary Leer:  

So, are there other issues in oncology that the Cancer Drug Parity Act addresses? 

Ashira Vantrees:  

So, the Cancer Drug Parity Act primarily addresses the issue of co-pay parity. So, the issue of copay parity is that some health plans required different cost sharing and typically a higher cost sharing for oral treatment compared to IV treatments, and co-pay parity requires that health plan provide the same cost sharing requirements for the oral and IV treatment. And really the issue of copay parity really came up when health plans started charging patients with cancer a higher copay for oral chemotherapy treatments compared to their IV chemotherapy treatment, and so obviously, this is really upsetting for patients with cancer who had come to this decision with their healthcare provider that this oral chemotherapy treatment was the best option for them. And then what was happening is they would go to collect their medication, and then be hit with this unexpectedly higher copay, than what they were used to. So, in response to this practice by insurers and health plans, states are passing Oral Parity Laws which prohibited health plans from charging a higher cost sharing, so a co-pay or a co-insurance for oral chemotherapy compared to IV chemotherapy and the Cancer Drug Parity Act is the federal version of that state legislation. 

And the reason federal legislation is needed is because while state laws are great, state laws don’t regulate all types of insurance. So, for example, state laws don’t regulate insurance that individuals get from their employer, federal legislation can do that, and so that’s why we need the Cancer Drug Parity Act to pass to ensure that patients with cancer when they’re choosing which treatment is the best for them, that’s not a decision they’re forced to make based on their cost sharing requirements.